PRIMIUM CHART
Mediclaim Insurance
 

 1. SALIENT FEATURE OF THE POLICY:  

1.1 The policy covers reimbursement of hospitalization expenses For illness/diseases or injury  sustained. 

1.2 In the event of any claim becoming admissible under this Scheme, the company will pay to the insured  person the Amount of such expenses as would fall under different heads   Mentioned  below, and as are reasonable and necessarily Incurred thereof by on behalf of  such insured person, but  Not exceeding the a Sum insured in aggregate in any one period  Of insurance stated in the schedule hereto .

 

A.  Room, Boarding , Nursing  expenses as provided by the Hospital/Nursing Home

 

Room Rent Limit : 1% of sum insured per day subject to  Maximum of Rs.5000 .If  admitted in  IC Unit-2% of Sum  Insured per day  Subjected to maximum of  Rs. 10,000 .Overall limit under this head: 25% of Sum insured per illness.

 

B. Surgeon, Anesthetist Medical Practitioner, consultants Specials Fees. Maximum limit  per illness-25% of  sum insured.

 

C. Anesthesia, Blood, Oxygen, OT charges , Sergical Appliances, Medicines, drugs , Diagnostic aterial & X-Ray, Dialysis, Chemotherapy, Radiotherapy, cost of pacemaker ,artificial limbs And cost of stent and implant. Maximum limit per illness-50% Of Sum insured .

 

 

Note  :(a) Hospitalization expenses of  person donating an organ During  the course of  organ transplant will also be payable  Subject to the sub limits under C" above applicable to The insured person.

            (b) Ambulance charges up to 1%  of sum insured subject to maximum limit of Rs.1000/- in a policy year will be reimbursed provided registered ambulance is used. This benefit is available only for  shifting patient from residence to hospital  if admitted to ICU or Emergency Ward or from one hospital to another  subject  to the sub limit under C" above applicable to  the insured person.

           (c) Company's liability in respect of  all claims admitted during the period of insurance shall not exceed the Sum insured for the person as mentioned in the schedule .

 

                       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:

  1.  It should have at least  15 inpatient beds. In  Class C" towns condition of number of beds may be reduced to 10

  2.  Fully equipped Operation theatre of its own whenever  surgical operations are carried out.

  3. Fully qualified nursing staff under its employment round the clock

  4.  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.


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