INSURER:‐UNITED INDIA INSURANCE COMPANY LIMITED. POLICY PERIOD: 26TH MARCH 20 11 to 25TH MARCH 20 12. Group Mediclaim Policy Premium payable by the associate Policy
Type
Members
Covered
Plan A
(Hospitalis
ation only)
Self+
Spouse+2
children
Self+Spous
e+2
children+
Parents
Self+
Spouse+2
children
Self+Spous
e+2
children+
Parents
Plan B
(Hospitalis
ation only)
Plan C
(Hospitalis
ation+OP)
Plan D
(Hospitalis
ation+OP)
Plan F
(Parents
Hospitalisat
ion only)
One set of
Parents
Only
Premium
payable
by
associate
s towards
Upto Grade G3
Grade G4 & above
Sum
Insured
Hospitalis
ation
Sum
Insured
OPD
Annual
Premium
payable by
the
associate
Sum
Insured
Hospitalis
ation
Sum
Insured
OPD
Annual
Premium
payable by the
associate
2 Lakhs
0
0
4 Lakhs
0
0
Parent
Cover
3 Lakhs
0
9,834
6 Lakhs
0
19,669
OPD
cover
2 Lakhs
10,000
9,588
4 Lakhs
20,000
19,176
Parent
cover +
OPD
cover
3 Lakhs
15,000
24,084
6 Lakhs
30,000
48,169
Parent
Cover
1 Lakh
0
2,681
2 Lakhs
0
5,363
HEALTH CARE EXPENSES
OPD
Hospitalization
Maternity
Domiciliary Hospitalization
OPD EXPENSES
Expenses Type
General OPD
Optical
Dental
Exclusions under OPD benefit
Covered in Plan C & D
Covered in all Plan
Covered in plan A,B,C &D
Not Covered.
Conditions
No Sublimit / capping
Actual or Rs 1100/‐per person per family per policy period or whichever is less.
Actual or Rs 1500/‐per person per family per policy period or whichever is less
1. Any expenses disallowed under hospitalization section due to any limitation or exclusion. 2. Maternity related expenses 3. Cost of spectacles, contact lenses, hearing aids. 4. Any expenses incurred for vaccination or inoculation, cosmetic or aesthetic of any treatment description.
The following conditions apply to payment under OPD benefit: 1. Each claim shall be supported by prescription of the attending Doctor’s Certificate, Bill/Receipt 2. Each cash memo shall be supported by prescription of the attending medical practitioner and investigation reports wherever applicable 3. No employee is permissible to opt under this section during the currency of the policy. 4‐ Claim amount will be disallowed if found any discrepancy in the medical bill like over writing or different name on the bill other than the patient.
CALCULATION MATRIX
Expenses Type
A. Room, Boarding and Nursing expenses as provided by the Hospital/Nursing Home not exceeding 1% of the sum insured per day or the actual a m o u n t whichever is less. This also includes nursing care, RMO charges, IV Fluids/Blood transfusion/injection administration charges and similar expenses.
Conditions
Actual or 1% of Sum Insured per day whichever is less.
B. In case of ICU a n d I C C U expenses not exceeding 2% of the sum insured per day or actual amount whichever is less.
Actual or 2% of Sum Insured per day whichever is less.
C. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees
No sublimit / Capping
D. Anesthesia, Blood, Oxygen, Operation
Theatre Charges, surgical appliances, Medicines
& Drugs, Diagnostic Materials and X‐ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Artificial Limbs, cost of prosthetic devices implanted during surgical procedure like pacemaker, orthopedic implants, infra cardiac valve replacements, vascular stents.
No sublimit / Capping
E. Hospitalization expenses (excluding c o s t o f organ) incurred for donor in respect of organ transplant to the insured.
No sublimit / Capping
ND. The amount payable under C & D above shall be at the rate applicable to the entitled room category. In case Insured opts for a room with rent higher than the entitled category as in A above, the charges payable under C & D shall be limited to the charges applicable to the entitled r oo m category only. Expenses Type
Pre Hospitalization Limit
Post Hospitalization Limit
Any one illness
Expenses Type
Total Maternity Limit
Normal Delivery Limit
Delivery by LSCS
PRE & POST HOSPITALIZATION EXPENSES
Conditions
30days
60days
45days
MATERNITY EXPENSES
Conditions
Actual or Rs 50,000/‐whichever is less
Actual or Rs 40000/‐whichever is less.
Actual or Rs 50000/‐whichever is less.
CONDITIONS RELATED WITH MATERNITY BENEFIT
These benefits are admissible only if the expenses are incurred in hospital/nursing home as in‐patient in India.
Expenses incurred in connection with voluntary medical termination of pregnancy during the first twelve weeks from the date of conception are not covered.
Pre‐natal and post‐natal expenses are not covered unless admitted in Hospital/nursing home and treatment is taken there under IPD.
Pre Hospitalization and post Hospitalization benefits are not available under this section of maternity.
Maternity expenses are covered up to 2 living children. Maternity limit will be same as mentioned above even in case of husband and wife both are the employee of same company and covered in the same policy separately. DAY ONE NEW BORN BABY COVERAGE.
SCOPE OF HOSPITALISATION COVER
.Age of the child
Within Maternity Sublimit
Within Family Floater Limit
Up to 90 days
Expenses for treatment along with mother in the same Hospital / Nursing home where he /she was born.
Expenses for treatment in the same hospital or separate Hospital / Nursing home from day on or after a discharge from the Hospital where he /she was born.
More than 90 days
Nil
Covered on the payment of an additional premium on pro‐rata basis for the remaining period of the policy.
New feature negotiated with the Insurance Co.:- For new
born baby,if there is no abnormality & child has developed common
ailment like neonatal Jaundice, cough,cold,viral fever etc with Dr.
consultation the same will be considered in normal applicable
maternity limit only.
If child is hospitalized separately within same hospital or any other
hospital for any abnormality / where hospitalization is required then
it would be included in normal family floater coverage, in case of
critical illness where the baby needs to be treated separately.
DISEASE WISE SUBLIMIT
Name Of Disease
EMP HAVING SUM INSURED 3 LAC
AND BELOW.
Cataract
Hernia
Hysterectomy
Cardiac Surgery
Brain Tumor Surgery
Pacemaker Implantation for Sick Sinus Syndrome
Kidney transplantation and renal Surgeries and surgeries of like same nature. Cancer Surgery
Hip Replacement
Knee Replacement
Actual or 10% of sum insured or Rs 25000/‐ Which ever is less
Actual or 15% of sum insured or Rs 35000/‐ Which ever is less
Actual or 20% of sum insured or Rs 50000/‐ Which ever is less
Actual or 70% of sum insured or Rs 2,00,000/‐ Which ever is less
Actual or 70% of sum insured or Rs 2,00,000/‐ Which ever is less
Actual or 70% of sum insured or Rs 2,00,000/‐ Which ever is less
Actual or 70% of sum insured or Rs 2,00,000/‐ Which ever is less Actual or 70% of sum insured or Rs 2,00,000/‐ Which ever is less
Actual or 70% of sum insured or Rs 2,00,000/‐ Which ever is less
Actual or 70% of sum insured or Rs 2,00,000/‐ Which ever is less
EMP HAVING SUM INSURED 4 LACS AND 6 LACS.
Actual or 10% of sum insured or Rs
25000/‐ Which ever is less
Actual or 15% of sum insured or Rs
35000/‐ Which ever is less
Actual or 20% of sum insured or Rs
50000/‐ Which ever is less
Actual or 75% of sum insured or Rs
2,50,000/‐ Which ever is les
Actual or 75% of sum insured or Rs
2,50,000/‐ Which ever is less
Actual or 75% of sum insured or Rs
2,50,000/‐ Which ever is less
Actual or 75% of sum insured or Rs
2,50,000/‐ Which ever is less Actual or 75% of sum insured or Rs 2,50,000/‐ Which ever is less
Actual or 75% of sum insured or Rs 2,50,000/‐ Which ever is less
Actual or 75% of sum insured or Rs 2,50,000/‐ Which ever is less
Note- Claims for the above mentioned diseases where there is a sublimit in the policy including maternity and major
surgeries can not be extended in any condition like two person from the same family or husband & wife both are working in
the same company and having separate cover in the same policy.
CO‐PAYMENT
1
OPD Expenses
2
Hospitalization Expenses
3
Maternity
4
Pre Hospitalization Expenses
5
Post Hospitalization Expenses
Not applicable.
10% of admissible amount
10% of admissible amount
10% of admissible amount
10% of admissible amount
Note: This co‐payment of 10% will not be applicable whenever the claim falls under the disease wise sublimit of specified major surgeries described under the policy if such claim relates to self, spouse or children enrolled. Hospitalization / maternity expenses are admissible subject to stay is hospital for more than 24hrs. LIST OF PROCEDURES IN WHICH HOSPITALIZATION FOR MORE THAN 24HRS NOT REQUIRED.
1
Appendectomy
2
Coronary angiographies
3
Coronary angioplasty
4
Dental surgery
5
D&C
6
Eye surgery
7
Fracture/ dislocation excluding hairline fracture
8
Radiotherapy
9
Lithotripsy
10
Incision and drainage of abscess
11
Colonoscopy
12
Haemodialysis
13
Hydrocoele
14
Hysterectomy
15
Inguinal/ventral/ umbilical/femoral hernia
16
Parenteral chemotherapy.
17
Piles/ fistula
18
Prostrate Surgery
19
Surgery of Sinus
20
Tonsillectomy
21
Liver aspiration
22
Sclerotherapy
23
Any other surgeries / procedures agreed by the TPA/ Company which require less than 24 hours hospitalisation and for which prior approval from TPA is mandatory.
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 STANDARD EXCLUSIONS 1
Injury / disease directly or indirectly caused by or arising from or attributable to invasion, Act of Foreign enemy, War like operations (whether war be declared or not)
2
4.5 a . Circumcision unless necessary for treatment of a disease not excluded here under or as may be necessitated due to an accident. b. vaccination or inoculation or change of life or cosmetic or aesthetic treatment of any description such as correction of eye sight, etc c. plastic surgery other than as may be necessitated due to an accident or as a part of any illness.
3
Cost of spectacles and contact lenses, hearing aids.
4
Dental treatment or surgery of any kind unless necessitated by accident and requiring hospitalization for surgery.
5
Convalescence, general debility, obesity, run‐down condition or rest cure, Congenital external disease or defects or anomalies, Sterility, Venereal disease, intentional self injury and use of intoxication drugs / alcohol. The treatment for genetic disorder like (Thalasaemia),, psychiatric disorder, obesity are excluded from the policy. 6
All expenses arising out of any condition directly or indirectly caused to or associated with Human T‐Cell Lymphotropic Virus Type III (HTLB ‐ III) or lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or Variation Deficiency Syndrome or any syndrome or condition of a similar kind commonly referred to as AIDS.
7
Charges incurred at Hospital or Nursing Home primarily for diagnosis x‐ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital / Nursing Home
8
Expenses on vitamins and tonics unless forming part of treatment for injury or diseases as Certified by the attending physician.
9
Injury or Disease directly or indirectly caused by or contributed to by nuclear weapon / Materials.
10
Deleted as maternity expenses are covered with deletion of nine month waiting period.
11
Naturopathy Treatment, acupressure, acupuncture, experimental and unproven treatments/therapies.
12
External and or durable Medical / Non‐medical equipment of any kind used for diagnosis and or treatment including CPAP, CAPD, and Infusion pump etc. Ambulatory devices i.e., walker, crutches, Belts, Collars, Caps, Splints, Slings, Braces, Stockings, elastocrepe bandages, external orthopedic pads, sub coetaneous insulin pump, Diabetic foot wear, Glucometer / Thermometer, alpha / water bed and similar related items etc., and also any medical equipment, which is subsequently used at home etc.
13
Any kind of Service charges, Surcharges, Admission Fees/Registration Charges levied by the hospital.
NOTICE OF CLAIM & CLAIM DOCUMENTS SUBMISSION
1
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 TPA named in the schedule immediately and in
case of emergency Hospitalization within 24 hours from the time of Hospitalization.
2
All supporting documents relating to the claim must be filed with TPA within 7 days from the date of discharge from the hospital. In case of post‐hospitalization, treatment (limited to 60 days), all claim documents should be submitted within 7 days after completion of such treatment.
IMPORTANT DEFINITIONS:‐ 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 a 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 beds. ii) Fully equipped operation theatres 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 b (i) in respect of number of beds be reduced to 10. NETWORK HOSPITAL: means hospital that has agreed with the TPA to participate for providing cashless health services to the insured persons. The list is maintained by and available with the TPA and the same is subject to amendment from time to time. MEDICAL PRACTITIONER: means a person who holds a degree/diploma of a recognised institution and is registered by Medical Council of any State of India. The term Medical Practitioner would include Physician, Specialist and Surgeon. CASHLESS FACILITY: means the TPA may authorize upon the Insureds’ request for direct settlement of admissible claim as per agreed charges between Net work Hospitals & the TPA. In such cases the TPA will directly settle all eligible amounts with the Net work Hospitals and the Insured Person may not have to pay any bills after the end of the treatment at Hospital to the extent the claim is covered under the policy. I .D. CARD: means the card issued to the Insured Person by the TPA to avail Cashless facility in the Network Hospital. LIMIT OF INDEMNITY: means the amount stated in the schedule against the name of each insured person which represents maximum liability for any and all claims made during the policy period in respect of that insured person for hospitalization taking place during the currency of the policy