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Health Insurance

All the below mentioned points will differ as per different plans and insurance service providers.  
 

In Patient treatment 

Covers Hospital expenses for admission longer than 24 hours.

Pre & Post Hospitalisation

Medical Expenses incurred due to Illness up to 30 days or 60 days period immediately before and 60 days or 90 days or 180 days immediately after an Insured Person’s admission to a Hospital. 

Day Care Procedure

Medical expenses for day care procedures where such procedures are undertaken by an Insured Person as an Inpatient in a Hospital for continuous period of less than 24 hours.

In Patient AYUSH Hospitalisation

Reimbursement of expenses for AYUSH treatment. Expenses for AYUSH treatment is considered only when the treatment has been undergone in a Government Hospital or in any Institute recognised by the Government and/or accredited by Quality Council of India/National Accreditation Board on Health.

 

Domestic Road Emergency Ambulance

Ambulance expenses incurred to transfer the Insured Person following an emergency to the nearest Hospital. 

 

Cover of Pre Existing disease

2 years , 3 years or 4 years depending on Insurance service provider.

 

Reset Benefit

Top-up plans that offer reset benefit allows for upto 100% reset of the sum insured once in a policy year. This option automatically comes into operation when the sum insured (including the accrued additional sum insured, if any) is insufficient because of previous, unrelated claims in the same policy year.

 

Hospital Daily Cash

 Allowance per day for hospital stay of minimum 3 consecutive days or more up to a maximum of 10 consecutive days.

 

Convalescence Benefit

Some amount is provided once for each Policy year during Policy Period, in case of Hospitalisation of minimum 10 consecutive days or more.

 

Critical Illness

Critical Illness cover for specified critical Illnesses/medical procedures like Cancer of specified severity, open chest CABG, First heart attack, major organ/bone marrow transplant, permanent paralysis of limbs, Kidney failure requiring regular dialysis, end stage liver disease; subject to a maximum of 2 adults. 

 

Organ Donor Expenses

Medical Expenses incurred in respect of the donor for any of the organ transplant surgery, provided the organ donated is for Insured persons, subject to a maximum of 2 adults. 

 

Value Added Services

• Free health check-up coupon to Insured for every Policy Year, subject to a maximum of 2 coupons per year for floater policies.

• Online Chat with Medical Practitioners

• Specialist e-Consultation with One Follow-up session

• Diet & Nutrition e-consultation

 
What are the major Exclusions in the Policy

Note: Following is an indicative list of the policy exclusions. Please refer to the policy clause for the complete list.

• Acupressure, acupuncture, magnetic and such other therapies

• Unproven experimental treatment

• Any expenses arising out of Domiciliary Treatment

• Treatment taken outside the country

• Cosmetic surgery

• Venereal diseases or any sexually transmitted diseases

• Dental treatment unless due to accident

 

Waiting Period

(a) Pre-existing diseases: Covered after 24 months or 36 after  months or 48 after Months depending upon the insurance provider.
(b) Specific waiting period: First 24 months or First 36 months or First 48 months for specific Illness and treatment. 
(c) In case of hypertension, diabetes and cardiac conditions, the waiting period will be 90 days unless disclosed as pre-existing
(d) Initial waiting period: 30 days for all illnesses (except Hospitalisation due to injury).

 

Payout Basis 

• Cashless or Reimbursement of covered medical expenses up to specified Sum Insured as per the scope of cover.

• Claim Service Guarantee

• Cashless Facility available at network hospitals.

 

Renewal Condition 

(a) Maximum renewal age – There will be life-long renewable without any age restriction for the cover. However Premium at the time of renewal is subject to change with change in age band.

(b) Grace Period – The renewal premium shall be paid to Us on or before the date of expiry of the Policy and in no case later than 30 days (Grace Period) from the expiry of the Policy.

(c) Floater Benefit – The floater benefit under this policy is available up to lifetime.

 

Renewal Benefits 

(a) Cumulative Bonus (Additional Sum Insured) – An Additional Sum Insured of 10% of Annual Sum Insured provided on each renewal for every claimfree year up to a maximum of 50%. In case of a claim under the policy, the accumulated Additional Sum Insured will be reduced by 10% of the Annual Sum Insured in the following year.

(b) Complimentary Health Check Up Coupons: One coupon per individual policy and two coupons per Floater policy will be offered.

 

Cancellation 

a) Disclosure to information norm: The policy shall be void and all premium paid hereon shall be forfeited to the company, in the event of misinterpretation, mis-description or non-disclosure of any material fact.

b) One can cancel the Policy by giving  15 days written notice for the cancellation of the Policy by registered post, and then the Insurance service provider will refund premium on short term rates for the unexpired Policy Period.

 

Day Care Centre

Day care centre means any institution established for day care treatment of illness and/or injuries or a medical setup with a hospital and which has been registered with the local authorities, wherever applicable, and is under supervision of a registered and qualified medical practitioner AND must comply with all minimum criterion as under.
i. has qualified nursing staff under its employment
ii. has qualified medical practitioner/s in charge
iii. has fully equipped operation theatre of its own where surgical procedures are carried out
iv. maintains daily records of patients and will make these accessible to the insurance company’s authorized personnel.

 

Domiciliary Hospitalisation

Domiciliary Hospitalisation means medical treatment for an illness/ disease/ injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances:

i. The condition of the patient is such that he/ she is not in a condition to be removed to a hospital, or

ii. The patient takes treatment at home on account of non availability of room in a hospital

 

Dental Treatment

Dental treatment implants means a treatment related to teeth or structures supporting teeth including examinations, fillings (where appropriate), crowns, extractions and surgery. The maximum limit is provided by the insurance service provider.

 

Emergency Care

Emergency care is management for a severe illness or injury which results in symptoms which occur suddenly and unexpectedly, and require immediate care by a medical practitioner to prevent death or serious long term impairment of insured’s personal health.

 

Maternity Expenses 

Maternity Expenses shall include –
i. Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during Hospitalisation)
ii. Expenses towards lawful medical termination of pregnancy during the policy period.

 

For Cashless Settlement

Cashless treatment is only available at a Network Provider. In order to avail of cashless treatment, the following procedure must be followed by Insured: 

Pre-authorization Prior to taking treatment and/ or incurring Medical Expenses at a Network Provider, Insured must contact the insurance service provider in house claim processing team accompanied with full particulars namely, Policy Number, Insured name,  insured relationship with Policy Holder, nature of Illness or Injury, name and address of the Medical may be relevant to the Illness/ Injury/ Hospitalisation.Practitioner/ Hospital and any other information that may be relevant to the Illness/ Injury/ Hospitalisation.

Insured person must request preauthorization at least 48 hours before a planned Hospitalisation and in case of an emergency situation , with in 24 hours of Hospitalisation. To avail of Cashless Hospitalisation facility, you are required to produce the health card, as provided to You with this Policy, subject to the terms and conditions for the usage of the said health card Or One can seek pre authorization by providing Policy number and ID proof to the hospital who can coordinate with claim team to provide cashless facility. Insurance service provider will consider the request after having obtained accurate and complete information for the Illness or Injury for which cashless Hospitalisation facility is sought by insured person and will confirm the request in writing.

 
   

Admin- Rajen Gala

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