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Mediclaim - Terms & Conditions
Salient feature of the policy
In the event of any claim/s 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 reasonably and necessarily incurred thereof by or on behalf of such Insured Person. But not exceeding the Sum Insured in aggregate mentioned in the schedule hereto:
Room, Boarding Expenses as provided by the hospital/nursing
home.
Nursing Expenses
Surgeon, Anesthetist, Medical Practitioner,
Consultants, Specialists Fees.
Anesthesia, Blood, Oxygen, Operation Theatre
Charges, Surgical Appliances, Medicines and Drugs, Diagnostic Materials
and x-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pace Maker, Artificial
Limbs and Cost of Organs and similar expenses.
Note:Company liability in respect of all claims admitted during the period of insurance shall
not exceed the Sum Insured per person mentioned in the Schedule.
Definitions
"Hospital/Nursing Home" means any institution in India established for indoor care and treatment of sickness and injuries and which
Either
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Has been registered either as a hospital or nursing home with the local authorities and is under
the supervision of a registered and qualified medical practitioner.
or
Should comply with minimum criteria as under
it should have at least 15 in patient beds.* fully equipped operation theatre of its own wherever surgical operations are carried out. fully qualified nursing staff under its employment round the clock. fully qualified Doctor(s) should be in charge round the clock.
(N.B.* In Class 'c' towns condition of number of beds be reduced to 10).
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The terms "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 for alcoholics, a hotel or a similar
place.
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"Surgical Operations" means manual and/or operative
procedures for correction of deformities and defects, repairs or injuries,
diagnosis and cure of diseases, relief of suffering and prolongation of
life.
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Expenses on Hospitalisation for minimum period
of 24 hours are admissible however this time limit will not apply for
specific treatments i.e. Dialysis, Chemotheraphy, Radiotherapy, Eye Surgery,
Dental Surgery, Lithotripsy (kidney stone removal), Tonsillectomy, D &
C taken in the Hospital/Nursing Home and the insured is discharged on
the same day, the treatment will be considered to be taken under Hospitalisation
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 hospitalisation and the procedure involves
specialised
infrastructural facilities available in hospitals.
(b) Due to technological advances hospitalisation
is required for less than 24 hours only.
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Domiciliary Hospitalisation Benefit means:
Medical treatment for a period exceeding three days for such illness/disease/injury
which in the normal course would require care and treatment at a Hospital/Nursing
Home but actually taken whilst confined at home in India under any of
the following circumstances namely
The condition of the patient such that he/she
cannot be removed to the Hospital/Nursing Home or
The patient cannot be removed to Hospital/Nursing
Home for lack of accommodation therein
Subject, however that domiciliary hospitalisation benefits shall not
cover:
expenses incurred for pre and post hospital treatment . expenses incurred for treatment for any of the following diseases:
Asthma Bronchitis Chronic Nephritis and Nephritic Syndrome Diarrhoea and all type of Dysentries including Gastrroenteritis Diabetes, Mellitus and Insipidus Epilepsy Hypertension Influenza, Cough and Cold All Psychiatric or Psychosomatic disorders Pyrexia of unknown origin for less than 10 days Tonsillitis and Upper Respiratory Tract Infection including Laryngitis and Pharangitis Arthritis, Gout and Rheumatism
Note:
When treatment such as Dialysis, Chemotherapy, Radiotherapy etc. is
taken in the Hospital/Nursing Home and the Insured is discharged on
the same day, the treatment will be considered to be taken under Hospitalisation
Benefit section. Liability of the Company under this clause is restricted
as stated in the Schedule attached hereto.
Any one illness
Any one illness will be deemed to mean continuous period of illness and it includes relapse within 105 days from the date of last consultation with the Hospital/Nursing Home where treatment has been taken. Occurrence of the same illness after a lapse of 105 days as stated above will be considered as fresh illness for the purpose of this policy.
Pre Hospitalisation :
Relevant medical expenses incurred during period up to 30 days prior to
hospitalisation on disease/illness/injury sustained will be considered as
part of claim as mentioned under item 1.0 above.
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Post Hospitalisation :
Relevant medical expenses incurred during period upto 60 days prior to
hospitalisation on disease/illness/injury sustained will be considered
as part of claim as mentioned under item 1.0 above
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Medical Practitioner:
means a person who holds a degree/diploma of a recognised institution
and is registered by Medical Council of respective State of India. The
term Medical Practitioner would include Physician, Specialist and Surgeon.
Qualified Nurse :
means a person who holds a certificate from a recognised Nursing Council
and who is employed on recommendations of the attending Medical Practitioner.
Exclusions
The Company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by my Insured Person in connection with or in respect of
All diseases/injuries, which are pre-existing
when the cover incepts for the first time. For the
purpose of applying this condition,the date of inception of the initial
mediclaim policy taken from
any of the Indian Insurance Companies shall be taken, provided the renewals
have been continuous
and withour any break.
Any disease other than those stated in clause
4.3 contracted by the insured person during the first 30 days from the commencement
date of the policy. This exclusion shall not, however, apply if in the opinion
of panel of Medical Practitioners constituted by the Company for the purpose,
the Insured Person, could not have known the existence of the Disease or
any symptoms of complaints thereof at the time of making the proposal for
insurance to the Company. This condition4.2. shall not, however, apply incase
of the insured person having been covered under this scheme or group insurance
scheme with any of the Indian Insurance Companies for a continuous period
of preceding 12 months without any break.
(Note: These excludsions 4.1 and 4.2 shall not however apply if.)
a. In the opinion of a Panel of Medical Practitioners constituted by the
Company for the purpose,;the Insured Person could not have known of the existence
of the disease or any symptoms or complaints there of at the time of making the proposal
for insurance to the Company.
b. The insured had not taken any consultation,treatment or medication, in
respect of the hospitalisation for which claim has beenlodged under
the policy prior to taking the insurance.
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During the first year of the operation of insurance
cover the expenses on treatment of diseases such as Cataract, Benign Prostatic
Hypertrophy, Hysterrectomy for Menorrhea or Fibromyoma, Hernia, Hydrocele,
Congenital Internal diseases Fistula in anus, Piles, Sinusitis and the
related disorders are not payable, If these diseases (other than congential
internal disease) are pre-existing at the time of proposal, they will
not be covered even during subsequent period of renewal too. If
the insured
is aware of the existence of congentital internal discase before inception
of policy, the same
will be treated as pre-existing.
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Injury or Disease directly or indirectly caused
by or arising from or attributable to War, Invasion, Act of Foreign Enemy,
War like operations (whether war be declared or not)
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Circumcision unless necessary for treatment
of a disease not excluded hereunder or as may be necessitated due to an
accident, vaccination, innoculation or change of sex of cosmetic or aesthetic
treatment of any description. Plastic surgery other than as may be necessitated
due to an accident or as a part of any illness.
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Cost of spectacles and contact lenses, hearing
aids.
Dental treatment or surgery of any kind, unless
requiring hospitalisation.
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Convalescence, general debility 'Run-down'
condition or Rest cure, congenital external disease or defects or anomalies,
sterility, veneral disease, intentional self-injury and use of intoxicating
drugs/alcohol.
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All expenses arising out of any condition
directly or indirectly caused to or associated with Human T-Cell Lymphotropic
Virus Type III (HTLB) or Lymphadenopathy Associated Virus (LAV) or the
Mutants Derivative orVariations Deficiency Syndrome or any syndrome or
condition of a similar kind commonly referred to as AIDS.
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Charges incurred at Hospital or Nursing
Home primarily for diagnostic, x-ray or laboratory examinations not consistent
with or incidental to the diagnosis and treatment of the positive existence
of presence of any ailment, sickness or injury, for which confinement
is required at a Hospital/Nursing Home.
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Expenses on vitamins and tonics, unless
forming part of treatment for injury or disease are certified by the attending
Physician.
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Injury or Disease directly or indirectly
caused by or contributed to by nuclear weapons/materials.
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Treatment arising from or traceable to
pregnancy, childbirth including caesarian section.Voluntary medical termination
of pregnancy during first 12 weeks from the date of conception.
- Naturopathy treatment.
Conditions
The Company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by my Insured Person in connection with or in respect of
Every notice or communication to be given or
made under this policy shall be delivered in writing at the address of the
Policy issuing office as shown in the Schedule.
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The premium payable under this Policy shall
be paid in advance. No receipt for Premium shall be valid except on the
official form of the company signed by a duly authorised official of the
company. The due payment of premium and the observance and fulfillment
of the terms, provisions, conditions and endorsements of this Policy by
the Insured Person in so far as they relate to anything to be done or
completed with by the Insured Person shall be a condition precedent to
any liability of the Company to make any payment under this Policy. No
waiver of any terms, provisions, conditions and endorsements of this policy
shall be valid unless made in writing and signed by an authorised official
of the Company.
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Upon the happening of any event which may give
rise to a claim under this Policy, notice with full particulars shall
be sent to the Company within 7days from the date of Death, Injury, Hospitalisation/Domiciliary
Hospitalisation.
All suportting documents relating to the Claim
must be filed within 30 days from date of discharge from the Hospital. 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 other
person to give such notice or file claim within the prescribed time limit.
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The Insured Person shall obtain and furnish
to the Company with all original bills, receipts and other documents upon
which, a claim is based and shall also give the Company such additional
information and assistance as the Company may require in dealing with
the claim.
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Any medical practitioner authorised by the
Company shall be allowed to examine the Insured Person in case of any
alleged injury or disease requiring Hospitalisatin when and so often as
the same may reasonably be required on behalf of the Company.
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The Company shall not be liable to make any
payment under this policy in respect of any claim, if such claim be in
any manner, fraudulent or supported by any fraudulent means or device
whether by the insured person or by any other person acting on his behalf.
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If at the time when any claim arises under
this Policy, there is in existence any other insurance (other than Cancer
Insurance Policy in collaboration with Indian Cancer Society), whether
it be effected by or on behalf of any insured person in respect of whom
the claim may have arisen covering the same loss, liability, compensation,
costs or expenses, the Company shall not be liable to pay or contribute
more than its rateable proportion of any loss, liability, compensation,
costs or expenses. The benefits under this Policy shall be in excess of
the benefits available under Cancer Insurance Policy.
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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's 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 |
| Upto one month |
1/4 of the annual rate |
| Upto three months |
1/2 of the annual rate |
| Upto six months |
3/4 of the annual rate |
| Exceeding six months |
Full annual rate |
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If any dispute or difference shall arise as
to the quantum to be paid under this Policy (liability being otherwise
admitted) such difference shall be referred to the decision of a sole
arbitrator to be appointed in writing by the parties or if they cannot
agree upon a single arbitrator within 30 days of any any party invoking
arbitration, the same shall be referred to a panel of three arbitrators.
Comprising of two arbitrators, one to be appointed by each of the parties
to the dispute/difference and the third arbitrator to be appointed by
such two arbitrators and arbitration shall be conducted under and in accordance
with the provisions of the Arbitration and Conciliation Oct,1996.arbitration
in accordance with the provisions of the Indian Arbitration Act, 1940
as amended from time to time and for the time being in force.
It is clearly agreed and understood that no difference or dispute shall
be referable to arbitration as herein before provided if the Company had
disputed or not accepted liability under or in respect of this Policy.
It is hereby expresly stipultated and declared that it shall be a condition
precedent to any right of action or suit upon this ppolicy that award
by such arbitrator/arbitrators of the amount of the loss
or damage shall be first obtained.
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If the Company shall disclaim liability to
the insured for any claim hereunder and if the insured shall not within
12 calendar months from the date of receipt of the notice of such disclaimer
notify the Company in writing that he does not accept such disclaimer
and intends to recover his claim from the Company, then the claim shall
for all purposes be deemed to have been abandoned and shall not thereafter
be recoverable hereunder.
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All medical/surgical treatments under this
policy shall have to be taken in India and admissible claims thereof shall
be payable in Indian currency.
Payment of claim
All claims under this policy shall be payable in Indian currency. All medical treatments for the purpose of this insurance will have to be taken in India only.
Cumulative bonus
Sum Insured under the Policy shall be progressively increased by 5% in respect of each claim free year of insurance, subject to maximum accumulation of 10 claim free years of insurance.
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In case of a claim under the policy in respect of Insured person, who has earned the cumulative bonus, 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.
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For existing policy holders(as date of implementation) the accrued amount of benefit of cumulative bonus, the bonus will be added to the Sum Insured, subject to the maximum 10 claim free years.
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Cumulative bonus will be lost if policy is not renewed on the date of expiry.
Waiver: In exceptional circumstances the seven days exception in period of renewal is permissible to be entitled for Cumulative bonus although the policy is renewed only subject to Medical Examination and exclusion of diseases.
Cost of health checkup
In addition to Cumulative Bonus, the insured shall be entitled for reimbursement of the cost of medical check-up once at the end of block of every four underwriting years, provided there are no claims reported during the block. The cost so reimbursable shall not exceed the amount equal to 1% of the amount of average sum insured during the block of four underwriting years.
IMPORTANT :
For Cumulative Bonus and Health Check-up Provisions as 1provisions as aforesaid.
Both Health Check-up and Cumulative Bonus provisions are applicable only in respect of continuous insurance without break excepting however, where in exceptional circumstances the break for a maximum of seven days is approved as a special case subject to medical examination and exclusion of disease during the break period. Health check-up benefit will be accrued after completion of four years continuous claim free insurance.
Age limit
This insurance is available to persons between the age of 5 years and 80 years. Children between the age of 3 months and 5 years of age can be covered provided one or both parents are covered concurrently.
Family discount
A discount of 10%in the total premium will be allowed comprising the insured and any one or more of the following:
Spouse
Dependent children (i.e. legitimate or legally adopted children)
Dependent parents
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