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a. Scope
Of Cover
1) Room, Boarding expenses as provided by the
Hospital/Nursing Home.
2) Nursing expenses.
3) Surgeon, Anaesthetist, Medical Practitioner,
Consultants, Specialists Fees.
4)Anaesthesia, Blood, Oxygen, Operation Theatre
Charges, Surgical appliances(any disposable consumables subject to upper
limit of 10% of Sum Insured), Medicines & Drugs, Diagnostic Materials
and X-Ray, Dialysis, Chemotherapy, Radiotherapy, Cost of pacemaker,
Artificial Limbs and cost of Stents and implants
Note: Hospitalization expenses of person donating an
organ during the course of organ transplant will also be payable subject to
the sub limits under “4” above applicable to the insured person
within the overall sum insured of the insured person.
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b. Other
benefits
1.
The guardian of the insured will be eligible for deduction under
Section 80 D of the Income Tax Act 1961 as amended from time to time, for
the premium paid under this section of the policy subject to limits
specified in the Income Tax Act.
2.The Policy will be serviced by Third Party
Administrators (TPA) for hospitalization expenses.
3. Cumulative Bonus
Sum insured under this 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.
In case of 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.
N.B.:
a) for existing Mediclaim
policy holders (as on date of implementation) of the company the accrued amount of
benefit of cumulative bonus will be added to the sum insured, subject to
maximum 10 claim free years.
b) Cumulative Bonus will be lost if policy is not
renewed on the date of expiry.
However, insured has the option either to avail
cumulative bonus or claim 5% discount in renewal premium in respect of each
claim free year of insurance subject to maximum of 10 claim free years of
insurance. This discount will not be applicable to the S.I. increased ,if any, by the insured at renewal.
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c.
Definitions
1.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 either as a Hospital or Nursing
Home with the local authorities and is under the supervision of the
registered and qualified medical practitioner OR
(b)
should comply with minimum criteria as under:
i.
It should have at least 15 inpatient beds. In
Class "C" towns condition of number of beds may be reduced to 10
ii.
Fully equipped Operation Theatre 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
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 of alcoholics, a hotel or a similar place.
2.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
3.Expenses of Hospitalization for
minimum period of 24 hours are admissible. However, this time limit is not
applied to specific treatments i.e. day care treatment for stitching of
wound/s, close reduction/s and application of POP casts, Dialysis,
Chemotherapy, Radiotherapy, Arthroscopy, Eye surgery, ENT surgery,
Laparoscopic surgery, Angiographies, Endoscopies, Lithotripsy (Kidney stone
removal), D & C, Tonsillectomy 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. This condition will also not
apply in case of stay in Hospital of less then 24 hours provided –
a)
the treatment is such that it
necessitates hospitalization and the procedure involves specialized
infrastructural facilities available in Hospitals.
and
b)
due to technological advances
hospitalization is required for less then 24 hours only.
4.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.
5. 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 mentioned under item 1.0 above
6.Post Hospitalisation:
Relevant Medical Expenses incurred up to 60 days after hospitalisation/
domiciliary hospitalisation on disease/illness/injury sustained will be
considered as part of claim mentioned under item 1.0 above
7.Medical Practitioner means a
person who holds a degree/diploma from a recognised institution and is
registered by Medical Council or respective State Council of India. The
term Medical Practitioner would include Physician, Specialist and Surgeon.
8.Qualified Nurse means a person who
holds a certificate of a recognised Nursing Council and who is employed on
the recommendations of the attending Medical Practitioner.
9.TPA means a Third Party
Administrator, who, for the time being, is licensed by the Insurance
Regulatory and Development Authority, and is engaged, for a fee or remuneration,
by whatever name called as may be specified in the agreement with the
Company, for the provision of health services.
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d.Exclusions:
The Company shall not be
liable to make any payment under this Policy in respect of any expenses
whatsoever incurred by any person in connection with or in respect of :
1. All diseases/injuries,
which are pre-existing when the cover incepts for the first time. This exclusion will be deleted after
three continuous claims free years under this policy.
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 condition 4.2
shall not however apply in case of the Insured Person having been covered
under this Scheme or any health insurance scheme with any one of the Indian
Insurance Companies for a continuous period of preceding 12 months without
any break.
3. During the first 2 years
of the operation of the policy the expenses incurred on treatment of
diseases such as Cataract, Benign Prostatic
Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele,
Congenital Internal Disease, Fistula in anus, Chronic fissure in anus,
Piles, Pilonidal Sinus, Sinusitis, Stone disease
of any site, Benign Lumps/growths in any part of the body, CSOM(Chronic Suppurative Otitis Media),
joints replacements of any kind unless arising out of accident, surgical
treatment of Tonsils, Adenoids and deviated nasal septums
and related disorders are not payable. If these diseases (other than
Congenital Internal Disease/Defects) are pre-existing at the time of
proposal, they will be covered only after four continuous claim free years
as mentioned in column 4.1 above. If the Insured is aware of the existence
of Congenital Internal Disease/Defect before inception of the 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 Warlike 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 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 part of any
illness.
6. The cost of spectacles
and contact lenses hearing aids.
7. Any Dental treatment or
surgery which is a corrective, cosmetic or aesthetic procedure, including
wear and tear, unless arising from accidental injury and which requires
hospitalization for treatment.
8. 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, rehabilitation therapy
in any form.
9. All expenses arising out
of any condition directly or indirectly caused to or associated with Human
T-Cell Lymphotrophic Virus Type III (HTLB-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.
10. Charges incurred at
Hospital or Nursing Home primarily for diagnostic,
X-Ray or laboratory examinations or other diagnostic studies not consistent
with nor 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.
11. Expenses on vitamins
and tonics unless forming part of treatment for injury or disease as
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 caesarean section.
14. Naturopathy treatment
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