Welcome, Guest    Sign in to Windows Live ID | Register  

  Industry Medical Portal |  Student Centre |  Sitemap |  Help 
FAQAbout Us |  Disclaimer & Legal |  Contact Us 
Healthy Living

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:

  1. Room, Boarding Expenses as provided by the hospital/nursing home.

  2. Nursing Expenses

  3. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees.

  4. 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

  1. 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

  2. Should comply with minimum criteria as under

    1. it should have at least 15 in patient beds.*

    2. fully equipped operation theatre of its own wherever surgical operations are carried out.

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

    4. 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).

  1. 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.

  2. "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.

  3. 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.

  4. 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

    1. The condition of the patient such that he/she cannot be removed to the Hospital/Nursing Home or

    2. The patient cannot be removed to Hospital/Nursing Home for lack of accommodation therein

      Subject, however that domiciliary hospitalisation benefits shall not cover:

      1. expenses incurred for pre and post hospital treatment .

      2. expenses incurred for treatment for any of the following diseases:

        1. Asthma

        2. Bronchitis

        3. Chronic Nephritis and Nephritic Syndrome

        4. Diarrhoea and all type of Dysentries including Gastrroenteritis

        5. Diabetes, Mellitus and Insipidus

        6. Epilepsy

        7. Hypertension

        8. Influenza, Cough and Cold

        9. All Psychiatric or Psychosomatic disorders

        10. Pyrexia of unknown origin for less than 10 days

        11. Tonsillitis and Upper Respiratory Tract Infection including Laryngitis and Pharangitis

        12. 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.

  1. 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.

  2. 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

  3. 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.

  4. 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

  1. 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.

  2. 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.

  3. 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.

  4. 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)

  5. 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.

  6. Cost of spectacles and contact lenses, hearing aids.

  7. Dental treatment or surgery of any kind, unless requiring hospitalisation.


  8. 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.

  9. 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.

  10. 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.

  11. Expenses on vitamins and tonics, unless forming part of treatment for injury or disease are certified by the attending Physician.

  12. Injury or Disease directly or indirectly caused by or contributed to by nuclear weapons/materials.

  13. 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.

  14. 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

  1. 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.

  2. 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.

  3. 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.

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. 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

  10. 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.

  11. 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.

  12. 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.

  1. 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.

    • 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.

    • 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:

  1. Spouse

  2. Dependent children (i.e. legitimate or legally adopted children)

  3. Dependent parents


|

Advertisement
Tell us what you think about Web Health Centre - Send us your feedback
Copyright © 2015 WebHealthCentre. All rights reserved. Brought to you by