WINSURE

PARIVAR – Mediclaim for Family

1. Salient Feature
2. Scope of Cover
3. Definitions
4. Exclusions
5. Age Limit 
6. Payment of Claims 
7. Sum Insured
8. Premium Chart 
9. Claims Minimization Clause 
10. Cancellation Clause 
11.Contribution Clause 
12. Cashless Access Services

1. Salient Feature

This is a Family Floater Health Insurance Policy wherein entire family will be covered under single Sum Insured.

The Policy covers reimbursement of Hospitalization expenses for illness/diseases contracted or injury sustained by the Insured Person. In the event of any claim becoming admissible under the policy, the Company either pay directly to the insured if TPA service is not availed by the insured or pay to the Hospital/Nursing Home through TPA the amount of such expenses subject to limits as would fall under different heads mentioned below, as are reasonably and necessarily incurred in respect thereof anywhere in India by or on behalf of such Insured Person but not exceeding Sum Insured (all claims in aggregate) for that family as stated in the Schedule in any one period of insurance.

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2. Scope Of Cover

Hospitalization Expenses:

N.B.    (a)   Total expenses incurred for any one illness is limited to 50% of the overall 

                 Sum Insured per family.

(b)        Company’s liability in respect of all claims admitted during the period of Insurance shall not exceed the Sum Insured per family as mentioned in

        the Schedule.

(c)     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.

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3. Definitions

3.1 Family means Self, Spouse & two dependant children up to an age of 25 years. Parents are not covered.

3.2 Hospital/Nursing Home, means any institution in India established for indoor care and treatment of disease 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 a registered and qualified medical practitioner.

      OR

b.      Hospital/Nursing Home run by Government.

      OR

c.       Should comply with minimum criteria as under :

                                 i.            It should have at least 15 inpatient beds. In Class “C” town the number of beds 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.

3.2.1 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 addiction or place of alcoholics, a hotel or a similar place.

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

3.4 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.

3.5. 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.

3.5.1 Medical Practitioner means a person who holds a degree/diploma from a recognized institution and is registered by the Medical Council of India or the respective State Councils. The term Medical Practitioner would include Physician, Specialist and Surgeon.

3.5.2 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.

3.5.3 TPA means a Third Party Administrator who 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.

3.5.4 Pre-Hospitalization : Relevant medical expenses incurred during period up to 15 days prior to hospitalization on disease/illness/injury sustained will be considered as part of claim mentioned under Hospitalization Expenses.

3.5.5 Post-Hospitalization : Relevant medical expenses incurred during period upto 30 days after hospitalization on disease/illness/injury sustained will be considered as part of claim mentioned under Hospitalization Expenses.

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4. Exclusions

The Company shall not be liable to make any payment under this Policy in respect of any expenses whatsoever incurred by any Insured 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 four continuous claim free policy years. For the purpose of applying this condition, the period of cover under Mediclaim policy taken from National Insurance Company only will be considered. Pre-existing disease like Diabetes and Hypertension will be covered from the inception of the policy on payment of additional premium by the insured.

4.1.1.             Insured shall bear 10% of any admissible claim if he is suffering from   

                    either Diabetes or Hypertension and 25% of the admissible claim amount

                    in case he is suffering from both diabetes and hypertension. This

                    provision is applicable only for claims arising out of Diabetes and/or

                    Hypertension.

4.2      Any disease other then 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 hospitalization due to accidental injury or if the Insured Person having been covered under this scheme or a similar Health Insurance Scheme with any of the Indian Insurance Companies for a continuous period of preceding 12 months without any break.

4.3      During the first 2 years of the operation of the policy the expenses incurred on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy, 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 OtitisMedia), 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 four continuous claim free years 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      Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident, 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 an accident or as part of any illness.

4.6      The cost of spectacles, contact lenses and 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.

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) orLymphadinopathy 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, miscarriage, abortion or complications of any of these including caesarean section.

4.14  Any treatment other than Allopathic System of Medicine.

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5. Age Limit

Persons between the age of 3 months to 60 years are eligible to enter the scheme. Fresh entrant beyond 60 years will not be covered. However, the policy may be extended up to the age of 65 years if it is renewed without break. In that case the premium applicable for 56-60 age band will be loaded  as shown in the Premium Chart.

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6. Payment of Claims

All claims under this policy shall be payable in Indian Currency only. All medical treatments for the purpose of this insurance will have to be taken in India only.

NOTICE TO CLAIM

Preliminary notice of claim with particulars relating to policy numbers, Name of Insured Person in respect of whom claim is made, nature of illness/injury and Name and Address of the attending Medical Practitioner/Hospital/Nursing Home should be given by the insured person to the TPA immediately and in case of emergency hospitalization within 24 hours from the date of Hospitalization.

In case of notice received beyond 24 hours from the time of Hospitalization etc., the matter may be referred to the insurer for considering waiver of the condition, wherever felt appropriate.

Final Claim along with receipted Bills/Cash Memos, Claim Form and list of documents as listed in the Claim Form etc., … should be submitted to the TPA within 30days from the date of completion of treatment.

NOTE : Waiver of the 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 insurer was placed it was not possible for him or any other person to give such notice or file claim within the prescribed time limit.

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7. Sum Insured

Rs.2,00,000/- to Rs.5,00,000/- in multiples of Rs.50,000/-

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8. Premium Chart

Up to 35 years

36 to 45 years

46 to 50 years

51 to 55 years

56 to 60 years

Note:

1.       In case any member of the family is suffering from hypertension or diabetes, 10% extra premium to be charged on the total premium.

2.       In case any member of the family is suffering from hypertension and diabetes, 25% extra premium to be charged on the total premium.

3.       If the policy is extended beyond 60 years, 25% loading on the premium for 50-60 years band is to be charged.

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9. Claims Minimization Clause

The Insured will at all times cooperate with the TPA/Company to contain claims ratio

by ensuring that the treatment charges and other expenses are reasonable and

necessary and will be subject to further sub-limits as may be required.

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10. Cancellation Clause

The policy may be renewed by mutual consent. The Company shall not however be

bound to give notice that it is due for renewal and the Company may at any time

cancel this policy by sending the insured 30 days notice by registered letter at the

insured’s last known address and in such event the Company shall refund to the

insured a pro-rata premium for un-expired period of insurance. The Company shall,

however, remain liable for any claim arose prior to the date of cancellation. The

insured may at any time cancel this policy and in such event the Company shall allow

refund of premium at Company’s Short Period Rate(Table given hereunder) provided

NO CLAIM has occurred upto the date of cancellation.

Period on risk                               Rate of premium to be charged

Upto 1 month                              ¼ th of the annual rate

Upto 3 months                            ½ of the annual rate

Upto 6 months                            ¾ th of the annual rate

Exceeding 6 months                 Full annual rate

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11.Contribution Clause

If the proposer is having more than one health insurance policies he should mention it

to the underwriter so that there is a reference of the additional policy No. on both

policies and that in case of a claim, underwriters will ensure that both the policies

would contribute proportionately.

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12. Cashless Access Services

Claims in respect of Cashless Access Services will be through the list of the network of

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-authorisation 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 as per terms and conditions of

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.