1. Salient Feature

Hospitalisation for illness, disease or accident, whether including surgery or not, imposes heavy financial burden on individuals, families, employers and welfare bodies.

2. Scope Of Cover

Mediclaim insurance policy has been devised under the aegis of the Government of India.The policy provides the following benefits.

1) Reimbursement of hospitalisation expenses which are reasonably and necessarily incurred,under the following heads:

a) Room, boarding expenses as provided by the hospital/nursing home.
b) Nursing expenses.
c) Fees of surgeon, anaesthetist, medical practitioner, consultant and specialist.
d) Expenses on account of anaesthesia, blood, oxygen, operation theatre charges, surgical appliances, medicines and drugs, diagnostic material, X-ray, dialysis, chemotherapy,radiotherapy, cost of pacemaker, artificial limbs and cost of organs and similar expenses.

2) Introduction of Sub-Limits:

The following provisions have been introduced:

a. Room, Board and Nursing Expenses as provided by the Hospital /Nursing Home- Room Rent limit  : 1 % of the Sum Insured per day  subject to maximum of Rs.5000./-. I.C. Unit expenses :  2 % of  Sum Insured per day subject to maximum  of  Rs. 10,000/-. Over all limits under this head  : 25% of S.I. per illness.

b.Surgeon, Anesthetist, Medical Practitioner,Consultants Special fees – maximum limits per illness – 25% of S.I.

c.Anesthesia, Blood, Oxygen, OT charges, Surgical appliance, Medicines, drugs, Diagnostic Material & X-Ray, Dialysis, Chemotherapy, Radiotherapy, cost of pacemaker, artificial limbs and cost of stent and implant.  Maximum limit per illness – 50% of Sum Insured.

d. Ambulance services – 1% of the sum insured subject to maximum of Rs 1000/- provided  registered ambulance is used for shifting patient from residence to hospital if admitted to ICU or emergency ward  OR  from one hospital to another subject to sub-limits under ‘c’ above.

e.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.

3) Premium paid for the policy towards self, spouse, dependent children and dependent parents are exempt from Income Tax under Sec. 80D of the l.T. Act.

4) Cost of Health Check Up and Cumulative Bonus – Benefits will accrue only if the Policy is a renewal of ‘National’.

3. Additional Features

1)Definition of Family:

a)Self (Primary Insured).
b)Spouse.
c)Dependent Children (i.e. legitimate or legally adopted children).  Children above 18 years, if employed, can not be covered. Male children, if not employed, but a bonafide student can be covered upto age of 25 years. Female children, if not employed, can be covered until the time she is married.

d)Dependent parents.

All members of the family must be covered under one policy.

2) Entry Age:

This insurance is available to a person between the age of 18 to 59 years.  However, the Policy can be renewed upto the age of 80 years as stipulated in the premium chart above.

a) Children above the age of 3 months can be covered provided parents are covered concurrently and suitable premium is paid. If the child above 18 years is employed or if the girl child is married, he or she shall cease to be covered under the policy. However male child can be covered upto the age of 25 years if he is a bonafide regular student and fully dependent on primary insured. Female child can be covered upto  the time, she is unmarried.

b) If the insured has taken continuous Mediclaim insurance policy with us for at least 5 years prior to attaining the  age of 80 years the policy can be renewed beyond the age of 80 upto the age of 90 years as a special case with the approval of Regional Incharge on case to case basis. The premium chargeable shall be 10% of the premium for 75-80 years age slabs for proposers above 85 and 20% of the premium for 75-80 age slabs for proposers above 90.

c) No inclusion of family member during currency of policy is permissible except for a new born child between the age of 3 months to 6 months and newly married spouse within 60 days of marriage.  Otherwise inclusion of family member shall be allowed only at the time of renewal. Prorata premium shall be charged for such inclusion during the currency of the policy for the unexpired period.

3) Sum Insured:

Minimum sum insured shall be Rs 50,000/- and can be increased in multiples of Rs 25,000/-upto Rs 5 lacs.  The sum insured must be identical for primary insured and the dependents.However, the children may be covered for 50% Sum Insured as per item no. 2 above.

4)TPA option:

The premium includes cashless facility through TPA. If the policyholder does not require cashless facility then 6% discount on premium may be given.

5)Pre -Acceptance Health Checkup:

Pre acceptance health check-up is mandatory when age is 50  years and above and he/she is seeking insurance cover for the first time as an individual or as member of a family where there is break in Insurance increase in sum insured on renewal.

Proposer/Insured Person will be required to undergo the following Medical Check-up or any other medical test as required by the Company either on his/her own or from its authorized
Network Diagnostic Centre in prescribed format. The cost shall be borne by the insured.

Age (in years) 50 and above

Medical Test
Physical Examination
Blood
Urine Sugar
Blood Pressure
Echo Cardiography
Eye Check Up Including Retinoscopy

If the insured was covered under any Health Insurance Policy of ‘National’ uninterruptedly for preceding 3 years, no pre-acceptance Medical check up is required.

4. Exclusions

The most important exclusion relates to pre-existing illness. If the insuring person had a health condition, existing prior to taking the policy, which required medical treatment, the same gets automatically excluded in the policy. To ensure that in subsequent renewals medical conditions incepting since the policy was taken do not get excluded, the insuring person must renew the policy without break. The other exclusions for illustrative purposes are :-

a) Exclusion of certain named diseases in the first year of the policy.

b) Congenital external disease, sterility, venereal disease, intentional self-injury, use of drugs,alcohol, rest cure etc.

c)  AIDS

d)  Charges primarily for diagnostic, laboratory examinations, and not related to any treatment in hospital. So also for vitamins and tonics unless prescribed for treatment.

e)  Dental treatment not requiring hospitaiisation.

f)  Treatment arising from or traceable to pregnancy, childbirth, including caesarean.

g)  Naturopathy treatment.

EXCLUSION 4.a, 4.b & 4.c have been amended. Pre-existing diseases shall be covered after 4 continuous claims free Policy years with ‘National’.  However, in case of exclusion 4.3, for renewals,existing condition shall apply, i.e. the one year exclusion applicable earlier shall be valid.