The policy covers reimbursement of Hospitalization/Domiciliary Hospitalization expenses for illness/diseases of injury sustained. In the event of any claim becoming dismissible under this scheme, the company will pay to the insured person the amount of such expenses would fall under different heads mentioned below, and as are reasonable and necessarily incurred thereof by or on behalf of such insured person, but not exceeding the sum insured in aggregate in any one period of insurance stated 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 & Drugs, Diagnostic Materials and X–ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial Limbs & Cost Organs and similar expenses.
This insurance scheme also provides for:
- Family discount in premium (refer item 6)
- Cumulative Bonus (refer item 9)
- Cost of Health Check up (refer item 10) (N.B. Renewal of insurance without break is essential)
- Has been registered either as Hospital or Nursing Home with the local authorities and is under the supervision of a registered and qualified Medical Practitioner. OR
- It should have at least 15 in–patient beds*
- Fully equipped operation theatre of its own wherever surgical operation are carried out.
- Fully qualified Nursing Staff under its employment round the clock.
- Fully qualified Doctor(s) should be in–charge round the clock.
Domiciliary Hospitalisation Benefit
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 is 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
Expenses incurred for pre and post hospital treatment and expenses incurred for treatment for any of the following diseases:
- Chronic Nephritis and Nephritic Syndrome.
- Diarrhea and all type of Dysenteries including Gastroenteritis.
- Diabetes Mellitus and Insipidus.
- Influenza, cough and Cold.
- All Psychiatric or Psychosomatic Disorders.
- Pyrexia of unknown Origin for less than 10 days.
- Tonsillitis & Upper Respiratory Tract Infection including laryngitis and Pharyngitis.
- Arthritis, Gout and Rheumatism.
When treatment such as Dialysis, Chemotherapy, Radiotherapy etc. if taken in the Hospital/Nursing Home and the Insured is Discharged on the same day, the treatment will be considered to be taken under Hospitalization Benefit section. Liability of the company under this clause is restricted as stated in the schedule attached hereto.
Any one illness will be deemed to mean continuous period of illness and includes relapse within 45 days from the date of last consultation with the Hospital/Nursing Home where treatment may have been taken. Occurrence of same illness after a lapse of 45 days as stated above will be considered as fresh illness for the purpose of this policy.
The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of.
All diseases/injuries which are pre–existing when the cover incepts for the first time.
Any diseases other than stated clause 4.3 contracted by the Insured Person during the first 30 days from the commencement date of the policy.
The 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 of the existence of the Disease or any symptoms or complaints thereof at the time of making then proposal for insurance to the Company This condition 4.2 shall not however apply in case 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 12 months without any break.
During the first year of the operation of insurance cover, the expenses on treatment of diseases such Cataract, Benign Prostates Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal Diseases, Fistula–in–ano, Piles, Sinusitis and related disorders are not payable. Injury or disease directly or indirectly caused by or arising from or attributable to War, Invasion, Act of Foreign Enemy, Warlike operations (whether war be declared or not). Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident, vaccination or inoculation or changes of life or cosmetic or aesthetic treatment for any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness.
- Cost of spectacles and contact lenses, hearing aids.
- Dental treatment or surgery of any kind of unless requiring hospitalization.
- Convalescence, general debility, “Run–down” condition or rest cure, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self–injury and use of intoxicating drugs/alcohol.
- All expenses arising out of any condition directly or indirectly caused to or associated with Human T–Cell Lymphotropic Virus type III (H T LB – III) or Lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome or condition of a similar kind commonly referred to as Aids.
- 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 or presence of any ailment, sickness or injury, for which confinement at a Hospital/Nursing Home
- Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending Physician.
- Injury or disease directly or indirectly caused by or contributed to by nuclear weapons/materials.
- Treatment arising from or traceable to pregnancy, childbirth including caesarian section.
- Voluntary medical termination of pregnancy during the first 12 weeks from the date of conception.
- Naturopathy treatment.
A discount of 10% in the total premium be allowed comprising the insured and any one or more of the following:
- Dependent Children (i.e. legitimate or legally adopted children).
- Dependent parents.
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 claims free years of insurance. 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 cumulative Bonus and Health Check up provisions as aforesaid.
Both Health Check up and cumulative bonus provisions are applicable where period of insurance as stated in the schedule attached hereto has commenced not later than a week after the expiry of last Mediclaim Insurance Policy, although Renewal is subject to medical check – up. Cumulative Bonus as accrued to the credit of the same policy holder will be added to sum insured under this policy.
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.
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 II (a) (b) (c) will be permissible. This is only a gist of the salient features for your information. For further details and conditions please contact:
Hutoxi P. Dadachanji
A 207 Gera Park.
Boat Club Rd.,