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1.3
This insurance scheme also provides for -
a. Family discount in premium (ref item 8)
b.Cumulative Bonus (refer item 11)
c.Cost of health check-up (refer item 12 )
( N.B. : Renewal of insurance without break is essential)
2. Definition
2.1 Insured person : Means
Person(s) named in the
schedule of the policy
2.2
Entire Contract : This Policy, Prospectus, proposal and Declaration given by the insured constitute the complete Contract of this policy .Any alteration with the mutual Consent of the insured and the insurer shall only be
evidenced by a duly signed and sealed endorsement on
the policy .
2.3 Period of Policy: This insurance policy is issued for a Period of one year as shown in the schedule.
2.4 Hospital/ Nursing Home , means any
institution in India
established for indoor care and treatment of sickness and injuries
and which either
(a)
(a) has been registered either as a hospital or Nursing Home
with the local authorities and is under the supervision of
the registered and qualified medical practitioner OR
(b)
(b) should comply with minimum criteria as under:
-
It should have at least 15 inpatient beds. In Class “C"
towns condition of number of beds may be reduced to 10
-
Fully equipped Operation theatre of its own whenever surgical operations are carried out.
-
Fully qualified nursing staff under its employment round the clock
-
Fully qualified doctors) should be in charge round
the clock
2.4.1 The term, "Hospital/
Nursing Home", shall not
include an establishment which is a place of rest, a place for the edge
, a place for drug addiction or place of alcoholics, a hotel
or a similar place.
2.5 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.
2.6 Expenses of Hospitalization for minimum period
of 24 hours are admissible . However this time limit is
not applied to specific treatments i.e. Dialysis , Parental
Chemotherapy, Radiotherapy, Eye surgery, Lithotripsy( Kidney stone rem-oval ), D& C , Tonsillectomy ,
Dental Surgery due
to acc- indent, Hysterectomy , Coronary Angioplasty , Coronary
Angiography, Surgery of Gall Bladder, Pancreas & Bile Duct,
surgery , Hernia Surgery of Hydrocele , Surgery Of Prostate ,
Gastrointestinal surgery , Genital Surgery Surgery of Nose , Surgery of throat , Surgery of appendix
Surgery of Urinary system , Arthroscopic knee Surgery, Laparoscopic
Therapeutic Surgeries , Any surgery under Anesthesia, Treatment
of fractures/Dislocation excluding Hairline fracture, Contracture
releases & minor reconstruct active procedures of limbs which
otherwise require hospitalization taken in the Hospital/Nursing
Home under the network of TAP and insured is discharged on
the same day . The treatment will be considered under Hospitalization
benefit.
Relaxation to 24 hours minimum duration for hospitalization
is also applicable:
(A)
If they are carried out in day care center networked by TPAs
where requirement of minimum number of beds
are overlooked but it must have (a) Fully equipped Operation
theatre (b) Fully qualified Day care staff (c)Fully qualified
surgeons/Post operative attending doctors.
(B) If it necessitates Hospitalization & involve
specialized infrastructural facilities available only in hospital
but due to technological advancement hospitalization is required for
less than 24 hours and/or the surgical procedure involved has to be
done under general general general anaesthesia.
Note Procedures/treatments Usually done in out Patient
department (OPD) are not payable under the policy even if converted
to Day Care Surgery Procedure or as inpatient in hospital for more
than 24hours.
3.0
3.0 Any one illness will be deemed to mean
continuous Period of illness and it includes relapse within 105
days from the date of discharge from the hospital /Nursing Home
where treatment may have been taken .Occurrence of same illness
after a lapse of 105 days as stated above will be considered as
fresh illness for the purpose of this policy.
3.1 Pre Hospitalization:Relevant Medical expenses
incurred during period up to 30 days prior to hospitalization /on
diseases/illness/injury sustained will be considered a part
of claim mentioned under item 1.0 above.
3.2. Post Hospitalization: Relevant medical expenses incurred up to
60 days after hospitalization/on disease/illness/injury sustain
will be considered as a part of claim mentioned under item 1.0
above.
3.3 Medical
Practitioner means a person who holds a degree/ diploma as
recognized institution and is registered by Medical Council or
respective state of India. The term Medical practitioner would
include physician, specialist and surgeon .
3.4 Qualified
nurse means a person who holds a certificate of A recognized
Nursing Council and who is employed on the Recommendation of the
attending medical practitioner.
3.5 Preexisting
Diseases means any ailment /disease /injury that the person is
suffering from (known/ not known , treated / untreated, declared or
not declared in the proposal ) whilst taking the policy. Any
complications arising from preexisting ailment/disease .
3.6
Third party administrators (TPA) means a third
party Administrators, who, for the time being ,is licensed by the
insurance regularity and Development Authority, and is engaged ,
for a fee or remuneration, by whatever name called as may be
specified in the agreement with the company, for the provision of
health services.
3.7
ID card means the card issued to the insured person by
the TPA to avail cashless facility in the network hospitals.
3.8 Network
Hospital Means hospitals that has agreed with the TPA to
participate for providing cashless health services to the insured
person. the list is maintained by and available with the TPA and the
same is subjected to amendment from time to time.
3.9 Cashless
facility means the TPA may authorize upon The insured's request for
direct settlement of admissible claim as per agree charges between
Network Hospitals & the TPA. In such cases the TPA will directly
settle all eligible amounts with the network hospitals and the end
of the treatment at hospital to the Extent the claim is covered
under the policy.
3.10
In-Patient : An insured person who is admitted to
Hospital and stays for at least 24 hours for the sole purpose of
receiving the treatment for suffered
ailment/illness/diseases/injury/accident during the currency of
policy.
3.11 Hospitalization
Period: The period for which insured person is admitted in the
hospital as inpatient and stays there for the purpose of receiving
the necessary and reasonable treatment for the
disease/ailment/contracted/injuries sustained during the period of
policy. the minimum period of stay shall be 24hours.
3.12 Reasonable
and customary expenses: means reasonable and customary
surgical/Medical treatment expenses with in the scope of cover of
this policy to treat the condition for which the insured person was
hospitalized.
3.13
Limit of Indemnity: means the amount stated in the schedule
against the name of each insured person which represent maximum
liability for any and all claims made during the policy period in
respect of that insured person with regard to hospitalization taking
place during currency of the policy.
4. Exclusions
The company shall not be liable to make any payment
under this policy in respect of any expenses whatsoever incurred by
any person in connection with or in respect of :
4.1 All
disease/injuries which are pre- existing when the cover inspect
for the first time. However, those diseases will be
covered after four continuous claim free policy years. For the
purpose of applying this condition ,the period of cover under
mediclaim policy taken from national insurance company only will be
considered.
This exclusion will also to
any complications arising from pre- existing ailment/disease
/injuries. Such Complications will be considered as a part of the
Pre-existing health condition or disease. To illustrate If a person
is suffering from hypertension or diabetes or both hypertension and
diabetes at the time of taking the policy, then policy shall be
subjected to following exclusions.
Diabetes
Hypertension
Diabetes&Hypertention
Diabetic Retinopathy
Coronary Artery disease Diabetic
retinopathy
Diabetic Nephropathy
Cerebro Vascular Accident Diabetic
Nephropathy
Diabetic Foot/wound
Hypertensive Nephropathy
Diabetic Foot/Wound
Diabetic Angiopathy
Internal Bleed/Haemorrhages Diabetic
Angiopathy
Diabetic Neuropathy
Diabetic Neuropathy
Hyper/Hypoglycaemic - shocks
Hyper/Hypoglycaemic - shocks
Coronary Artery Diease
Cerebro Vascular-Accident
Hypertensive- Nephropathy
Internal Bleed/Haemrhages
4.2
Any Disease other than those
stated in clause 4.3 Contracted by the insured person during the the
first thirty days from the commencement date of the policy.the
condition 4.2 shall not however apply in case of the insured
person having been covered under this Scheme or group insurance
scheme with our company for a continuous period of preceding 12
month without any break or is hospitalized due to accidental
injuries suffered after inception of the policy.
4.3 During the first one year of the operation of the policy the
Expenses on treatment of Benign ENT disorders & Surgeries like
Tonsillectomy/Adenoidectomy/Mastoidec-Tomy/Typanoplasty.
Treatment of diseases such as Cataract, Benign Prostatic
Hyperthropathy, Hysterectomy, Hernia , Hydrocele,Congenital Internal
Diseases, Fissures/ Fistula in anus, Piles, Sinusitis And related
disorders, Polycystic ovarian diseases, Non- Infective arthritis,
Undescended Testis, Surgery of gall bladder & bile duct excluding
Malignancy, Surgery of Genitor-Urinary System excluding malignancy,
Pilonidal Sinus, Gout & Rheumatism, Hypertension Diabetes, Calculus
diseases Surgery for prolapsed intervertebral disc unless arising
from accident, surgery of varicose veins are not payable for first
two years of the policy. Treatment for joint replacement due to
degenerative degenerative conditions, Age related osteoarthritis and
osteoporosis are not payable for first four years of operation of
the policy.
If these diseases are pre-existing at the time of proposal ,will
be covered only after four continuous claim free policy years.
Note :If continuity of cover is not maintained with national
insurance company limited sub sequent cover will be treated as fresh
for application of clauses 4.1, 4.2 & 4.3 above.
clauses 4.1, 4.2 & 4.3 above.
4.4 Injury or disease directly or indirectly caused by or
arising from or attributable to War invasion Act of Foreign Enemy
warlike operation ( whether war be declared or not ) and injury or
disease directly or indirectly caused by or contributed to by
nuclear weapons / materials.
4.5 Circumcision unless necessary for treatment or or disease
not excluded hereunder or as may be necessitated due to as accident
or as a part of any illness.
4.6 Surgery for correction of eye sight , cost of spectacles,
contact lenses, hearing aids etc.
4.7 Dental treatment or surgery corrective, cosmetic or aesthetic
procedure, filling of cavity, root canal, wear & tear unless arising
due to an accident and requiring hospitalization.
requiring hospitalization.
4.8 Convalescence general debility ‘Run Down’ condition or
rest cure, congenital external disease or defects or anomalies ,
sterility , infertility /sub fertility or assisted conception
procedures, venereal disease, intentional self-injury, suicide, all
psychiatric & psychosomatic disorders/ disease accident due to
misuse or abuse of drugs alcohol or use of intoxications substances.
4.9 All expenses arising out of any condition directly or
indirectly caused to or associated with human T-cell Lymphotrophic
Virus Type-iii (HTLB-iii) or Lymphadinopathy Associated Virus (LAV)
or the Mutants Derivative or variations deficiency syndrome or any
syndrome or condition or a similar kind commonly referred to as AIDS
, complications of AIDS and other sexually transmitted diseases
(STD).
4.10 Expenses incurred primarily for evaluation/ diagnostic
purposes not followed by active treatment during hospitalization.
4.11 Expenses on vitamins and tonics unless forming part of
treatment for injury or diseases as certified by the attending
physician.
4.12 Treatment arising from or traceable to
pregnancy/childbirth including caesarean section, miscarriage,
abortion or complications thereof including changes in chronic
condition arising out of pregnancy.
4.13 Naturopathy, unproven procedure/treatment
experimental or alterative medicine/treatment including acupuncture,
acupressure, magneto-therapy etc.
4.14 Expenses on irrelevant investigation/treatment; private
nursing charges, referral fee to family physician, outstation
Doctor/Surgeon/ consultants’ fees etc.
4.15 Genetical disorders/stem cell implantation/surgery
4.16 External/durable medical /non-medical equipment of any kind
used for diagnosis/treatment including CPAP,CAPD, infusion pump
etc., ambulatory devices like walker/crutches/belts
/splints/slings/braces/stockings/diabetic footwear /glucometer/thermometer
& similar related items & any medical equipment which could be used
at home subsequently.
4.17 Non-medical expenses including personal comfort/convenience
items/services such as telephone/television/aya/barber/beauty
services/doet charges/baby food/cosmetics/napkins/toiletries/guest
services etc.
4.18 Change of treatment from one pathy to unother unless being
agreed/allowed & recommended by the consultant under whom treatment
is taken.
4.19 Treatment of obesity or condition arising therefrom
(including morbid obesity) and any other weight control
program/services/supplies.
4.20 Arising from any hazardous activity including scuba diving,
motor racing, parachuting, hand gliding, rock or mountain climbing
etc. unless agreed by insurer.
4.21 Treatment received in convalescent home/hospital, health
hydro/nature care clinic & similar establishments.
4.22 Stay in hospital for domestic reason where no active regular
treatment is given by specialist.
4.23 Out-patient diagnostic/medical/surgical procedures/
treatments, non-prescribed drugs/medical supplies/ hormone
replacement therapy, sex change or any treatment related to this.
4.24 Massages/steambath / Surodhara & alike Ayurvedic treatment.
4.25 Any kind of service charges/surcharges, admission fees/
registration charges etc. levied by hospital.
4.26 Doctor’s home visit charges/attendant, nursing charges
during pre& post Hospitalization period.
4.27 Treatment which the insured was on before hospitalization
and required to be on after discharge for the ailment/
disease/injury different for the one for which hospitalization was
necessary.
5. ENTRY
AGE LIMIT
The insurance is available to persons between the age of 18
years and 59 years. However, the policy can be renewed up to an age
of 80 years. Children above the age of 3 months can be covered
provided parents are covered concurrently.
6.
SUM INSURED
Minimum Rs.50,000/- and maximum Rs.5,00,000 in multiples of
Rs.25,000.
7. PREACCEPTANCE MEDICAL CHECK UP:
No Medical Check up is required below 50 years of age. For
persons in the age of 50 years and above pre acceptance Medical
Check up is mandatory. However, if the insured was covered under any
health insurance Policy of national insurance company
uninterruptedly for preceding three years no Pre acceptance Medical
Check up is required. Other persons have to undergo Pre acceptance
medical check up at their own cost for Blood/ Urine Sugar, Blood
pressure, Echo cardiography and eye check up including retinoscopy.
Pre acceptance Medical Check up can be done
only in network Diagnostic Centers of the Company.
8. FAMILY DISCOUNT
8.1 A discount of 10% in the total premium will be allowed
comprosing the insured and any one or more of the following.
i) Spouse
ii) Dependent children (i.e. legitimate or legally
adopted children). Children above 18 years, if employed, can not be
covered up to age of 25 years. Female children, if not employed, can
be covered until the time she is married.
iii) Dependent parents
Midterm inclusion of member in the family cover can be
considered only for:
i) Newborn between 3
months to 6 months
ii) Newly married spouse
within 60 days of marriage
9. NOTICE
OF CLAIM
9.1 Preliminary notice of claim with particulars
relating to policy Numbers, name of insured person in respect of
whom claim is made nature of illness/injury and Name and Address of
the attending medical practitioner/Hospital/Nursing Home should be
given to the TPA/Insurance Company within seven days from the date
of Hospitalization / injury/ Death.
9.2 Final claim along with receipted Bills/ Cash memos
claim form and list of documents as listed in the claim form etc.
Should be submitted to the company within 30 days of discharge from
the hospital and where post hospitalization treatment is not
completed within 30 days, from the date of completion of
post-hospitalization treatment.
Note :Waiver of this condition may be considered in extreme
cases of hardship where it is proved to the satisfaction of the
company that under the circumstances in which the Insured was placed
it was not possible for him or any person to give such notice or
file claim within the prescribed time limit.
10. PAYMENT
OF CLAIM
All claims under this policy shall be payable in the Indian
currency All medical treatments for the purpose of this insurance
will have to be taken in India only.
11. CUMULATIVE BONUS
Sum insured under the policy shall be progressively increased
by 5% in respect of each claim free year of insurance under this
policy, subject to maximum accumulation of 10 claim free years of
insurance.
In case of a claim under the policy in respected of insured
person who has earned the cumulative the increased percentage will
be reduced by 10% of sum insured at the next renewal. However, basic
sum insured will be maintained and will not be reduced.
12. COST OF HEALTH CHECK UP
In addition to cumulative bonus, the insured shall be entitled
for reimbursement of cost of medical check up once at the end of
block of every four underwriting years with National Insurance
Company Limited provided there are no claim reported during the
block. The cost so reimbursable shall not exceed the amount equal to
1% of the average Sum insured Excluding Cumulative Bonus
during the block of four claims free underwriting years.
N.B.: For cumulative Bonus and Health check up provisions as
aforesaid:
i)
Both health check-up and Cumulative Bonus provisions are applicable
where period of insurance as stated in the scheduled attached here
to has commence not later than a week after expiry of the last
Mediclaim Insurance Policy, although renewal is allowed subject to
medical check-up.
ii) Cumulative bonus as accrued to the credit of
the same policy holder will be added to sum insured under this
policy.
iii) Health check-up benefit will be accrued
in case of policy holder where policy year has commenced.
13. This Insurance policy is issued for a period of one
year and subject to review. Continuation of Insurance cover will be
available if the renewal premium insured becomes eligible to
following benefits from first day after renewal:
a. Cumulative
bonus if accrued (Ref. item 11)
b. Cost
of health check-up if due (ref. item 12)
c.
Payment for hospitalization cost for diseases/illness/injury
sustained even during first 30 days of renewal (Ref. Deletion of 4.2
)
RENEWAL OF INSURANCE COVER:
A further period of 7 days from the date of expiry will be
permissible in exceptional cases subject to Health Certificate from
Medical practitioner.
N.B.: Any diseases contracted during the period of 7 days
extension will be excluded from the date of renewal in addition to
other diseases excluded in the expiring policy , whereas other
benefits mentioned above in item 13(a), (b), (c) will be
permissible.
14 PAYMENT OF PREMIUM:
As per table attached.
15. CANCELLATION CLAUSE:
The policy may be renewed by mutual consent. The company shall
not however be bound to give notice that it is due for renewal and
the Company may at any time cancel this Policy by Sending the
insured 30 days notice by registered letter at the insured last
known address and in such event the company shall refund to the
insured a pro-rata premium for unexpired period of insurance. The
company shall , however, remain liable for any claim which arose
prior to the date of cancellation. The insured may at any time
cancel this policy and in such event the company shall allow refund
of premium at company’s short period rate only (table given here
below) provided no claim has occurred up to the date of
cancellation.
PERIOD OF RISK RATE OF PREMIUM TO BE
CHARGED
Up to one month
1/4th of the annual rate
Up to three months
1/2th of the annual rate
Up to Six months
3/4th of the annual rate
Exceeding six months
Full annual rate
This prospectus shall form part of your proposal form, hence please
sign as you have noted the contents of this prospectus.
I/We declare that I/We have read the prospectus and have understood
the same. I accept the policy, subject to terms, exceptions and
conditions prescribed therein and further disclose that on the event
of finding anything contrary to what has been declared by me, I/We
shall be held responsible for all consequences thereof and insurance
company shall incure no liability under this insurance. |
