Individual Mediclaim Insurance Policy

Introduction

This policy covers hospitalisation and domiciliary hospitalisation expenses incurred by the Insured (including family members) for illness / disease or accidental injury and shall include hospital charges (room & boarding and operation theatre), fees of surgeon, anesthetist, nurses, cost of medicine, oxygen, blood, cost of appliances like pacemaker, artificial limbs and cost of organs.

Scope of Cover

• The Policy offers the feature of Third Party Administrator services.
• The Policy covers illness / disease or accidental injury leading to expenses of various types referred to above.
• Hospitalization expenses and domiciliary hospitalisation expenses referred to above shall be subject to a maximum of the sum insured at inception of the policy.
• The Policy covers individuals aged between 5 and 75 years. However, children aged between 3 months and 5 years can be covered if one or both parents are covered concurrently.
• Exemption under section 80 (D) of the Income Tax Act, 1961 is presently available for premium paid by cheque.
• The Insured is entitled to reimbursement of the cost of medical check-up once at the end of a block of every four underwriting years provided there were no claims reported during the block. The cost so reimbursable shall not exceed an amount equal to 1% of the average sum insured during the block of four underwriting years.
• The sum insured under the policy shall be progressively increased by 5% in respect of each claim free year of insurance subject to a maximum accumulation of 10 claim free years of insurance. In the event of a claim under the policy in respect of an Insured Person who has earned any cumulative bonus, the increased sum insured will be reduced by 10 % at the time of renewal. However, the basic sum insured will be maintained at all times.

Exclusion

• The policy will not cover expenses relating to-
• Treatment of asthma, chronic nephritis and nephritis syndrome, gastro-enteritis, diabetes mellitus and insipidus, epilepsy, hypertension, influenza, cough and cold, all psychiatric or psychosomatic disorders, pyrexia of unknown origin for less than 10 days, tonsillitis and URTI, arthritis, rheumatism (as far as domiciliary hospitalisation is concerned).
• Any treatment relating to any illness / disease already in existence at the time of proposal.
• Any disease / injury during first 30 days of commencement of policy (accidental injury is not an exclusion).
• Treatment of cataract, benign prosthetic hypertrophy, hysterectomy for menorrhagia on fibromyoma, hernia, bydorcele, congenital internal disease, fistula in anus, sinusitis and related disorders during first year of cover.
• Vaccination, inoculation, circumcision or change of life or cosmetic or aesthetic treatment, plastic surgery unless necessitated due to accident or as a part of any illness.
• Dental treatment or surgery of any kind unless requiring hospitalisation.
• Cost of spectacles contact lenses and hearing aids.
• Convalescence, general debility. “run-down” condition, sterility, venereal disease, intentional self-injury, use of drugs and and intoxicants.
• Any variation of deficiency syndrome or AIDS.
• Hospital / nursing home charges not consistent with or incidental to the diagnosis and treatment: vitamins, tonics not forming part of any treatment.
• Treatment arising from or traceable to pregnancy or child birth.
• Voluntary medical termination of pregnancy within first 12 weeks of confinement.
• Nuclear perils and war group of perils.
• Naturopathy treatment.