VARISTHA Mediclaim for Senior Citizens
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Salient
Feature
1. Scope
of Cover
2&3. Definitions
4. Exclusions
5. Payment
of Claim
6. Cumulative
Bonus
7. Cost
of Health Check Up
8. Co-payment
9. TPA
Services
10. Premium
11. Claim Procedure
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Salient Feature
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This
policy has been designed to cater to the needs of our Senior Citizens. It
covers Hospitalization and Domiciliary Hospitalization Expenses under Section
I as well as expenses for treatment of Critical Illnesses ,if opted for, under
Section II. Diseases covered under Critical
Illnesses are as under:
· Coronary Artery Surgery
· Cancer
· Renal Failure i.e. Failure for both kidneys
· Stroke
· Multiple Sclerosis
· Major Organ Transplants like kidney, Lung, Pancreas or
Bone marrow
· Paralysis and blindness at extra premium
Critical
Illness cover is an optional cover under the policy. Persons who will not opt
for critical illness cover are entitled to Hospitalization and Domiciliary
hospitalization expenses cover for those diseases categorized above as
critical illness but up to the limit of Sum Insured under Section I i.e.
under Hospitalization and Domiciliary Hospitalization Expenses and the claim
for those diseases will be paid on reimbursement basis or as cashless
hospitalization. Person opting for Critical Illness cover may opt for claim
either under Section I or Section II(if not hospitalized) or under both
sections for those diseases categorized above as Critical Illnesses but claim under Section I will
be paid either on reimbursement basis or as cashless hospitalization if it is
otherwise admissible. If in any policy year a critical illness is diagnosed
and claim paid thereafter, in subsequent renewals the person may avail cover
both under Section I & II but with the exclusion, both under Section I
& II, of that particular critical illness which has been diagnosed and
claim paid in the preceding policy year.
Sum Insured: Sum
Insured is fixed per person.
Under Hospitalization & Domiciliary Hospitalization
Cover sum Insured is Rs.1,00,000/-
and under Critical Illness cover Sum Insured is
Rs.2,00,000/-.
Age Group: For fresh entry in to the scheme-60
years to 80 years. However, for renewal, age limit will be extended up to 90
years in which case the premium of 76-80 age band will be loaded by 10% up to
85 years and 20% up to 90 years of age.
Preacceptance
Medical Check up: No Medical Check up is required if
the insured was covered under any Health Insurance Policy of National
Insurance Company or other Insurance companies uninterruptedly for preceding
three years. Other persons have to undergo medical check up at their own cost
for Blood/Urine Sugar, Blood Pressure, Echo-cardiography and eye check up
including retinoscopy.
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1. Scope Of Cover
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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.
Hospitalisation Benefits
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Limits
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A
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(i)Room, Boarding expenses a
provided by the Hospital/Nursing Home
(ii) If admitted in IC Unit
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i)Up to 1% of Sum Insured per
day
ii)Up to 2% of Sum Insured per
day
Overall limit:25% of the S.I.
per illness/injury
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B
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Surgeon, Anaesthetist, Medical
Practitioner, Consultants, Specialists Fees, Nursing Expenses
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Up to 25% of Sum Insured per
illness/ Injury
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C
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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 stent & implants
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Up to 50% of Sum Insured per
illness/Injury
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1) Company's overall liability in respect of claims arising
due to Cataract is Rs.10,000/- and that of Benign Prostatic 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.Rs.1000/- in a policy year will be
reimbursed.
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2. Definitions
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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 OR
(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 Operation means 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 hospitalisation benefits shall not cover:
i) Expenses incurred for pre and
post hospital treatment and
ii) Expenses incurred for any of
the following diseases;
1. Asthma
2. Bronchitis
3. Chronic Nephritis and Nephritic Syndrome
4. Diarrhea and all type of dysenteries including
Gastroenteritis
5. Diabetes Mellitus and Insipidus
6. Epilepsy
7. Hypertension
8. Influenza, Cough and Cold
9. All Psychiatric or Psychosomatic Disorders
10. Pyrexia of unknown Origin for less than 10 days
11. Tonsillitis and Upper Respiratory Tract Infection
including Laryngitis and Pharingitis
12. 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 recognised 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 recognised 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 Preexisting 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.
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4. Exclusions
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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 after one claim free year.
Only two preexisting 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
Prostatic 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 septums 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 betreated 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 Lymphadinopathy 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
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5. Payment of Claim
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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.
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6. Cumulative Bonus
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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.
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7. Cost of Health Check Up
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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.
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8. Co-payment
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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.
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9. TPA Services
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Services of TPA will be available
under this policy.
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10. Premium
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Sum Insured
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Premium
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60-65 years
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66-70 years
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71-75 years
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76-80 years
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Mediclaim
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1,00,000
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4180
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5196
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5568
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6890
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Critical Illness
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2,00,000
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2007
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2130
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2200
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2288
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TOTAL
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6187
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7326
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7768
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9178
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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 preexisting 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%.
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11.Claims Procedure
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11.1 Section I:
Upon the happening of any event,
which may give rise to a claim under this section notice with full
particulars shall be sent to the Company within 7 days from the date of
Injury / Hospitalization/Domiciliary Hospitalization.
5.1 Claim must be filed within 30 days from date of discharge
from the Hospital and where post-hospitalization treatment is not completed,
it shall be within 30 days from the date of completion of
Post-hospitalization treatment.
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NOTE: Waiver of this condition may be
considered in extreme cases of hardship where it is proved to the
satisfaction of the Company that under the circumstances in which the Insured
was placed it was not possible for him or any other person to give such notice
or file claim within the prescribed time limit.
Claims will be settled by the Third Party Administrators (TPA). They will send details of the claims
procedure for emergency/planned hospitals.
Documents to be submitted:
1. Claim form
2. First consultation document
3. Copy of admission advice
4. Discharge Summary
5. Prescription with bills & receipts
6. Test Reports
7. Any other document required by TPA pertaining to this
insurance contract/policy.
Procedure for availing Cashless
Access Services in Network Hospital / Nursing Home.
Claims in respect of Cashless
Access Services will be through the list of network Hospitals/Nursing Homes
and is subject to pre-admission authorization. The TPA shall, upon getting the
related medical information from the insured persons/ network provider,
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 a
patient.
The TPA reserves the right to deny
pre-authorization in case the insured person is unable to provide the
relevant medical details as required by the TPA. The TPA will make it clear to the
insured person that denial of Cashless Access is in no way construed to be
denial of treatment. 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 subject to admissibility of claim under the terms
and conditions of the policy.
The TPA may repudiate the claim,
giving reasons, if not covered under the terms of the policy. The
insured person shall have right of appeal to 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.
11.2 Section II:
Upon detection of any critical
illness, which may give rise to a claim under this section, notice with full
particulars shall be sent to the Company within 15 days from the date of
diagnosis of the disease.
Claim documents as mentioned hereunder must be submitted
to the company after 30 days from the date of diagnosis of the disease.
1) Doctor’s certificate confirming diagnosis of the critical
illness along with date of diagnosis.
2) Pathological/other diagnostic test reports confirming the
diagnosis of the critical illness.
3) Any other documents required by the company
Section II: Critical
Illness Cover (Optional):
Under this section the Company
shall pay to the Insured Person, the compensation as set against such Insured
Person’s name in the schedule, should an Insured Person be diagnosed, during
the period of insurance set in the schedule, as suffering from a critical
illness stated hereunder, symptoms (and/or the treatment) of which were not
present in such Insured Person at any time prior to inception of this Policy.
1. Stroke
2. Cancer
3. Renal failure
4. Major Organ Transplant
5. Multiple sclerosis
6. Coronary artery surgery
7. Paralysis and Blindness at
additional premium
Waiting Period:
No claim will be paid, if a
critical illness as specified in the policy incepts or manifests during the
first 90 days of the inception of the policy.
Survival Period:
The insured person needs to
survive for 30 successive days after the diagnosis of the critical illness in
order to make his claim.
Provisos
1. Each of the above illnesses
mentioned in the Policy, must be confirmed by a registered medical
practitioner appointed by the company and must be supported by clinical,
radiological, histological and laboratory evidence acceptable to the company
and to be reconfirmed by a Registered Medical Practitioner appointed by the
company.
2. The Company shall compensate the
Insured on behalf of the insured Person only once in respect of any
particular Critical Illness.
3. The Cover under the Policy will
cease upon payment of the compensation on the happening of a Critical Illness
and no further payment will be made for any consequent disease or any
dependent disease.
Exclusions:
The
Company shall not pay any benefit to any insured Person who suffers an event
giving rise to a Critical Illness which arises or is caused by or associated
with directly or indirectly by any one of the following:
1. The
ingestion of drugs other than those prescribed by a practicing and duly
qualified member of the medical profession.
2. The
ingestion of medicines, prescribed or not, for treatment of drug addiction
and any treatment relating to drug addiction.
3. Any attempt by the Insured Person at
suicide or any injury, which is self inflicted or in any manner wilfully
caused by or on behalf of the Insured Person.
4. Where the Insured Person at any time
suffered from the condition commonly known as AIDS or was infected by the
commonly called HIV virus. The terms AIDS and HIV will be interpreted as
broadly as possible so as to include all or any mutants, derivatives or
variations thereof. The onus will always be on the Insured Person to show
that any event was not caused by or did not arise through AIDS or HIV.
5. The Company will not be liable for a
Critical Illness and/or its symptoms (and/or the treatment) of which were
present in the Insured Person at any time before inception of the Policy or
the date on which cover was granted to such Insured Person, or which manifest
themselves within a period of 90 days from such date, whether or not the
Insured Person had knowledge that the symptoms or treatment were related to
such Critical Illness. In the event of any interruption in cover, the terms
of this exclusion will apply as new from recommencement of cover.
6. No claim will be payable if the
Insured Person smokes 40 or more cigarettes / cigars
or equivalent tobacco intake in a
day.
7. No claim will be payable if a
critical illness is caused directly or indirectly or contributed to by or
arising from:
(i) Ionising Radiations or contamination
by radioactivity from any nuclear fuel or from any nuclear waste from the
combustion of nuclear fuel or nuclear weapons materials.
(ii). War, Invasion, Act of Foreign enemy,
Hostilities, Civil War, Rebellion, Revolution, Insurrection, Mutiny,
Military, or Usurped Power, Seizure, Capture, Arrest, Restraints and
Detainment of all Kings, Princes and People of whatever nation condition or
quality whatsoever.
Special Note: The company reserves the right to
review the premium rate, terms and conditions of this policy at the
time of renewal.
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