United Health Insurance Policy Gold Policy-Wording


HEALTH INSURANCE POLICY - GOLD

1.      WHEREAS the insured designated in the schedule hereto has by a proposal and declaration dated as stated in the schedule which shall be the basis of this contract and is deemed to be incorporated herein has applied to UNITIED INDIA INSURANCE COMPANY (hereinafter called the INSURED PERSON) and has paid premium as considered for such insurance.

1.1    NOW THIS POLICY WITNESSES that subject to the terms, conditions, exclusions and definitions contained herein or enclosed, or otherwise expressed here on the company undertakes that if during the period stated in the schedule or during the continuance of this policy by renewal any insured person shall contract any disease or suffer from any illness ( hereinafter called DISEASE ) or sustain any bodily injury through accident ( hereinafter called INJURY) and if such disease or injury shall require any such insured person, upon the advice of a duly qualified physician/medical/specialist/medical practitioner (hereinafter called MEDICAL PRACTITINOER) or of a duly qualified Surgeon (hereinafter called SURGEON) to incur hospitalization /domiciliary hospitalization expenses for medical/Surgical treatment at any Nursing Home/Hospital in India as herein defined (hereinafter called HOSPITAL) as an inpatient the company will pay through TPA to the hospital / Nursing Home or the Insured person the amount of such expenses as are reasonably and necessarily incurred in respect thereof by or on behalf of Insured person but not exceeding the Sum Insured in aggregate in any one period of Insurance stated in the schedule hereto.

1.2    In the event of any claim/s becoming admissible under this scheme, the company will pay through TPA to the Hospital / Nursing Home or the Insured person the amount of such expenses as would fall under different heads mentioned below, and as are reasonably and necessarily incurred hereof by or on behalf of such Insured Person, but not exceeding the Sum Insured in aggregate mentioned in the schedule hereto.

A)      Room, Boarding Expenses as provided by the hospital /Nursing home

B)      Nursing Expenses

C)      Surgeon, Anesthetist, Medical Practitioner, Consultant, Specialists Fees

D)      Anesthetist, Blood, Oxygen, Operation Theatre Charges, Surgical appliances, Medicines & Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy Cost of pacemaker, Artificial Limbs & Cost of Organs and similar expenses.

Expenses in respect of the following specified illnesses will be restricted as detailed below;

Hospitalization Benefits

Limits restricted to

a). Cataract

a). 10% of the SI or Max of Rs.25,000/-

b). Hernia

b). 15% of the SI or Max of Rs.30,000/-

c). Hysterectomy

c). 20% of the SI or Max of Rs.50,000/-

d). Major Surgery - Angioplasty

d). 70% of the SI or Max of Rs. 2lacs

e). Pre & Post Hospitalization

e). Maximum 10% of the Sum Insured

 (N.B: Company Liability in respect of all claims admitting during the period of Insurance shall not exceed the Sum Insured per person as mentioned in the schedule)

2.       DEFINITIONS:

2.1.1  HOSPITAL / NURSING HOME means any institution in India established for indoor care and treatment of sickness and injuries and which

                                                                     Either

(a)     Has been registered as Hospital or Nursing Home with the local authorities and is under the supervision of a registered and qualified Medical Practitioner.

                                                                     Or

(b)     Should Comply with minimum criteria as under:-

i)       It should have at least 15 inpatient beads.

ii)      Fully equipped operation theatre of its own wherever surgical operations are carried out.

iii)     Fully qualified Nursing Staff under its employment round the clock.

iv)     Fully qualified Doctor(s) should be in-charge round the clock.

N.B: In class ‘C’ towns condition 2b (i) of number of beds be reduced to 10.

2.1.2  The term ‘Hospital/Nursing Home’ shall not include an establishment which is a place of rest, a place for the aged, a place for Drug-addicts or place of alcoholics a hotel or a similar place. 

2.2     ‘Surgical Operation’ means manual and / or operative procedures for correction of deformities and defects, repair of injuries, Diagnosis and cure of diseases, relief of suffering and prolongation of life.

2.3     Expenses on Hospitalization for minimum period of 24 hours are admissible. however, this time limit is not applied to specific treatments, i.e. Dialysis, chemotherapy , Radiotherapy; Eye Surgery, Dental Surgery, Lithotripsy ( kidney Stone removal ), D & C, Tonsillectomy taken in the Hospital / Nursing Home and the Insured is Discharged on the same day, the treatment will be considered to be taken under hospitalization Benefit. This condition will also not apply in case of stay in hospital of less than 24 hours provided.

a)      The treatment is such that it necessitates and the procedure involves specialized infrastructural facilities available in hospitals.

b)      Due to technological advances hospitalization is required for less than 24 hours only.

Note: Procedures/treatments usually done in outpatient department are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours

2.4     At the inception of the policy, if the insured declares the existence of diabetes, hypertension, Cholesterol, then the policy will not pay for the expenses incurred for the direct treatment of these illnesses. However, other complications not having a direct bearing to these illnesses but contracted during the policy period necessitating hospitalization, such expenses will be reimbursed provided they are not otherwise excluded as per policy conditions. An additional premium of 30% will be charged on the basic premium.


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