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Module-III Mediclaim Insurance (Individual):

Module-III Mediclaim Insurance (Individual) 1


MEDICLAIM INSURANCE POLICY ( INDIVIDUALS ) Any insured Person shall contract any disease or suffer from any illness / ailment / disease or sustain any bodily injury through accident and if such disease or injury shall require an attention of Medical Specialist/Medical Practitioner, Surgeon to incur (a) hospitalisation expenses for medical/surgical treatment at any Nursing Home/Hospital in India as an inpatient OR (b) on domiciliary treatment in India under Domiciliary Hospitalisation Benefits, the TPA will pay to the Hospitals (only if treatment is taken at Network Hospital(s) with prior consent of TPA) or to the insured person if policy is serviced by the TPA .Otherwise the Company will pay to the Insured Person. But not exceeding the sum insured in aggregate in any one period of insurance. 2


REASONABLE & CUSTOMARY EXPENSES REIMBURSABLE UNDER THE POLICY Room, Boarding and Nursing Expenses as provided by the Hospital /Nursing Home not exceeding 1 % of the Sum Insured or Rs. 5000 /- per day whichever is less. I.C. Unit expenses not exceeding 2% of the Sum Insured or Rs. 10,000 /- per day whichever is less.. (Room including I.C.U. stay should not exceed total number of admission days). 3

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Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees. Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, Cost of Prosthetic devices implanted during surgical procedure like pacemaker, Relevant Laboratory / Diagnostic test, X-Ray etc. 4

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Ambulance services - 1% of the sum insured or Rs 2000/- whichever is less shall be reimbursable in case patient has to be shifted from residence to hospital in case of admission in Emergency Ward / I.C.U. or from one Hospital / Nursing home to another Hospital / Nursing Home by registered ambulance only for better medical facilities. 5

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Note: 1. Company’s Liability in respect of all claims admitted during the Period of insurance shall not exceed the Sum Insured per Person mentioned in the Schedule. 2.Hospitalization expenses incurred for donating an organ by the donor (excluding cost of organ if any) to the insured person during the course of organ transplant will also be payable. However in any case the liability of the Company will be limited to over all Sum Insured of the Insured Person. 6


DEFINITIONS ‘‘HOSPITAL/NURSING HOME: means any institution in India established for indoor care and treatment of sickness and injuries and which either Is duly licensed and registered as a Hospital or Nursing Home with the appropriate authorities and is under the supervision of a registered and qualified Medical Practitioner. OR In areas where licensing and registration facilities with appropriate authorities are not available, the institution must be one recognised in locality as Hospital / Nursing Home and should comply with minimum criteria as under 7

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It should have at least 15 in-patient medical beds in case of Metro cities, A Class cities & B class cities or 10 in- patient medical beds in case of “C class” cities. Classification of cities shall be as per Govt of India Notifications issued in this respect from time to time. Fully equipped and engaged in providing Medical and Surgical facilities along with Diagnostic facilities i.e. Pathological test and X-ray, E.C.G. etc for the care and treatment of injured or sick persons as in-patient. 8

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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 physically in-charge round the clock. 9

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Note: 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 a place for alcoholics, a hotel or a similar place. In case of Ayurvedic / Homeopathic / Unani treatment, Hospitalisation expenses are admissible only when the treatment is taken as in-patient, in a Government Hospital / Medical College Hospital. 10

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Surgical Operation’ means manual and/ or operative procedures for correction of deformities / defects and injuries, cure of diseases, relief of suffering and prolongation of life. 11


HOSPITALISATION PERIOD Expenses on Hospitalisation are admissible only if hospitalisation is for a minimum period of 24 hours. (A) This time limit will not apply to following specific treatments taken in the Networked Hospital / Nursing Home where the Insured is discharged on the same day. Such treatment will be considered to be taken under Hospitalisation Benefit. 12

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Haemic Dialysis, Parental Chemotherapy, Radiotherapy, Eye Surgery, Lithotripsy (kidney stone removal), Tonsillectomy, D&C Dental surgery following an accident Hysterectomy Coronary Angioplasty Coronary Angiography Surgery of Gall bladder, Pancreas and bile duct Surgery of Hernia 13

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Surgery of Hydrosol. Surgery of Prostrate. Gastrointestinal Surgery. Genital Surgery. Surgery of Nose. Surgery of throat. Surgery of Appendix. Surgery of Urinary System. Treatment of fractures / dislocation excluding hair line fracture, Contracture releases and minor reconstructive procedures of limbs which otherwise require hospitalisation. Arthroscopic Knee surgery. Laparoscopic therapeutic surgeries. Any surgery under General Anaesthesia. Or any such disease / procedure agreed by TPA/Company before treatment. 14


DAY CARE CENTRE The requirement of minimum beds will be overlooked provided following conditions are met. The operation theatre is fully equipped for the surgical operation required in respect of sickness / ailment / injury covered under the policy. Day Care nursing staff is fully qualified. The doctor performing the surgery or procedure as well as post operative attending doctors are also fully qualified for the specific surgery / procedure. 15

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This condition of minimum 24 hours Hospitalisation will also not apply provided The treatment is such that it necessitates hospitalisation and the procedure involves specialised infrastructural facilities available only in hospitals, But due to technological advances hospitalisation is required for less than 24 hours. AND / OR Surgical procedure involved has to be done under General Anaesthesia. 16

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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 as in-patient but actually taken whilst confined at home in India under any of the following circumstances namely: 18

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The condition of the patient is such that he/she cannot be removed to the Hospital/Nursing Home OR The patient cannot be removed to Hospital/Nursing home due to lack of accommodation in any hospital in that city / town / village. 19

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Subject to the condition that Domiciliary Hospitalisation benefit shall not cover Expenses incurred for pre and post hospital treatment and Expenses incurred for treatment for any of the following diseases : 20

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Asthma Bronchitis, Chronic Nephritis and Nephritic Syndrome, Diarrhoea and all types of Dysenteries including Gastro-enteritis, Diabetes Mellitus and Insipidus, Epilepsy, Hypertension, 21

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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. 22


OTHER DEFINITIONS AND INTERPRETATIONS INSURED PERSON : Means Person(s) named on the schedule of the policy. ENTIRE CONTRACT: The policy / proposal and declaration given by the insured constitute the complete contract of the policy. Only Insurer may alter the terms and conditions of this policy. Any alteration that may be made by the insurer shall only be evidenced by a duly signed and sealed endorsement on the policy. 23

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THIRD PARTY ADMINISTRATOR (TPA): means any Company who has obtained licence from IRDA to practice as a third party administrator and is appointed by the Company. NETWORK HOSPITAL: means hospital that has agreed with the TPA to participate for providing cashless health services to the insured persons. The list is maintained by and available with the TPA and the same is subject to amendment from time to time. 24

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HOSPITALISATION PERIOD: The period for which an insured person is admitted in the hospital as inpatient and stays there for the sole purpose of receiving the necessary and reasonable treatment for the disease / ailment contracted / injuries sustained during the period of policy. The minimum period of stay shall be 24 hours 25

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PRE-HOSPITALISATION: Relevant medical expenses incurred during the period upto 30 days prior to hospitalisation on disease/ illness/ injury sustained will be considered as part of claim. 26

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POST-HOSPITALISATION: Relevant medical expenses incurred for the period of 60 days after hospitalisation on disease/illness/injury sustained will be considered as part of claim. 27

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MEDICAL PRACTITIONER: means a person who holds a degree/diploma of a recognised institution and is registered by Medical Council of any State 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 28

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PRE EXISTING HEALTH CONDITION OR DISEASE: means any ailment / disease / injuries that the person is suffering from, (treated / untreated, declared or not declared in the proposal form) while taking a policy for the first time. Further any complications arising from pre-existing ailment / disease / injuries will be considered as a part of that pre existing health condition. 29

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IN-PATIENT: An Insured person who is admitted to hospital and stays for at least 24 hours for the sole purpose of receiving the treatment for suffered ailment / illness / disease / injury / accident during the currency of the policy. 30

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CASHLESS FACILITY: means the TPA may authorise upon the Insured's request for direct settlement of admissible claim as per agreed charges between Net work Hospitals & the TPA. In such cases the TPA will directly settle all eligible amounts with the Net work Hospitals and the Insured Person may not have to pay any bills after the end of the treatment at Hospital to the extent the claim is covered under the policy. 31

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ANY ONE ILLNESS: Any one illness will be deemed to mean continuous period of illness and it includes relapse within 105 days from the date of discharge from the Hospital / nursing home from where the treatment was taken. Occurrence of the same illness after a lapse of 105 days will be considered as fresh illness. 32


EXCLUSIONS Pre-existing health condition or disease or ailment / injuries: Any ailment / disease / injuries / health condition which are pre-existing (treated / untreated, declared / not declared in the proposal form), when the cover incepts for the first time are excluded upto 4 years of the policy being in force continuously 33

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To illustrate if a person is suffering from hypertension or diabetes or both hypertension and diabetes at the time of taking the policy, then policy shall be subject to following exclusions. 34

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Diabetes Hypertension Diabetes & Hypertension Diabetic Retinopathy Cerebra Vascular accident Diabetic Retinopathy Diabetic Nephropathy Hypertensive Nephropathy Diabetic Nephropathy Diabetic Foot /wound Internal Bleed/ Haemorrhages Diabetic Foot Diabetic Angiopathy Coronary Artery Disease Diabetic Angiopathy Diabetic Neuropathy Diabetic Neuropathy Hyper / Hypoglycaemic shocks Hyper / Hypoglycaemic shocks Coronary Artery Disease Cerebra Vascular accident Hypertension Nephropathy Internal Bleeds/ Haemorrhages 35

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Any disease other than those stated hereunder, contracted by the Insured person during the first 30 days from the commencement of insurance except treatment for accidental external injuries. 36

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Polycystic ovarian diseases . 1 year Cataract. 2 Years Piles. 2 Years Sinusitis and related disorders. 2 Years Gout and Rheumatism. 2 Years Joint Replacement due to Degenerative condition. 4 Years 37

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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) or by nuclear weapons / materials. Circumcision (unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to any accident), vaccination, inoculation or change of life or cosmetic or of aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness. 38

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Surgery for correction of eye sight, cost of spectacles, contact lenses, hearing aids etc. Any dental treatment or surgery which is corrective, cosmetic or of aesthetic procedure, filling of cavity, root canal including wear and tear etc unless arising from disease or injury and which requires hospitalisation for treatment.

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Convalescence, general debility, “run down” condition or rest cure, congenital external diseases or defects or anomalies, sterility, any fertility, sub-fertility or assisted conception procedure, venereal diseases, intentional self-injury/suicide, all psychiatric and psychosomatic disorders and diseases / accident due to and or use, misuse or abuse of drugs / alcohol or use of intoxicating substances or such abuse or addiction etc. 40

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All expenses arising out of any condition directly or indirectly caused by, or associated with Human T-cell Lymph tropic Virus Type III (HTLD - III) or Lymohadinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome or condition of similar kind commonly referred to as AIDS, HIV and its complications including sexually transmitted diseases.. Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic purposes which is not followed by active treatment for the ailment during the hospitalised period. 41

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Expenses on vitamins and tonics etc unless forming part of treatment for injury or disease as certified by the attending physician. Any Treatment arising from or traceable to pregnancy, childbirth, miscarriage, caesarean section, abortion or complications of any of these including changes in chronic condition as a result of pregnancy. Naturopathy treatment, unproven procedure or treatment, experimental or alternative medicine and related treatment including acupressure, acupuncture, magnetic and such other therapies etc. 42

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Expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalisation or primary reasons for admission. Private nursing charges, Referral fee to family doctors, Out station consultants / Surgeons fees etc,. Genetically disorders and stem cell implantation / surgery. 43

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External and or durable Medical / Non medical equipment of any kind used for diagnosis and or treatment including CPAP, CAPD, Infusion pump etc., Ambulatory devices i.e. walker , Crutches, Belts ,Collars ,Caps , splints, slings, braces ,Stockings etc of any kind, Diabetic foot wear, Glucometer / Thermometer and similar related items etc and also any medical equipment which is subsequently used at home etc.. 44

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All non medical expenses including Personal comfort and convenience items or services such as telephone, television, Aya / barber or beauty services, diet charges, baby food, cosmetics, napkins , toiletry items etc, guest services and similar incidental expenses or services etc.. Change of treatment from one pathy to other pathy unless being agreed / allowed and recommended by the consultant under whom the treatment is taken. Treatment of obesity or condition arising there from (including morbid obesity) and any other weight control programme, services or supplies etc... 45

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Any treatment received in convalescent home, convalescent hospital, health hydro, nature care clinic or similar establishments. Any stay in the hospital for any domestic reason or where no active regular treatment is given by the specialist. Out patient Diagnostic, Medical or Surgical procedures or treatments, non-prescribed drugs and medical supplies, Hormone replacement therapy, Sex change or treatment which results from or is in any way related to sex change. 46

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NOTICE OF CLAIM: Immediate notice of claim with particulars relating to Policy Number, ID Card No., Name of insured person in respect of whom claim is made, Nature of disease / illness / injury and Name and Address of the attending medical practitioner / Hospital/Nursing Home etc. should be given to the Company / TPA while taking treatment in the Hospital / Nursing Home by Fax, Email. Such notice should be given within 48 hours of admission or before discharge from Hospital / Nursing Home, unless waived in writing. 47

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CLAIM DOCUMENTS: Final claim along with hospital receipted original Bills/Cash memos/reports, claim form and list of documents as listed below should be submitted to the Company / TPA within 7 days of discharge from the Hospital / Nursing Home. 48

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Original bills, receipts and discharge certificate / card from the hospital. Medical history of the patient recorded by the Hospital. Original Cash-memo from the hospital (s) / chemist (s) supported by proper prescription. Original receipt, pathological and other test reports from a pathologist / radiologist including film etc supported by the note from attending medical practitioner / surgeon demanding such tests. Attending Consultants / Anaesthetists / Specialist certificates regarding diagnosis and bill / receipts etc. 49

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Any other information required by TPA / Insurance Company. All documents must be duly attested by the insured person. In case of post hospitalisation treatment (limited to 60 days) all supporting claim papers / documents as listed above should also be submitted within 7 days after completion of such treatment ( upto 60 days or actual period which ever is less ) to the Company / T.P.A. In addition insured should also provide the Company / TPA such additional information and assistance as the Company / TPA may require in dealing with the claim. 50


PROCEDURE FOR AVAILING CASHLESS ACCESS SERVICES IN NETWORK HOSPITAL/NURSING HOME Claim in respect of Cashless Access Services will be through the TPA provided admission is in a listed hospital in the agreed list of the networked Hospitals / Nursing Homes and is subject to pre admission authorization. The TPA shall, upon getting the related medical details / relevant information from the insured person / network Hospital / Nursing Home, 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 in-patient. 51

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The TPA reserves the right to deny pre-authorisation in case the hospital / insured person is unable to provide the relevant information / medical details as required by the TPA. In such circumstances denial of Cashless Access should in no way be construed as denial of claim. 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 within 7 days of the discharge from Hospital / Nursing Home. 52

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Should any information be available to the TPA which makes the claim inadmissible or doubtful requiring investigations, the authorisation of cashless facility may be withdrawn. However this shall be done by the TPA before the patient is discharged from the Hospital. 53


REPUDIATION A (I): The TPA, if policy is being serviced by them, shall repudiate the claim if not covered / not payable under the policy. The TPA shall mention the reasons for repudiation in writing to the insured person. The insured person shall have the right to appeal / approach the policy issuing office of 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 on TPA. A ( II): If policy is serviced by Insurance Company, in case of repudiation of claim, insured shall have the right to appeal to the concerned Regional Office of the Insurance Company, if he/she feels that the claim is payable 54

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B : If claim is repudiated by the company as per A (1) & A (II) but the insured feels that his / her claim is payable then insured person shall have a right to appeal / approach the Grievance Cell of the Company. C: The Central Government has established an office of the Insurance Ombudsman for redressal of grievances of upto Rs 20 lacs related to personal lines of insurances . 55

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COST OF HEALTH CHECK : The Insured shall be entitled for reimbursement of cost of Health check up undertaken once at the expiry of a block of every four continuous claim free underwriting years provided there are no claims reported during the block. The cost so reimbursable shall not exceed the amount equal to 1% of the average basic sum Insured during the block of four claim free underwriting years. 57



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SUM INSURED: The Company’s liability in respect of all claims admitted during the period of Insurance shall not exceed the sum insured opted by the Insured person. Minimum sum insured is Rs 50,000/- and in multiples of Rs 25,000/- upto Rs 2, 00,000/-. Beyond the Sum Insured of Rs. 200000/- in multiples of Rs. 50000/- upto Rs 500000/-. 59

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