Chapter 4

HEALTH INSURANCE

MEDICLAIM POLICY INDIVIDUAL

SALIENT FEATURES OF THE POLICY:
Policy provides for reimbursement of hospitalization/domiciliary hospitalization expenses for
illness/ disease suffered or accidental injury sustained during policy period.

In the event of any admissible claim, the amount of such expenses as would fall under
different heads mentioned below, reasonably and necessarily incurred thereof.

 a. Room, Boarding Expenses for hospital/nursing home

 b. Nursing Expenses

 c. Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees

 d. Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances,

Medicines & Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy,
Cost of Pacemaker, Artificial Limbs & Cost of Organs and similar expenses.

Liability in respect of all claims admitted during the period of insurance will up to Sum
Insured.
 Mediclaim insurance scheme also provides for:
 a. Family discount in premium

 b. Cumulative Bonus

 c. Cost of Health Check-up

(Note: Renewal of insurance without break is essential)

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:

o i. It should have at least 15 in-patient beds

o ii. Fully equipped operation theatres of its own wherever surgical operations are carried out.

o iii. Fully qualified Nursing Staff under its employment round the clock.

o iv. Fully qualified Doctor(s) should be in-charge round the clock.

In Class 'C' town condition of number of beds be reduced to 10.

The term '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.
"Surgical Operation" means manual and/or operative procedures for correction of
deformities and defects, repair of injuries, diagnosis and cure of diseases, relief of suffering
and prolongation of life.
Expenses on Hospitalization for minimum period of 24 hours are admissible. However, this
time limit is not applied to specific treatments i.e. Dialysis, Chemotherapy, Radio therapy,
Eye Surgery, Dental Surgery, Lithography (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 Hospitalization Benefit.

MEDICAL PRACTITIONER:
Means a person who holds a degree/diploma of a recognized 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 of a recognized Nursing Council and who is
employed on recommendation of the attending Medical Practitioner.

PRE-HOSPITALISATION

Expenses incurred prior to hospitalization during the period unto 30 days will be considered
as part of claim.

POST- HOSPITALISATION

Expenses incurred during the period unto 60 days after hospitalization will be considered as
part of claim.

EXCLUSIONS:
The Company shall not be liable to make any payment in respect of any expenses incurred
in respect of:

All diseases/injuries, which are pre-existing when the cover incepts for the first time. Any
disease other than those stated contracted during the first 30 day. This exclusion shall not
however, apply if in the opinion of Panel of Medical Practitioners constituted by the
Company for the purpose, the Person could not have known of the existence of the Disease
or any symptoms or complaints thereof at the time of making the proposal. In case of
renewal insurance policy without any break preexisting condition shall not apply.
 Claim not payable in respect of any expenses incurred in connection or in respect of:
1. Pre-existing disease when cover incepts for the first time.
2. Any disease contracting during the first 30 days after commencement of policy in case of
following.
 Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma,
Hernia, Hydrocele, Congenital Internal Diseases, Fistula in anus, Piles, Sinusitis and related
disorders. Designed and Formatted by Revmax

 Dental treatment or surgery unless requiring hospitalization, convalescence, and general

debility, rundown condition or rest cure, congenital external disease or defects or anomalies
sterility, venereal disease, internal self-injury and use of intoxicating drug or alcohol.

 Various conditions commonly referred to AIDS

 Charges incurred for checkup.

 Expenses on vitamins, tonics unless forming part of treatment.

 Treatment arising of childbirth including caesarian.

 Voluntary medical termination of pregnancy during first 12 weeks from date of conception.

 Naturopathy treatment.

 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).

 Circumcision unless necessary for treatment of a disease not excluded hereunder or as

may be necessitated due to an accident, vaccination or inoculation or change of life or
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.

 Cost of spectacles, contact lenses and hearing aids.

 Any dental treatment or surgery which is a corrective, cosmetic or aesthetic procedure,

including wear and tear, unless arising from disease or injury and which requires
hospitalization for treatment.
 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.

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:

 i. The condition of the patient is such that he/she cannot be removed to the hospital/nursing
Home or

 ii. The patient cannot be removed to hospital/nursing home for lack of accommodation
therein

Subject however that domiciliary hospitalization benefits shall not cover:

 i. Expenses incurred for pre and post hospital treatment and

 ii. Expenses incurred for treatment for any of the following diseases

 Asthma

 Bronchitis

 Chronic Nephritis and Nephritic Syndrome

 Diarrhea and all type of Dysenteries including Gastro-enteritis

 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 Pharingitis

 Arthritis, Gout and Rheumatism

 When treatment such as Dialysis, Chemotherapy, Radio therapy 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 Hospitalization Benefit section.

 Liability of the Company under this clause is restricted as stated in the schedule of company
concerned.

ANY ONE ILLNESS

Any one illness will be deemed to mean continuous period of illness and it 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.

AGE LIMIT

5 to 80 years. Child between ages of 3 months to 5 years can be covered if one or both
parents are covered simultaneously. However once policy is issued the age limit condition
does not apply on renewal i.e. mediclaim policy will continue for life time.

FAMILY DISCOUNT
 10% discount on total premium payable is available for insurance of any one or more of the
following:

1. Spouse.
2. Eligible dependent children
3. Dependent parents.
4. Married woman can include her parents as dependents.
5. Married woman can include her parents in laws as her dependents.
Commutative Bonus:
5% of each claim free year maximum for 10 years maximum discount is 50%. In case of
claim reduction by 10% from cumulative bonus. Original sum insured will not be affected.

Health Checkup

Once in 4 years if no claim preferred during the period of four years. Cost of checkup is 1%
of average sum insured for block of 4 years provided no break. However 7 days break is
permissible subject to medical examination.

Condition:
Preliminary notice of claim within 7 days.
Final claim bills to be submitted within 30 days of completion of treatment.
All medical treatment will have to be taken in India only & claims are payable in Indian
currency only.
Sum Insured and premium

The sum insured is available from Rs.15000/- to Rs. 5 Lakhs with multiple of Rs.5, 000/-.
Domiciliary 20% of sum insured up to 1lakh and 15% of sum insured next 1 lakh 10% rest of
sum insured. However these days covers are available for higher amounts as per
requirement of proposer.

Premium is related to age and sum insured.

Premium also qualifies tax benefit as applicable under section 80 D of IT Act.

Proposal Form

Full detail of insured and his physical condition and declaration consist having read the
conditions and such declaration is the basis of contract.

Medical Questionnaire

If diabetes, Hypertension, Chest Pain or coronary insufficiency then medical report from
doctor is required.

Any person can avail this policy

With permission geographical limit may be extended for shorter period for Nepal & Bhutan.
Dog bite or any other animal bite claim can paid under domiciliary hospitalization

Policy is available for life time provided policy is renewed without break.

In case insured dies during currency of policy name to continue till expiry of the policy

Policy to be renewed with mutual consent

When additional member is added on account of marriage or child attaining the age of 3
months can be covered midterm. Family discount would also be available where period of
cover is 6 months or more.

NOTICE OF CLAIM
Preliminary notice of claim with particulars relating to Policy Numbers, Name of insured
person in respect of whom claim is made, Nature of illness/Injury and Name and Address of
the attending medical practitioner/Hospital/Nursing Home should be given to the Insurance
Company within seven days from the date of Hospitalization/Injury/Death.

Final claim along with hospital receipted Bills/Cash memos, claim form and list of
documents as listed in the claim form etc. should be submitted to the company within 30
days of discharge from the Hospital or completion of treatment.

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.

PAYMENT OF CLAIM:
All claims under the policy shall be payable in Indian currency.

All medical treatments for the purpose of this insurance will have to be taken in India only.

Both Health Check-up and Cumulative bonus provisions are applicable where period of
insurance not later than a week after the expiry of the last Mediclaim Insurance Policy,
although Renewal is allowed subject to medical check-up.

Cumulative Bonus as accrued to the credit of the same policyholder will be added to sum
insured under this policy.

IMPORTANT
Premium paid under Mediclaim (Hospitalization and Domiciliary Hospitalization) Insurance
is eligible for Income Tax deduction as per provisions under Section 80-D of the Income Tax
(Amendment) Act, 1986 subject to payment of premium by cheque only.

Cashless Service through TPAs

 Third Party Administrator, which will enable availing cashless service in select hospitals.
This service will be subject to the limits, terms, conditions, and exclusions of the mediclaim
policy.

The TPA shall be providing an identity Card and a guidebook, which shall guides through
the procedures to be adopted for availing cashless service.

Providing cashless service and in no case the insurer or the TPA will be responsible for the
quality of care/treatment provided in the hospitals. Insured can avail treatment in non-
network hospitals remains on reimbursement basis.

FLOATER MEDICLAIM POLICY:

This policy is on same principal with only difference that in Individual mediclaim policy
premium is charged for each insured person and varies depending on age & sum insured &
total premium payable is subject to family discount where as in this policy proposer select
one fixed sum insured which available to covered person during the year which can be
availed by or all subject to limit of sum insured selected. Premium in such policy is

comparatively much lesser than family policy. Its quite popular these days. The main
difference in this policy is :

 Cumulative Bonus is not available

 Sum insured is fixed for all, in case the claim occurs or accident takes place the sum
insured may not be adequate. But premium is quite less payable in case of floater policy.

GROUP MEDICLAIM POLICY

SALIENT FEATURES OF THE POLICY

The Group Mediclaim policy will be available to any Group/Association/ Institution/Corporate
Body of more than 50 persons.

The policy covers reimbursement of Hospitalization and or Domiciliary Hospitalization

expenses only for illness/diseases contracted or injury sustained by the Insured Person.

Expenses on Hospitalization for minimum period of 24 hours are admissible. However, this
time limit is not applied to specific treatments i.e. Dialysis, Chemotherapy etc.

Policy does not cover such diseases, which have been in existence at the time of proposing
this insurance. Any expenses on any disease/injury incurred during first 30 days of
commencement of insurance cover, during the first year of the operation of the policies the
expenses on treatment of specific diseases, War, Nuclear war, and allied perils,
Circumcision unless

Necessary for treatment of disease, the cost of spectacles, contact lenses and hearing aids,
Dental treatment orsurgery of any kind unless requiring hospitalization, Expenses on
vitamins and tonics unless forming part of treatment, Treatment arising from or traceable to
pregnancy, Naturopathy treatment.

This Insurance is available to persons between the age of 5 years and till member of the
group.

The Group Discount is permissible depending upon the total number of Insured persons
covered under the Group policy at the inception.

The Group Mediclaim policy benefits are identical to individual policy. The policy can be
granted to any Group/Association/ Institution/ Corporate body.

The difference are as under:

Cumulative bonus is not available.

Health Checkup expense are not payable if excluded depending on policy terms.

Group discount in the premium is available.

Renewal premium is subject to Bonus/Malus clause.

Maternity benefit extension is available at extra premium.

Group Discount:
A discount in the premium is allowed for the total premium Group Discount Scale.
Maternity Expenses Benefit Extension
This is an optional cover, which can be obtained on payment of 10% of the total basic
premium for all the Insured Person under the Policy. Option for Maternity Benefits has to be
exercised at the inception of the Policy period. The maximum benefit allowable under this
clause will be upto Rs. 50,000/- or the sum Insured opted by the member of the group
whichever is lower. The Benefits are admissible only if the expenses are incurred in
Hospital/Nursing Home as in-patients in India. Expenses incurred in connection with
voluntary medical termination of pregnancy during the first 12 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.

BONUS/MALUS:
Low Claim Ratio Discount will be allowed on the total premium at renewal only depending
upon the incurred claims ratio for the entire group insured under the Group Mediclaim
Insurance Policy for the preceding three completed years excluding the year immediately
preceding the date of renewal.
The Total Premium payable at renewal of the Group Policy will be loaded at the following
scale depending upon the incurred claims ratio for the entire group insured under the Group
Mediclaim Insurance Policy for the preceding three completed years excluding the year
immediately preceding the date of renewal.

In case of low claim ratio discount in premium is allowed. The discount ranges from 5% to
40% depending upon claim ratio.

Similarly loading is applied if the claim ratio is high or on account of adverse claim ratio. The
loading ranges 25% to 150%.

PRE-EXISTING DISEASE CLAUSE:

Such diseases, which have been in existence at the time of proposing this insurance. Pre-
existing conditions means any injury which existed prior to the effective date of this
insurance. Pre-existence condition also means any sickness or its symptoms, which existed
prior to the effective date of this insurance, whether or not the insured person had
knowledge that the symptoms were relating to the sickness. Complications arising from
preexisting disease will be considered part of that pre-existing condition.

PAYMENT OF PREMIUM
Depending upon the age of the insured person (s) and sum insured selected for that
person.

Managed Health Care

These are a new & innovative concept & in health insurance it refers to provision of total
and integrated claim service; through what are known as Third party administrators (TPA) to
health insurance policyholders. With effect from 1-10- 2002 Third party administrators (TPA)
who are licensed by IRDA. For cash less service, the insured has to approach the hospital
approved by TPA for this purpose. For those who do not approach TPA for cashless
treatment, TPA will make the claim payment on reimbursed basis.

IRDA has licensed various TPA's to provide cashless service to policy holders.

The service made available includes:

Wide network of hospital/nursing homes all over India where policyholders can avail of cash
less services.
Cash less service means admission to network hospitals without admission fee or deposit
and payment of covered expenses at the time of discharge. Thus there is no need for follow
up for reimbursement by patient or relatives.