VARISTHA Mediclaim for Senior Citizens
1. Scope of Cover
5. Payment of Claim
6. Cumulative Bonus
7. Cost of Health Check Up
9. TPA Services
This policy has been designed to
cater to the needs of our Senior Citizens. It covers Hospitalization and Domiciliary
Hospitalization Expenses under Section I as well as expenses for treatment
of Critical Illnesses ,if opted for, under Section II. Diseases covered
under Critical Illnesses are as under:
Coronary Artery Surgery
Renal Failure i.e. Failure for both kidneys
Major Organ Transplants like kidney, Lung, Pancreas or Bone marrow
Paralysis and blindness at extra premium
Critical Illness cover is an
optional cover under the policy. Persons who will not opt for critical illness
cover are entitled to
Hospitalization and Domiciliary hospitalization expenses cover for those
diseases categorized above as critical illness but up to the limit of Sum
Insured under Section I i.e. under Hospitalization and Domiciliary
Hospitalization Expenses and the claim for those diseases will be paid on
reimbursement basis or as cashless hospitalization. Person opting for
Critical Illness cover may opt for claim either under Section I or Section
II(if not hospitalized) or under both sections for those diseases
categorized above as Critical Illnesses but claim under Section I
will be paid either on reimbursement basis or as cashless hospitalization
if it is otherwise admissible. If in any policy year a critical illness is
diagnosed and claim paid thereafter, in subsequent renewals the person may
avail cover both under Section I & II but with the exclusion, both
under Section I & II, of that particular critical illness which has
been diagnosed and claim paid in the preceding policy year.
Sum Insured: Sum Insured is fixed per person.
Under Hospitalization &
Domiciliary Hospitalization Cover sum Insured is Rs.1,00,000/-
and under Critical Illness cover
Sum Insured is Rs.2,00,000/-.
For fresh entry in to the scheme-60 years to 80 years. However, for
renewal, age limit will be extended up to 90 years in which case the
premium of 76-80 age band will be loaded by 10% up to 85 years and 20% up
to 90 years of age.
Preacceptance Medical Check up: No Medical Check up is required
if the insured was covered under any Health Insurance Policy of National
Insurance Company or other Insurance companies uninterruptedly for
preceding three years. Other persons have to undergo medical check up at
their own cost for Blood/Urine Sugar, Blood Pressure, Echo-cardiography and
eye check up including retinoscopy.
1. Scope Of
Section I- Hospitalization and
Domiciliary Hospitalization Expenses Cover:
1.0 In the event of any claim/s becoming admissible under
this section, 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 hereof by or on behalf of such Insured
Person but not exceeding the Sum Insured in aggregate mentioned in the
(i)Room, Boarding expenses a
provided by the Hospital/Nursing Home
(ii) If admitted in IC Unit
i)Up to 1% of Sum Insured per
ii)Up to 2% of Sum Insured per
Overall limit:25% of the S.I.
Surgeon, Anaesthetist, Medical
Practitioner, Consultants, Specialists Fees, Nursing Expenses
Up to 25% of Sum Insured per illness/
Anesthesia, Blood, Oxygen, OT
charges, Surgical appliances(any disposable surgical consumables subject
to upper limit of 7% of Sum Insured), Medicines, drugs, Diagnostic
material & X-Ray, Dialysis, Chemotherapy, Radiotherapy, cost of
pacemaker, artificial limbs, Cost of stent & implants
Up to 50% of Sum Insured per
Company's overall liability in respect of claims arising due to Cataract
is Rs.10,000/- and that of Benign Prostatic Hyperplasia is Rs
2) Company's liability in
respect of all claims admitted during the period of Insurance shall not
exceed the Sum Insured for the person as mentioned in the Schedule.
Liability of the company under Domiciliary Hospitalization clause is
limited to 20% of the Sum Insured under Section I and within the overall
limit of sum Insured under section I.
4) Hospitalization expenses of
person donating an organ during the course of organ transplant will also be
payable subject to the sub limits under “C” above applicable to the insured
person within the overall sum insured of the insured person.
5) Ambulance charges up to a
maximum limit of Rs.Rs.1000/- in a policy year will be reimbursed.
Hospital/Nursing Home‚ means any institution in India established for indoor care
and treatment of sickness and
injuries and which either
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
It should have at least 15 inpatient beds. In Class "C" towns
condition of number of beds may be reduced to 10
Fully equipped Operation Theatre of its own wherever surgical
operations are carried out.
Fully qualified nursing staff under its employment round the clock
Fully qualified Doctor(s) should be in charge round the clock
2.1.1 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
2.2 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
2.3 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 –
the treatment is such that it necessitates hospitalization and the
procedure involves specialized infrastructural facilities available in
due to technological advances hospitalization is required for less
then 24 hours only.
2.4 Domiciliary Hospitalization
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 to however that
domiciliary hospitalisation benefits shall not cover:
i) Expenses incurred for pre and
post hospital treatment and
ii) Expenses incurred 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 and Upper Respiratory Tract Infection including
Laryngitis and Pharingitis
Arthritis, Gout and Rheumatism
Note: When treatment such as Dialysis,
Chemotherapy, Radiotherapy 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 attached hereto.
3.0 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.
3.1 Pre Hospitalization:
Relevant Medical Expenses incurred during period up to 30 days prior to
hospitalization/domiciliary hospitalization on disease/illness/injury
sustained will be considered as part of claim mentioned under item 1.0
3.2 Post Hospitalization:
Relevant Medical Expenses incurred up to 60 days after hospitalization/
domiciliary hospitalization on disease/illness/injury sustained will be
considered as part of claim mentioned under item 1.0 above
3.3 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.
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.
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.
3.6 Preexisting Diseases means
any ailment/disease/injury that the person is suffering from (known/not
known, treated/untreated, declared or not declared in the proposal) whilst
taking the policy.
Any complications arising from
pre-existing ailment/disease/injury will be considered as Preexisting
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:
All diseases/injuries which are pre existing when the cover incepts
for the first time. However, those diseases will be covered after one claim
free year under this policy. Cost of treatment towards dialysis,
chemotherapy & radiotherapy for diseases existing prior to the
commencement of this policy is excluded from the scope of cover of this
policy even after one claim free year.
Only two preexisting diseases
(Diabetes and/or Hypertension) will be covered from the inception of the policy
provided the company receives additional premium for covering these
preexisting diseases and mentions the same in the schedule. . However, any
ailment already manifested or being treated and attributable to diabetes
and/or hypertension or consequences thereof at the time of inception of
insurance will not be covered even on payment of additional premium for
covering diabetes and/or hypertension.
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 group insurance scheme with
any one of the Indian Insurance Companies for a continuous period of
preceding 12 months without any break.
During the first one year 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 one claim free year 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.
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).
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 as accident or as part of any illness.
The cost of spectacles and contact lenses, hearing aids.
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.
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.
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.
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.
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 caesarean section.
All claims under this section shall
be payable in Indian currency. All medical treatments for the purpose of
this insurance will have to be taken in India only.
Sum insured under this section 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.: 1) for existing policy
holders (as on date of implementation) the accrued amount of benefit of
cumulative bonus will be added to the sum insured, subject to maximum 10
claim free years.
2) Cumulative Bonus will be lost if policy
is not renewed on the date of expiry.
Waiver: In exceptional circumstances
where policy is renewed within 7 days from expiry date, the renewal is
permissible to be entitled for cumulative bonus although the policy is
renewed only subject to Medical Examination and exclusion of diseases
developed during the break period .
insured has the option either to avail Cumulative Bonus or claim 5%
discount in renewal premium will be allowed 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.
7. Cost of
Health Check Up
In addition to the cumulative
Bonus, the insured shall be entitled for reimbursement of the cost of
medical check up once at the end of block of every three
underwriting years provided there are no claims reported during the block.
The cost so reimbursable shall not exceed the amount equal to 2 % of the
amount of average sum insured excluding cumulative bonus during block of
three underwriting years.
For Cumulative Bonus and Health Check-up provision as
Both Health check-up
and Cumulative bonus provisions are applicable only in respect of
continuous insurance without break except however, where in exceptional
circumstances, the break in period
for a maximum of seven days is approved as a special case subject to
medical examination and exclusion of disease during the break period.
check up benefit will be accrued after completion of three years continuous
claim free insurance.
has to bear 10% of all the admissible claims(Compulsory Excess). However,
20% co-payment will be considered if the insured opt for the same. In such
cases 10% additional discount in premium will be allowed.
to bear additional 10% of all admissible claims if the claim arises out of
pre-existing diseases for which the insured opted cover and paid additional
provision is in addition to the compulsory excess stated herein above and
applicable only for claims arising out of Pre-existing Diseases.
of TPA will be available under this policy.
10.1 For fresh
entrants to National Insurance above premium will be loaded by 10%.
10.2 Under Mediclaim Section(Section I), if
the insured intends to cover pre-existing diseases of Hypertension and/or
Diabetes from the inception of the policy he/she has to pay additional premium @10% for either
hypertension or diabetes & 20% for hypertension & diabetes
for first year of the policy. However, if a fresh entrant suffers from
blood pressure/hypertension and/or diabetes and opts for Critical Illness
cover, the same may be covered at additional premium @10% for either
hypertension or diabetes & 20% for hypertension & diabetes provided
no organ of the proposer is affected in consequence of blood pressure and/
or diabetes. If the medical report indicates occurrence of any such
consequential complication, those proposals will be declined.
Loading for preexisting
Diabetes and/or Hypertension to be applied on Total Premium for first year
and on Critical Illness Premium only from 2nd year onwards.
10.3 At the time of taking this policy, if
a person suffers from any of the terminal diseases referred under Critical
Illness cover mentioned below, that particular disease will never be
covered under Section II of this policy even on payment of additional
10.4 Cover for Paralysis and Blindness under
and Blindness may be covered under Critical Illness by loading the Critical
Illness premium by 15% in each case or 25% in case of both covers together.
10.5 Under Group
Policy, if the incurred claim ratio of the group exceeds 70% then the
renewal premium will be loaded on 70% as if basis i.e.
if the incurred claim ratio of any policy year exceeds 70% renewal premium
will be loaded in such a way that the incurred claim ratio of expiring
policy becomes 70%.
Upon the happening of any event,
which may give rise to a claim under this section notice with full particulars
shall be sent to the Company within 7 days from the date of Injury /
Claim must be filed within 30 days from date of discharge from the
Hospital and where post-hospitalization treatment is not completed, it
shall be within 30 days from the date of completion of Post-hospitalization
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.
will be settled by the Third Party Administrators
(TPA). They will send details of the claims procedure
for emergency/planned hospitals.
Documents to be submitted:
First consultation document
3. Copy of admission advice
4. Discharge Summary
5. Prescription with bills &
6. Test Reports
7. Any other document required by TPA
pertaining to this insurance contract/policy.
Procedure for availing Cashless
Access Services in Network Hospital / Nursing Home.
Claims in respect of Cashless
Access Services will be through the list of network Hospitals/Nursing Homes
and is subject to pre-admission authorization. The TPA shall, upon getting the related
medical information from the insured persons/ network provider, verify that
the person is eligible to claim under the policy and after satisfying
itself will issue a pre-authorisation letter/ guarantee of payment letter
to the Hospital/Nursing Home mentioning the sum guaranteed as payable, also
the ailment for which the person is seeking to be admitted as a
The TPA reserves the right to deny
pre-authorization in case the insured person is unable to provide the
relevant medical details as required by the TPA. The TPA will make it clear to the insured
person that denial of Cashless Access is in no way construed to be denial
of treatment. The insured person may
obtain the treatment as per his/her treating doctor’s advice and later on
submit the full claim papers to the TPA for reimbursement subject to
admissibility of claim under the terms and conditions of the policy.
The TPA may repudiate the claim,
giving reasons, if not covered under the terms of the policy. The insured person shall have right of
appeal to the insurance company if he/she feels that the claim is payable.
The insurance company’s decision in this regard will be final and binding
11.2 Section II:
Upon detection of any critical
illness, which may give rise to a claim under this section, notice with
full particulars shall be sent to the Company within 15 days from the date
of diagnosis of the disease.
Claim documents as mentioned
hereunder must be submitted to the company after 30 days from the date of
diagnosis of the disease.
Doctor’s certificate confirming diagnosis of the
critical illness along with date of diagnosis.
Pathological/other diagnostic test reports confirming
the diagnosis of the critical illness.
Any other documents required by the company
Section II: Critical Illness Cover (Optional):
Under this section the Company
shall pay to the Insured Person, the compensation as set against such
Insured Person’s name in the schedule, should an Insured Person be
diagnosed, during the period of insurance set in the schedule, as suffering
from a critical illness stated hereunder, symptoms (and/or the treatment)
of which were not present in such Insured Person at any time prior to
inception of this Policy.
3. Renal failure
4. Major Organ Transplant
5. Multiple sclerosis
6. Coronary artery surgery
7. Paralysis and Blindness at
No claim will be paid, if a critical
illness as specified in the policy incepts or manifests during the first 90
days of the inception of the policy.
The insured person needs to
survive for 30 successive days after the diagnosis of the critical illness
in order to make his claim.
1. Each of the above illnesses mentioned in
the Policy, must be confirmed by a registered medical practitioner
appointed by the company and must be supported by clinical, radiological,
histological and laboratory evidence acceptable to the company and to be
reconfirmed by a Registered Medical Practitioner appointed by the company.
2. The Company shall compensate the Insured
on behalf of the insured Person only once in respect of any particular
3. The Cover under the Policy will cease
upon payment of the compensation on the happening of a Critical Illness and
no further payment will be made for any consequent disease or any dependent
shall not pay any benefit to any insured Person who suffers an event giving
rise to a Critical Illness which arises or is caused by or associated with
directly or indirectly by any one of the following:
1. The ingestion of drugs other than those
prescribed by a practicing and duly qualified member of the medical
2. The ingestion of medicines, prescribed
or not, for treatment of drug addiction and any treatment relating to drug
3. Any attempt by the Insured Person at
suicide or any injury, which is self inflicted or in any manner wilfully
caused by or on behalf of the Insured Person.
4. Where the Insured Person at any time
suffered from the condition commonly known as AIDS or was infected by the
commonly called HIV virus. The terms AIDS and HIV will be interpreted as
broadly as possible so as to include all or any mutants, derivatives or
variations thereof. The onus will always be on the Insured Person to show
that any event was not caused by or did not arise through AIDS or HIV.
5. The Company will not be liable for a
Critical Illness and/or its symptoms (and/or the treatment) of which were
present in the Insured Person at any time before inception of the Policy or
the date on which cover was granted to such Insured Person, or which
manifest themselves within a period of 90 days from such date, whether or
not the Insured Person had knowledge that the symptoms or treatment were
related to such Critical Illness. In the event of any interruption in
cover, the terms of this exclusion will apply as new from recommencement of
6. No claim will be payable if the Insured
Person smokes 40 or more cigarettes / cigars
or equivalent tobacco intake in a
7. No claim will be payable if a critical
illness is caused directly or indirectly or contributed to by or arising
(i) Ionising Radiations or contamination by
radioactivity from any nuclear fuel or from any nuclear waste from the
combustion of nuclear fuel or nuclear weapons materials.
(ii). War, Invasion, Act of Foreign enemy,
Hostilities, Civil War, Rebellion, Revolution, Insurrection, Mutiny,
Military, or Usurped Power, Seizure, Capture, Arrest, Restraints and
Detainment of all Kings, Princes and People of whatever nation condition or
Special Note: The company reserves the right
to review the premium rate, terms and
conditions of this policy at the time of renewal.