Scope of Policy & Cover

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 Schedule hereto.

Hospitalization Benefits		Limits
A	(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 day (ii) Up to 2% of Sum Insured per dayOverall limit:25% of the Sum Insured per illness/injury
B	Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees, Nursing Expenses	Up to 25% of Sum Insured per illness/ Injury
C	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 stents & implants	Up to 50% of Sum Insured per illness/Injury

1) Company's overall liability in respect of claims arising due to

* Cataract is Rs.10,000/-

* Benign Prostate Hyperplasia is Rs 20,000/- only.

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.

3) 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.1000/- in a policy year will be reimbursed.

2. Definitions

2.1. Hospital/Nursing Home‚ means any institution in India established for indoor care and treatment of sickness and injuries and which either

(a) 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

(b) should comply with minimum criteria as under:

i. It should have at least 15 inpatient beds. In Class "C" towns condition of number of beds may be reduced to 10.

ii. Fully equipped Operation Theatre of its own, wherever surgical operations are carried out.

iii. Fully qualified nursing staff under its employment round the clock

iv. 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 similar place.

2.2 Surgical Operationmeans 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 –

(a) The treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available in Hospitals.

and

(b) 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 hospitalization benefits shall not cover:

i) Expenses incurred for pre and post hospital treatment and

ii) Expenses incurred for any of the following diseases:-

Asthma
Bronchitis
Chronic Nephritis and Nephritic Syndrome
Diarrhea and all type of dysenteries including Gastro-enteritis
Diabetes Mellitus and Diabetes insipidus
Epilepsy
Hypertension
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 Pharyngitis
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 above.

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 recognized institution and is registered by Medical Council or respective State Council of India. The term Medical Practitioner would include Physician, Specialist and Surgeon.

3.4 Qualified Nurse means a person who holds a certificate of a recognized Nursing Council and who is employed on the recommendations of the attending Medical Practitioner.

3.5 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 Pre-existing 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 Diseases.

4. Exclusions

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:

4.1 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 afterone claim free year.

Only two pre-existing 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.

4.2 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.

4.3 During the first one year of the operation of the policy the expenses incurred on treatment of diseases such as Cataract, Benign Prostate 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 septum 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.

4.4 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).

4.5 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.

4.6 The cost of spectacles and contact lenses, hearing aids.

4.7 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.

4.8 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.

4.9 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 Lymphadenopathy 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.

4.10 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.

4.11 Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician.

4.12 Injury or disease directly or indirectly caused by or contributed to by nuclear weapons/materials.

4.13 Treatment arising from or traceable to pregnancy childbirth including caesarean section.

4.14 Naturopathy treatment

5. Payment of Claim

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.

6. Cumulative Bonus

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.

However, 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.

Important

For Cumulative Bonus and Health Check-up provision as aforesaid:

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.

Health check up benefit will be accrued after completion of three years continuous claim free insurance.

8. Co-payment

Insured 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.

Insured has 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 premium. This provision is in addition to the compulsory excess stated herein above and applicable only for claims arising out of Pre-existing Diseases.

9. TPA Services

Services of TPA will be available under this policy.

10. Premium

	Sum Insured	Premium
		60-65 years	66-70 years	71-75 years	76-80 years
Mediclaim	1,00,000	4180	5196	5568	6890
Critical Illness	2,00,000	2007	2130	2200	2288
	TOTAL	6187	7326	7768	9178

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 pre-existing 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 premium.

10.4 Cover for Paralysis and Blindness under Critical Illness:

Paralysis 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%.