7f3d3Module-III Mediclaim Insurance Individual)

8/8/2019 7f3d3Module-III Mediclaim Insurance Individual)

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ModuleModule--III Mediclaim InsuranceIII Mediclaim Insurance(Individual)(Individual)

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MEDICLAIM INSURANCE POLICY MEDICLAIM INSURANCE POLICY ((INDIVIDUALSINDIVIDUALS))

Any Any insuredinsured PersonPerson shallshall contract contract anyany diseasedisease oror suffersufferfromfrom anyany illnessillness / / ailment ailment / / diseasedisease oror sustainsustain anyany bodilybodilyinjuryinjury throughthrough accident accident andand if if suchsuch diseasedisease oror injuryinjury shallshallrequirerequire anan attentionattention of of MedicalMedical Specialist/MedicalSpecialist/MedicalPractitioner,Practitioner, SurgeonSurgeon toto incurincur (a)(a) hospitalisationhospitalisation expensesexpensesforfor medical/surgicalmedical/surgical treatment treatment at at anyany NursingNursingHome/HospitalHome/Hospital inin IndiaIndia asas anan inpatient inpatient OROR (b)(b) onondomiciliarydomiciliary treatment treatment inin IndiaIndia underunder DomiciliaryDomiciliaryHospitalisationHospitalisation Benefits,Benefits, thethe TPATPA willwill paypay toto thethe HospitalsHospitals(only(only if if treatment treatment isis takentaken at at NetworkNetwork Hospital(s)Hospital(s) withwithpriorprior consent consent of of TPA)TPA) oror toto thethe insuredinsured personperson if if policypolicy isis

servicedserviced byby thethe TPATPA ..OtherwiseOtherwise thethe CompanyCompany willwill paypay totothethe InsuredInsured PersonPerson.. But But not not exceedingexceeding thethe sumsum insuredinsured ininaggregateaggregate inin anyany oneone periodperiod of of insuranceinsurance. .

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REASONABLE & CUSTOMARY EXPENSESREASONABLE & CUSTOMARY EXPENSESREIMBURSABLE UNDER THE POLICYREIMBURSABLE UNDER THE POLICY

Room,Room, BoardingBoarding andand NursingNursing ExpensesExpenses asasprovidedprovided byby thethe HospitalHospital /Nursing /Nursing HomeHomenot not exceedingexceeding 11 %% of of thethe SumSum InsuredInsured ororRsRs.. 50005000 / /-- perper dayday whicheverwhichever isis lessless..II..CC.. Unit Unit expensesexpenses not not exceedingexceeding 22%% of of thethe SumSum InsuredInsured oror RsRs.. 1010,,000000 / /-- perper dayday

whicheverwhichever isis lessless....(Room(Room includingincluding II..CC..UU.. staystay shouldshould not not exceedexceed totaltotal numbernumber of of admissionadmission days)days)..

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Surgeon,Surgeon, Anaesthetist, Anaesthetist, MedicalMedical

Practitioner,Practitioner, Consultants,Consultants, SpecialistsSpecialists FeesFees..Anaesthesia, Anaesthesia, Blood,Blood, Oxygen,Oxygen, OperationOperationTheatreTheatre Charges,Charges, SurgicalSurgical Appliances, Appliances,

MedicinesMedicines && Drugs,Drugs, Dialysis,Dialysis,Chemotherapy,Chemotherapy, Radiotherapy,Radiotherapy, Artificial ArtificialLimbs,Limbs, Cost Cost of of ProstheticProsthetic devicesdevicesimplantedimplanted duringduring surgicalsurgical procedureprocedure likelikepacemaker,pacemaker, Relevant Relevant LaboratoryLaboratory / /DiagnosticDiagnostic test,test, X X--RayRay etcetc..

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Ambulance Ambulance servicesservices -- 11%% of of thethe sumsuminsuredinsured oror RsRs 20002000/ /-- whicheverwhichever isis lessless

shallshall bebe reimbursablereimbursable inin casecase patient patient hashastoto bebe shiftedshifted fromfrom residenceresidence toto hospitalhospital inincasecase of of admissionadmission inin EmergencyEmergency WardWard / /II..CC..UU.. oror fromfrom oneone HospitalHospital / / NursingNursinghomehome toto anotheranother HospitalHospital / / NursingNursing HomeHomebyby registeredregistered ambulanceambulance onlyonly forfor betterbettermedicalmedical facilitiesfacilities..

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NoteNote::11.. Company sCompany s LiabilityLiability inin respect respect of of allallclaimsclaims admittedadmitted duringduring thethe PeriodPeriod of of insuranceinsurance shallshall not not exceedexceed thethe SumSum InsuredInsuredperper PersonPerson mentionedmentioned inin thethe ScheduleSchedule. .

22..HospitalizationHospitalization expensesexpenses incurredincurred forfordonatingdonating anan organorgan byby thethe donordonor (excluding(excludingcost cost of of organorgan if if any)any) toto thethe insuredinsured personperson

duringduring thethe coursecourse of of organorgan transplant transplant willwillalsoalso bebe payablepayable. . HoweverHowever inin anyany casecase thetheliabilityliability of of thethe CompanyCompany willwill bebe limitedlimited totooverover allall SumSum InsuredInsured of of thethe InsuredInsured PersonPerson..

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DEFINITIONSDEFINITIONS HOSPITAL/NURSING HOSPITAL/NURSING HOMEHOME:: meansmeans anyany institutioninstitution inin

IndiaIndia establishedestablished forfor indoorindoor carecare andand treatment treatment of of sicknesssickness andand injuriesinjuries andand whichwhich eithereither

IsIs dulyduly licensedlicensed andand registeredregistered asas aa HospitalHospital ororNursingNursing HomeHome withwith thethe appropriateappropriate authoritiesauthoritiesandand isis underunder thethe supervisionsupervision of of aa registeredregistered andandqualifiedqualified MedicalMedical PractitionerPractitioner. .

OROR

InIn areasareas wherewhere licensinglicensing andand registrationregistrationfacilitiesfacilities withwith appropriateappropriate authoritiesauthorities areare not not available,available, thethe institutioninstitution must must bebe oneone recognisedrecognisedinin localitylocality asas HospitalHospital / / NursingNursing HomeHome andand shouldshould

complycomply withwith minimumminimum criteriacriteria asas underunder7


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It It shouldshould havehave at at least least 1515 inin--patient patient

medicalmedical bedsbeds inin casecase of of MetroMetro cities,cities, A AClassClass citiescities && BB classclass citiescities oror 1010 inin--patient patient medicalmedical bedsbeds inin casecase of of C C classclasscitiescities.. ClassificationClassification of of citiescities shallshall bebe asas

perper Govt Govt of of IndiaIndia NotificationsNotifications issuedissued ininthisthis respect respect fromfrom timetime toto timetime..FullyFully equippedequipped andand engagedengaged inin providingprovidingMedicalMedical andand SurgicalSurgical facilitiesfacilities alongalong withwithDiagnosticDiagnostic facilitiesfacilities ii..ee.. PathologicalPathological test test andand X X--ray,ray, EE..CC..GG.. etcetc forfor thethe carecare andandtreatment treatment of of injuredinjured oror sicksick personspersons asas inin--patient patient. . 8


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FullyFully equippedequipped operationoperation theatretheatre of of itsits

own,own, whereverwherever surgicalsurgical operationsoperations arearecarriedcarried out out..

FullyFully qualifiedqualified nursingnursing staff staff underunder itsitsemployment employment roundround thethe clockclock..

FullyFully qualifiedqualified Doctor(s)Doctor(s) shouldshould bebephysicallyphysically inin--chargecharge roundround thethe clockclock..

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Note:Note:TheThe termterm Hospital/Nursing Hospital/Nursing Home Home shallshall not not includeinclude ananestablishment establishment whichwhich isis aa placeplace of of rest,rest, aa placeplace forfor thethe aged,aged, aaplaceplace forfor drugdrug addictsaddicts oror aa placeplace forfor alcoholics,alcoholics, aa hotelhotel oror aa

similarsimilar placeplace..InIn casecase of of Ayurvedic Ayurvedic / / HomeopathicHomeopathic / / UnaniUnani treatment,treatment,HospitalisationHospitalisation expensesexpenses areare admissibleadmissible onlyonly whenwhen thethe treatment treatment isis takentaken asas inin--patient,patient, inin aa Government Government HospitalHospital / / MedicalMedicalCollegeCollege HospitalHospital..

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SurgicalSurgical OperationOperation meansmeans manualmanual and/and/ oror operativeoperativeproceduresprocedures for for correctioncorrection of of deformitiesdeformities / / defectsdefects andandinjuries,injuries, curecure ofof diseases,diseases, reliefrelief ofof sufferingsuffering andandprolongationprolongation of of lifelife..

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HOSPITALISATION PERIODHOSPITALISATION PERIOD

ExpensesExpenses onon HospitalisationHospitalisation areareadmissibleadmissible onlyonly if if hospitalisationhospitalisation isis forfor aaminimumminimum periodperiod of of 2424 hourshours..

( A)( A) ThisThis timetime limit limit willwill not not applyapply totofollowingfollowing specificspecific treatmentstreatments takentaken inin thethe

NetworkedNetworked HospitalHospital / / NursingNursing HomeHome wherewherethethe InsuredInsured isis dischargeddischarged onon thethe samesamedayday.. SuchSuch treatment treatment willwill bebe consideredconsidered totobebe takentaken underunder HospitalisationHospitalisation Benefit Benefit..

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Haemic Dialysis,Haemic Dialysis,Parental Chemotherapy,Parental Chemotherapy,Radiotherapy,Radiotherapy,Eye Surgery,Eye Surgery,Lithotripsy (k idney stone removal),Lithotripsy (k idney stone removal),Tonsillectomy,Tonsillectomy,

D&CD&CDental surgery following an accidentDental surgery following an accidentHysterectomyHysterectomyCoronary AngioplastyCoronary Angioplasty

Coronary AngiographyCoronary AngiographySurgery of Gall bladder, Pancreas and bile ductSurgery of Gall bladder, Pancreas and bile ductSurgery of HerniaSurgery of Hernia

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Surgery of Hydrosol.Surgery of Hydrosol.Surgery of Prostrate.Surgery of Prostrate.Gastrointestinal Surgery.Gastrointestinal Surgery.

Genital Surgery.Genital Surgery.Surgery of Nose.Surgery of Nose.Surgery of throat.Surgery of throat.Surgery of Appendix.Surgery of Appendix.

Surgery of Urinary System.Surgery of Urinary System.Treatment of fractures / dislocation excludingTreatment of fractures / dislocation excludinghair line fracture, Contracture releases and minorhair line fracture, Contracture releases and minorreconstructive procedures of limbs whichreconstructive procedures of limbs whichotherwise require hospitalisation.otherwise require hospitalisation.

Arthroscopic Knee surgery. Arthroscopic Knee surgery.Laparoscopic therapeutic surgeries.Laparoscopic therapeutic surgeries.Any surgery under General Anaesthesia. Any surgery under General Anaesthesia.Or any such disease / procedure agreed byOr any such disease / procedure agreed by

TPA/Company before treatment.TPA/Company before treatment.14


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DAY CARE CENTREDAY CARE CENTRE

The requirement of minimum beds will beThe requirement of minimum beds will beoverloo k ed provided following conditionsoverloo k ed provided following conditionsare met.are met.The operation theatre is fully equipped forThe operation theatre is fully equipped for

the surgical operation required in respectthe surgical operation required in respectof sic k ness / ailment / injury coveredof sic k ness / ailment / injury coveredunder the policy.under the policy.Day Care nursing staff is fully qualified.Day Care nursing staff is fully qualified.

TheThe doctordoctor performingperforming thethe surgerysurgery ororprocedureprocedure as as wellwell asas postpost operativeoperativeattendingattending doctorsdoctors areare alsoalso fullyfully qualifiedqualifiedforfor thethe specificspecific surgerysurgery / / procedureprocedure. .

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This condition of minimum 24 hoursThis condition of minimum 24 hoursHospitalisation will also not applyHospitalisation will also not apply

providedprovidedTheThe treatmenttreatment is is suchsuch thatthat it it necessitatesnecessitateshospitalisationhospitalisation and and thethe procedureprocedureinvolvesinvolves specialisedspecialised infrastructuralinfrastructuralfacilitiesfacilities availableavailable onlyonly inin hospitals,hospitals,

But due to technological advancesBut due to technological advances

hospitalisation is required for less than 24hospitalisation is required for less than 24hours.hours.AND / OR AND / ORSurgical procedure involved has to beSurgical procedure involved has to bedone under General Anaesthesia.done under General Anaesthesia.

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: PROCEDURES / TREATMENTS: PROCEDURES / TREATMENTSUSUALLY DONE IN OUT PATIENTUSUALLY DONE IN OUT PATIENTDEPARTMENT ARE NOT PAYABLEDEPARTMENT ARE NOT PAYABLE

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DOMICILIARY HOSPITALISATIONDOMICILIARY HOSPITALISATIONBENEFITBENEFIT

meansmeans MedicalMedical treatmenttreatment for for aa periodperiodexceedingexceeding threethree daysdays forfor suchsuchillness/disease/injuryillness/disease/injury which which inin thethenormalnormal coursecourse wouldwould requirerequire carecare andandtreatmenttreatment at at aa hospitalhospital / / nursingnursing homehomeasas inin--patientpatient butbut actuallyactually ta k enta k en whilstwhilstconfinedconfined at at homehome inin IndiaIndia underunder anyany ofofthethe followingfollowing circumstancescircumstances namelynamely ::

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TheThe conditioncondition of of thethe patientpatient is is suchsuchthatthat he/shehe/she cannotcannot bebe removedremoved to tothethe Hospital/NursingHospital/Nursing HomeHome

ORORTheThe patientpatient cannotcannot bebe removedremoved to toHospital/NursingHospital/Nursing homehome duedue toto lac klac k ofofaccommodationaccommodation in in anyany hospitalhospital in inthatthat citycity / / towntown / / villagevillage..

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Subject to the condition thatSubject to the condition thatDomiciliary Hospitalisation benefitDomiciliary Hospitalisation benefitshall not covershall not coverExpenses incurred for pre and postExpenses incurred for pre and posthospital treatment andhospital treatment andExpenses incurred for treatment forExpenses incurred for treatment forany of the following diseases :any of the following diseases :

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Asthma AsthmaBronchitis,Bronchitis,Chronic Nephritis and Nephritic Syndrome,Chronic Nephritis and Nephritic Syndrome,Diarrhoea and all types of DysenteriesDiarrhoea and all types of Dysenteriesincluding Gastroincluding Gastro- -enteritis,enteritis,Diabetes Mellitus and Insipidus,Diabetes Mellitus and Insipidus,

Epilepsy,Epilepsy,Hypertension,Hypertension,

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Influenza, Cough and Cold,Influenza, Cough and Cold,All Psychiatric or Psychosomatic All Psychiatric or PsychosomaticDisorders,Disorders,

Pyrexia of un k nown origin for lessPyrexia of un k nown origin for lessthan 10 days,than 10 days,Tonsillitis and Upper RespiratoryTonsillitis and Upper RespiratoryTract infection including LaryngitisTract infection including Laryngitisand Pharingitis,and Pharingitis,Arthritis, Gout and Rheumatism. Arthritis, Gout and Rheumatism.

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OTHER DEFINITIONS AND INTERPRETATIONSOTHER DEFINITIONS AND INTERPRETATIONS

INSURED PERSONINSURED PERSON : Means Person ( s): Means Person ( s)named on the schedule of the policy.named on the schedule of the policy.

ENTIREENTIRE CONTRACTCONTRACT :: TheThe policypolicy / / proposalproposalandand declarationdeclaration givengiven byby thethe insuredinsuredconstituteconstitute the the completecomplete contractcontract of of thethepolicypolicy. . OnlyOnly InsurerInsurer maymay alteralter thethe termsterms

andand conditionsconditions of of thisthis policypolicy. . Any Any alterationalterationthatthat maymay bebe mademade byby thethe insurerinsurer shallshall onlyonlybebe evidencedevidenced by by aa dulyduly signedsigned andand sealedsealedendorsementendorsement on on thethe policypolicy. .

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THIRD PARTY ADMINISTRATORTHIRD PARTY ADMINISTRATOR( TPA) : means any Company who has( TPA) : means any Company who hasobtained licence from IRDA toobtained licence from IRDA topractice as a third party administratorpractice as a third party administratorand is appointed by the Company.and is appointed by the Company.

NETWORKNETWORK HOSPITALHOSPITAL :: meansmeans hospitalhospitalthatthat hashas agreedagreed withwith thethe TPATPA totoparticipateparticipate for for providingproviding cashlesscashless

healthhealth servicesservices to to thethe insuredinsured personspersons. .TheThe listlist isis maintainedmaintained by by andand availableavailablewithwith thethe TPATPA andand thethe samesame isis subjectsubjecttoto amendmentamendment fromfrom timetime toto timetime. .

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HOSPITALISATION PERIOD : HOSPITALISATION PERIOD : TheThe periodperiod forfor whichwhich anan insuredinsuredpersonperson is is admittedadmitted in in thethe hospitalhospital as asinpatientinpatient andand staysstays therethere forfor thethe solesole

purposepurpose of of receivingreceiving thethe necessarynecessaryandand reasonablereasonable treatmenttreatment for for thethediseasedisease / / ailmentailment contractedcontracted / /injuriesinjuries sustainedsustained duringduring thethe periodperiodofof policypolicy. . TheThe minimumminimum periodperiod ofofstaystay shallshall bebe 2424 hourshours

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PREPRE--HOSPITALISATIONHOSPITALISATION :: RelevantRelevantmedicalmedical expensesexpenses incurredincurred duringduring thethe

periodperiod uptoupto 3030 daysdays priorprior totohospitalisationhospitalisation on on disease/disease/ illness/illness/injuryinjury sustainedsustained willwill bebe consideredconsidered as aspartpart ofof claimclaim. .

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POSTPOST--HOSPITALISATIONHOSPITALISATION :: RelevantRelevant

medicalmedical expensesexpenses incurredincurred forfor thetheperiodperiod ofof 6060 daysdays afterafter hospitalisationhospitalisationonon disease/illness/injurydisease/illness/injury sustainedsustainedwillwill bebe consideredconsidered as as partpart ofof claimclaim. .

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MEDICAL PRACTITIONER :MEDICAL PRACTITIONER :

meansmeans a a personperson whowho holdsholds a a

degree/diplomadegree/diploma of of aa recognisedrecognisedinstitutioninstitution andand isis registeredregistered by byMedicalMedical CouncilCouncil ofof anyany StateState ofofIndiaIndia. . TheThe termterm MedicalMedicalPractitionerPractitioner wouldwould includeincludePhysician,Physician, SpecialistSpecialist andand SurgeonSurgeon. .

QUALIFIED NURSEQUALIFIED NURSE::

means a person who holds ameans a person who holds acertificate of a recognised Nursingcertificate of a recognised NursingCouncilCouncil

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PRE EXISTING HEALTH CONDITION ORPRE EXISTING HEALTH CONDITION ORDISEASE : DISEASE :

means any ailment / disease / injuries thatmeans any ailment / disease / injuries thatthe person is suffering from, ( treated /the person is suffering from, ( treated /untreated, declared or not declared inuntreated, declared or not declared in

the proposal form) while ta k ing a policythe proposal form) while ta k ing a policyfor the first time.for the first time.

Further any complications arising fromFurther any complications arising fromprepre--existing ailment / disease / injuriesexisting ailment / disease / injurieswill be considered as a part of that prewill be considered as a part of that preexisting health condition.existing health condition.

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ININ--PATIENTPATIENT ::

An An InsuredInsured personperson whowho isis admittedadmitted to to

hospitalhospital andand staysstays forfor atat leastleast 2424hourshours forfor thethe solesole purposepurpose of of receivingreceivingthethe treatmenttreatment for for sufferedsuffered ailmentailment / /illnessillness / / diseasedisease / / injuryinjury / / accidentaccidentduringduring thethe currencycurrency of of thethe policypolicy. .

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CASHLESSCASHLESS FACILITYFACILITY ::

meansmeans thethe TPATPA maymay authoriseauthorise uponuponthethe Insured'sInsured's requestrequest forfor directdirectsettlementsettlement of of admissibleadmissible claimclaim asas perperagreedagreed chargescharges betweenbetween NetNet wor kwor k

HospitalsHospitals & & thethe TPATPA.. InIn suchsuch casescasesthethe TPATPA willwill directlydirectly settlesettle allall eligibleeligibleamountsamounts withwith thethe NetNet wor kwor k HospitalsHospitalsandand thethe InsuredInsured PersonPerson maymay notnot havehavetoto paypay anyany billsbills afterafter thethe endend ofof thethetreatmenttreatment at at HospitalHospital to to thethe extentextentthethe claimclaim isis coveredcovered underunder thethe policypolicy. .

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ANY ANY ONEONE ILLNESSILLNESS ::

Any Any oneone illnessillness willwill bebe deemeddeemed to tomeanmean continuouscontinuous periodperiod ofof illnessillness andanditit includesincludes relapserelapse withinwithin 105105 daysdays

fromfrom thethe datedate ofof dischargedischarge fromfrom thetheHospitalHospital / / nursingnursing homehome fromfrom wherewherethethe treatmenttreatment waswas ta kenta ken.. OccurrenceOccurrenceofof thethe samesame illnessillness afterafter a a lapselapse ofof105105 daysdays willwill bebe consideredconsidered as as freshfreshillnessillness. .

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EXCLUSIONSEXCLUSIONS

PrePre--existingexisting healthhealth conditioncondition or ordiseasedisease or or ailmentailment / / injuriesinjuries ::

Any Any ailmentailment / / diseasedisease / / injuriesinjuries / /

healthhealth conditioncondition whichwhich areare prepre--existingexisting ( treated( treated / / untreated,untreated, declareddeclared / / notnot declareddeclared in in thethe proposalproposal form),form),whenwhen thethe covercover inceptsincepts forfor thethe firstfirst

timetime areare excludedexcluded uptoupto 44 yearsyears ofof thethepolicypolicy beingbeing inin forceforce continuouslycontinuously

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ToTo illustrateillustrate if if aa personperson is is sufferingsufferingfromfrom hypertensionhypertension or or diabetesdiabetes or or bothbothhypertensionhypertension and and diabetesdiabetes at at thethe timetimeofof ta k ingta k ing thethe policy,policy, thenthen policypolicy shallshallbebe subjectsubject to to followingfollowing exclusionsexclusions. .

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DiabetesDiabetes HypertensionHypertension Diabetes &Diabetes &HypertensionHypertension

DiabeticDiabeticRetinopathyRetinopathy

Cerebra Vascular accidentCerebra Vascular accident Diabetic RetinopathyDiabetic Retinopathy

DiabeticDiabeticNephropathyNephropathy

Hypertensive NephropathyHypertensive Nephropathy Diabetic NephropathyDiabetic Nephropathy

Diabetic Foot /woundDiabetic Foot /wound Internal Bleed/ HaemorrhagesInternal Bleed/ Haemorrhages Diabetic Foot Diabetic Foot

Diabetic AngiopathyDiabetic Angiopathy Coronary Artery DiseaseCoronary Artery Disease Diabetic AngiopathyDiabetic Angiopathy

Diabetic NeuropathyDiabetic Neuropathy Diabetic NeuropathyDiabetic NeuropathyHyper /Hyper /HypoglycaemicHypoglycaemicshocksshocks

Hyper / HypoglycaemicHyper / Hypoglycaemicshocksshocks

Coronary Artery DiseaseCoronary Artery Disease

Cerebra Vascular accident Cerebra Vascular accident

HypertensionHypertensionNephropathyNephropathy

Internal Bleeds/Internal Bleeds/

HaemorrhagesHaemorrhages35


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Any Any diseasedisease otherother thanthan thosethose statedstatedhereunder,hereunder, contractedcontracted by by thethe InsuredInsured

personperson duringduring thethe firstfirst 3030 daysdays fromfromthethe commencementcommencement of of insuranceinsuranceexceptexcept treatmenttreatment for for accidentalaccidentalexternalexternal injuriesinjuries. .

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Polycystic ovarian diseases .Polycystic ovarian diseases . 1 1 yearyearCataract.Cataract. 2 2 Years YearsPiles.Piles. 22 Years Years

Sinusitis and related disorders.Sinusitis and related disorders. 2 2 Years Years

Gout and Rheumatism.Gout and Rheumatism. 2 2 Years Years

Joint Replacement due toJoint Replacement due toDegenerative condition.Degenerative condition.

44 Years Years

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InjuryInjury oror diseasedisease directlydirectly oror indirectlyindirectly causedcausedbyby oror arisingarising fromfrom oror attributableattributable to to War,War,Invasion,Invasion, Act Act ofof ForeignForeign Enemy,Enemy, WarWar li k elik eoperationsoperations ( whether( whether warwar bebe declareddeclared or or not)not) ororbyby nuclearnuclear weaponsweapons / / materialsmaterials. .

CircumcisionCircumcision ( unless( unless necessarynecessary forfor treatmenttreatment of ofaa diseasedisease notnot excludedexcluded hereunderhereunder or or asas maymay bebenecessitatednecessitated due due toto anyany accident),accident), vaccination,vaccination,inoculationinoculation or or changechange ofof lifelife oror cosmeticcosmetic or or ofof

aestheticaesthetic treatmenttreatment of of anyany description,description, plasticplasticsurgerysurgery otherother thanthan asas maymay bebe necessitatednecessitated due duetoto anan accidentaccident or or asas aa partpart ofof anyany illnessillness. .

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Convalescence,Convalescence, generalgeneral debility,debility, run rundowndown conditioncondition or or restrest cure,cure,congenitalcongenital externalexternal diseasesdiseases or ordefectsdefects oror anomalies,anomalies, sterility,sterility, anyanyfertility,fertility, subsub--fertilityfertility oror assistedassistedconceptionconception procedure,procedure, venerealvenerealdiseases,diseases, intentionalintentional selfself--injury/suicide,injury/suicide, all all psychiatricpsychiatric andandpsychosomaticpsychosomatic disordersdisorders andanddiseasesdiseases / / accidentaccident duedue toto andand oror use,use,misusemisuse oror abuseabuse ofof drugsdrugs / / alcoholalcohol ororuseuse ofof intoxicatingintoxicating substancessubstances or orsuchsuch abuseabuse oror addictionaddiction etcetc. .

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All All expensesexpenses arisingarising outout ofof anyany conditionconditiondirectlydirectly oror indirectlyindirectly causedcaused by,by, ororassociatedassociated withwith HumanHuman T T--cellcell LymphLymph

tropictropic Virus Virus TypeType IIIIII ( HTLD( HTLD -- III)III) ororLymohadinopathyLymohadinopathy Associated Associated Virus Virus ( LAV)( LAV)oror thethe MutantsMutants DerivativeDerivative or or Variations VariationsDeficiencyDeficiency SyndromeSyndrome or or anyany SyndromeSyndromeoror conditioncondition of of similarsimilar k indk ind commonlycommonlyreferredreferred to to asas AIDS, AIDS, HIVHIV andand itsitscomplicationscomplications includingincluding sexuallysexuallytransmittedtransmitted diseasesdiseases.. ..

ExpensesExpenses incurredincurred at at HospitalHospital oror NursingNursingHomeHome primarilyprimarily forfor evaluationevaluation / /diagnosticdiagnostic purposespurposes whichwhich isis notnotfollowedfollowed byby activeactive treatmenttreatment for for thetheailmentailment duringduring thethe hospitalisedhospitalised periodperiod. .

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ExpensesExpenses onon vitaminsvitamins andand tonicstonics etcetc unlessunlessformingforming partpart ofof treatmenttreatment for for injuryinjury oror diseasedisease

asas certifiedcertified byby thethe attendingattending physicianphysician. .

Any Any TreatmentTreatment arisingarising fromfrom oror traceabletraceable to topregnancy,pregnancy, childbirth,childbirth, miscarriage,miscarriage, caesareancaesarean

section,section, abortionabortion or or complicationscomplications of of anyany ofofthesethese includingincluding changeschanges in in chronicchronic conditioncondition as asaa resultresult ofof pregnancypregnancy. .

NaturopathyNaturopathy treatment,treatment, unprovenunproven procedureprocedure or ortreatment,treatment, experimentalexperimental or or alternativealternativemedicinemedicine andand relatedrelated treatmenttreatment includingincludingacupressure,acupressure, acupuncture,acupuncture, magneticmagnetic andand suchsuchotherother therapiestherapies etcetc. .

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ExpensesExpenses incurredincurred forfor investigationinvestigation or ortreatmenttreatment irrelevantirrelevant to to thethe diseasesdiseasesdiagnoseddiagnosed duringduring hospitalisationhospitalisation or orprimaryprimary reasonsreasons forfor admissionadmission. . PrivatePrivatenursingnursing charges,charges, ReferralReferral feefee toto familyfamilydoctors,doctors, OutOut stationstation consultantsconsultants / /SurgeonsSurgeons feesfees etc,etc,. .

GeneticallyGenetically disordersdisorders andand stemstem cellcellimplantationimplantation / / surgerysurgery. .

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ExternalExternal andand oror durabledurable MedicalMedical / / NonNonmedicalmedical equipmentequipment of of anyany k indk ind usedused forfordiagnosisdiagnosis andand oror treatmenttreatment includingincluding CPAP,CPAP,

CAPD,CAPD, InfusionInfusion pumppump etcetc. .,, Ambulatory Ambulatorydevicesdevices i i..ee.. wal k erwal k er ,, Crutches,Crutches, BeltsBelts ,Collars,Collars,Caps,Caps , , splints,splints, slings,slings, bracesbraces ,Stoc k ings,Stoc k ings etcetcofof anyany k ind,k ind, DiabeticDiabetic footfoot wear,wear,GlucometerGlucometer / / ThermometerThermometer and and similarsimilarrelatedrelated itemsitems etcetc andand alsoalso anyany medicalmedicalequipmentequipment whichwhich isis subsequentlysubsequently usedused atathomehome etcetc....

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All All nonnon medicalmedical expensesexpenses includingincluding PersonalPersonalcomfortcomfort andand convenienceconvenience itemsitems oror servicesservices suchsuchasas telephone,telephone, television,television, Aya Aya / / barberbarber ororbeautybeauty services,services, dietdiet charges,charges, babybaby food,food,cosmetics,cosmetics, nap k insnap k ins , , toiletrytoiletry itemsitems etc,etc, guestguestservicesservices andand similarsimilar incidentalincidental expensesexpenses or orservicesservices etcetc....

ChangeChange ofof treatmenttreatment fromfrom oneone pathypathy toto otherotherpathypathy unlessunless beingbeing agreedagreed / / allowedallowed andandrecommendedrecommended by by thethe consultantconsultant underunder whomwhomthethe treatmenttreatment is is ta k enta k en..

TreatmentTreatment of of obesityobesity oror conditioncondition arisingarising theretherefromfrom ( including( including morbidmorbid obesity)obesity) andand anyany otherotherweightweight controlcontrol programme,programme, servicesservices or or suppliessuppliesetcetc......

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Any Any treatmenttreatment receivedreceived in in convalescentconvalescent

home,home, convalescentconvalescent hospital,hospital, healthhealthhydro,hydro, naturenature carecare clinicclinic oror similarsimilarestablishmentsestablishments. .Any Any staystay inin thethe hospitalhospital forfor anyany domesticdomestic

reasonreason oror wherewhere nono activeactive regularregulartreatmenttreatment is is givengiven byby thethe specialistspecialist. .OutOut patientpatient Diagnostic,Diagnostic, MedicalMedical ororSurgicalSurgical proceduresprocedures or or treatments,treatments, non non--

prescribedprescribed drugsdrugs andand medicalmedical supplies,supplies,HormoneHormone replacementreplacement therapy,therapy, SexSexchangechange oror treatmenttreatment whichwhich resultsresults fromfromoror isis inin anyany wayway relatedrelated to to sexsex changechange. .

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NOTICENOTICE OFOF CLAIMCLAIM ::

ImmediateImmediate noticenotice ofof claimclaim withwith particularsparticularsrelatingrelating to to PolicyPolicy Number,Number, IDID CardCard NoNo..,,NameName ofof insuredinsured personperson in in respectrespect of ofwhomwhom claimclaim isis made,made, NatureNature ofof diseasedisease / /illnessillness / / injuryinjury andand NameName andand Address Address ofof

thethe attendingattending medicalmedical practitionerpractitioner / /Hospital/NursingHospital/Nursing HomeHome etcetc. . shouldshould bebegivengiven toto thethe CompanyCompany / / TPATPA whilewhile ta k ingta k ingtreatmenttreatment in in thethe HospitalHospital / / NursingNursing HomeHomebyby Fax,Fax, EmailEmail. . SuchSuch noticenotice shouldshould bebe givengiven

withinwithin 4848 hourshours ofof admissionadmission or or beforebeforedischargedischarge fromfrom HospitalHospital / / NursingNursing Home,Home,unlessunless waivedwaived inin writingwriting. .

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CLAIMCLAIM DOCUMENTSDOCUMENTS::

FinalFinal claimclaim alongalong withwith hospitalhospitalreceiptedreceipted originaloriginal Bills/CashBills/Cashmemos/reports,memos/reports, claimclaim formform andand listlistofof documentsdocuments as as listedlisted belowbelow shouldshouldbebe submittedsubmitted to to thethe CompanyCompany / / TPATPAwithinwithin 7 7 daysdays ofof dischargedischarge fromfrom thetheHospitalHospital / / NursingNursing HomeHome. .

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O i i l bill i d di hO i i l bill i d di h


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Original bills, receipts and dischargeOriginal bills, receipts and dischargecertificate / card from the hospital.certificate / card from the hospital.Medical history of the patient recordedMedical history of the patient recorded

by the Hospital.by the Hospital.Original CashOriginal Cash- -memo from the hospitalmemo from the hospital( s) / chemist ( s) supported by proper( s) / chemist ( s) supported by properprescription.prescription.

Original receipt, pathological and otherOriginal receipt, pathological and othertest reports from a pathologist /test reports from a pathologist /radiologist including film etc supportedradiologist including film etc supportedby the note from attending medicalby the note from attending medical

practitioner / surgeon demanding suchpractitioner / surgeon demanding suchtests.tests.Attending Consultants / Anaesthetists / Attending Consultants / Anaesthetists /Specialist certificates regardingSpecialist certificates regardingdiagnosis and bill / receipts etc.diagnosis and bill / receipts etc. 49

A h i f i i d b A /A h i f i i d b A /


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Any other information required by TPA / Any other information required by TPA /Insurance Company.Insurance Company.

All documents must be duly attested by All documents must be duly attested by

the insured person.the insured person.InIn casecase ofof postpost hospitalisationhospitalisation treatmenttreatment( limited( limited toto 6060 days)days) allall supportingsupporting claimclaimpaperspapers / / documentsdocuments as as listedlisted aboveabove shouldshouldalsoalso bebe submittedsubmitted withinwithin 7 7 daysdays afteraftercompletioncompletion of of suchsuch treatmenttreatment (( uptoupto 6060daysdays oror actualactual periodperiod whichwhich everever isis lessless ) ) totothethe CompanyCompany / / TT..PP..A A.. InIn additionaddition insuredinsuredshouldshould alsoalso provideprovide thethe CompanyCompany / / TPATPAsuchsuch additionaladditional informationinformation andand assistanceassistanceasas thethe CompanyCompany / / TPATPA maymay requirerequire in indealingdealing withwith thethe claimclaim. . 50


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PROCEDURE FOR AVAILING CASHLESS ACCESSPROCEDURE FOR AVAILING CASHLESS ACCESSSERVICES IN NETWORK HOSPITAL/NURSING HOMESERVICES IN NETWORK HOSPITAL/NURSING HOME

ClaimClaim inin respectrespect of of CashlessCashless Access Access ServicesServices willwillbebe throughthrough thethe TPATPA providedprovided admissionadmission is is inin aalistedlisted hospitalhospital in in thethe agreedagreed listlist ofof thethenetwor k ednetwor k ed HospitalsHospitals / / NursingNursing HomesHomes andand isissubjectsubject to to prepre admissionadmission authorizationauthorization. . TheThe TPATPAshall,shall, uponupon gettinggetting thethe relatedrelated medicalmedical detailsdetails / /relevantrelevant informationinformation fromfrom thethe insuredinsured personperson / /networ knetwor k HospitalHospital / / NursingNursing Home,Home, verifyverify thatthat thethepersonperson is is eligibleeligible toto claimclaim underunder thethe policypolicy andandafterafter satisfyingsatisfying itselfitself willwill issueissue a a prepre--authorisationauthorisation letterletter / / guaranteeguarantee of of paymentpaymentletterletter toto thethe HospitalHospital / / NursingNursing HomeHomementioningmentioning the the sumsum guaranteedguaranteed as as payable,payable, alsoalsothethe ailmentailment forfor whichwhich thethe personperson is is see k ingsee k ing toto bebeadmittedadmitted as as inin--patientpatient. .

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TheThe TPATPA reservesreserves thethe rightright toto denydeny prepre--authorisationauthorisation in in casecase thethe hospitalhospital / /

insuredinsured personperson is is unableunable toto provideprovide thetherelevantrelevant informationinformation / / medicalmedical detailsdetails asasrequiredrequired byby thethe TPATPA.. InIn suchsuchcircumstancescircumstances denialdenial ofof CashlessCashless Access Accessshouldshould inin nono wayway bebe construedconstrued as as denialdenialofof claimclaim. . TheThe insuredinsured personperson maymay obtainobtainthethe treatmenttreatment as as perper his/herhis/her treatingtreatingdoctor sdoctor s adviceadvice andand laterlater onon submitsubmit thethefullfull claimclaim paperspapers to to thethe TPATPA forforreimbursementreimbursement withinwithin 7 7 daysdays ofof thethedischargedischarge fromfrom HospitalHospital / / NursingNursing HomeHome. .

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Should any information be availableShould any information be availableto the TPA which ma k es the claimto the TPA which ma k es the claiminadmissible or doubtful requiringinadmissible or doubtful requiringinvestigations, the authorisation ofinvestigations, the authorisation ofcashless facility may be withdrawn.cashless facility may be withdrawn.However this shall be done by theHowever this shall be done by the

TPA before the patient is dischargedTPA before the patient is dischargedfrom the Hospital.from the Hospital.

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REPUDIATIONREPUDIATION

A A ( I)( I) :: TheThe TPA,TPA, ifif policypolicy isis beingbeing servicedserviced byby them,them,

shallshall repudiaterepudiate thethe claimclaim ifif notnot coveredcovered / / notnotpayablepayable underunder thethe policypolicy. . TheThe TPATPA shallshall mentionmention thethereasonsreasons forfor repudiationrepudiation in in writingwriting toto thethe insuredinsuredpersonperson. . TheThe insuredinsured personperson shallshall havehave thethe rightright totoappealappeal / / approachapproach thethe policypolicy issuingissuing officeoffice ofof thethe

insuranceinsurance companycompany if if hehe / / sheshe feelsfeels thatthat thethe claimclaim isispayablepayable. . TheThe insuranceinsurance company scompany s decisiondecision in in thisthisregardregard willwill bebe finalfinal andand bindingbinding onon TPATPA..

A A (( II)II) :: IfIf policypolicy isis servicedserviced byby InsuranceInsurance Company,Company,inin casecase ofof repudiationrepudiation of of claim,claim, insuredinsured shallshall havehavethethe rightright toto appealappeal toto thethe concernedconcerned RegionalRegional OfficeOfficeofof thethe InsuranceInsurance Company,Company, if if he/shehe/she feelsfeels thatthat thetheclaimclaim isis payablepayable

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BB :: If If claimclaim isis repudiatedrepudiated byby thethe companycompany asasperper A A ((11)) && A A (II)(II) but but thethe insuredinsured feelsfeels that that hishis / / herher claimclaim isis payablepayable thenthen insuredinsuredpersonperson shallshall havehave aa right right toto appealappeal / /approachapproach thethe GrievanceGrievance CellCell of of thethe

CompanyCompany. .

CC:: TheThe CentralCentral Government Government hashas establishedestablished

anan officeoffice of of thethe InsuranceInsurance OmbudsmanOmbudsman forforredressalredressal of of grievancesgrievances of of uptoupto RsRs 2020 lacslacsrelatedrelated toto personalpersonal lineslines of of insurancesinsurances ..

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FRAUD / MISREPRESENTATION /FRAUD / MISREPRESENTATION /CONCEALMENTCONCEALMENT

CONTRIBUTIONCONTRIBUTION

CANCELLATION CLAUSECANCELLATION CLAUSE

ARBITRATION CLAUSE ARBITRATION CLAUSE

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COSTCOST OFOF HEALTHHEALTH CHECKCHECK ::

TheThe InsuredInsured shallshall bebe entitledentitled forforreimbursementreimbursement of of costcost ofof HealthHealthchec kchec k upup underta k enunderta k en onceonce atat thetheexpiryexpiry ofof aa bloc kbloc k ofof everyevery fourfour

continuouscontinuous claimclaim freefree underwritingunderwritingyearsyears providedprovided therethere areare nono claimsclaimsreportedreported duringduring thethe bloc kbloc k .. TheThe costcost

soso reimbursablereimbursable shallshall notnot exceedexceed thetheamountamount equalequal toto 11%% ofof thethe averageaveragebasicbasic sumsum InsuredInsured duringduring thethe bloc kbloc k ofoffourfour claimclaim freefree underwritingunderwriting yearsyears. .

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PREPRE--ACCEPTANCE HEALTH CHECKUP ACCEPTANCE HEALTH CHECKUP

Age Age 4545--5555 ABOVE 55 Years ABOVE 55 YearsPHYSICAL EXAMINATIONPHYSICAL EXAMINATION PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

URINE ( MICROALBUMIN UREA)URINE ( MICROALBUMIN UREA) URINE ( MICROALBUMIN UREA)URINE ( MICROALBUMIN UREA)

MEDICALMEDICALTESTTEST

GLYCOCYLATED, HAEMOGLOBINGLYCOCYLATED, HAEMOGLOBIN GLYCOCYLATED HAEMOGLOBINGLYCOCYLATED HAEMOGLOBIN

ULTRASONOGRAPHY ( WHOLEULTRASONOGRAPHY ( WHOLE ABDOMEN AND PELVIS) ABDOMEN AND PELVIS)

ULTRASONOGRAPHY ( WHOLEULTRASONOGRAPHY ( WHOLE ABDOMEN AND PELVIS) ABDOMEN AND PELVIS)

ELECTRO CARDIO GRAMELECTRO CARDIO GRAM XX--RAY BOTH KNEESRAY BOTH KNEES( ANTEPOSTERIOR AND( ANTEPOSTERIOR ANDLATREL)LATREL)

COMPLETE EYE TEST INCLUDINDCOMPLETE EYE TEST INCLUDINDFUNDUS ETCFUNDUS ETC

COMPLETE EYE TESTCOMPLETE EYE TESTINCLUDIND FUNDUS ETCINCLUDIND FUNDUS ETC

STRESS TEST ( TMT)STRESS TEST ( TMT)

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SUMSUM INSUREDINSURED ::

TheThe Company sCompany s liabilityliability inin respectrespect of of allallclaimsclaims admittedadmitted duringduring thethe periodperiod ofofInsuranceInsurance shallshall notnot exceedexceed thethe sumsum

insuredinsured optedopted byby thethe InsuredInsured personperson..MinimumMinimum sumsum insuredinsured is is RsRs 5050,,000000/ /--andand inin multiplesmultiples of of RsRs 2525,,000000/ /-- uptouptoRsRs 22,, 0000,,000000/ /--.. BeyondBeyond thethe SumSumInsuredInsured of of RsRs.. 200000200000/ /-- inin multiplesmultiples of ofRsRs.. 5000050000/ /-- uptoupto RsRs 500000500000/ /--..

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7f3d3Module-III Mediclaim Insurance Individual)

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Transcript of 7f3d3Module-III Mediclaim Insurance Individual)