WINSURE

VIDYARTHI-Mediclaim for Students

1. Salient Feature 
2.Section I - Hospitalization for illness, diseases or accident       
3.Section II & III - Personal Accident to  student and guardian of the student

4.Premium Chart

5.Claims Procedure

a.Section I

b.Section II & III

1. Salient Feature

VIDYARTHI-Mediclaim for Students is a unique policy designed

 to provide Health and Personal accident cover to the students. It 

also provides for continuation of insured students education in case 

of death or permanent total disablement of the guardian due to

 accident. 

Parents/Legal Guardian of individual student in any Registered

 Educational Institution affiliated to any State Board, Council, 

University and AICTE or any other Govt. Statutory Authority, 

within the territory of India may take this policy. The Educational

 Institutions may also take a Group Policy covering named students

 enrolled with them.

Age: 3 years to 25 years.

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2. Section I - Hospitalization for illness, diseases or accident

a. Scope Of Cover

1) Room, Boarding expenses as provided by the Hospital/Nursing 

Home.

2) Nursing expenses.              

3) Surgeon, Anaesthetist, Medical Practitioner, Consultants, 

Specialists Fees.

4)Anaesthesia, Blood, Oxygen, Operation Theatre Charges, 

Surgical appliances(any disposable consumables subject to upper 

limit of 10% of Sum Insured), Medicines & Drugs, Diagnostic 

Materials and X-Ray, Dialysis, Chemotherapy, Radiotherapy, 

Cost of pacemaker, Artificial Limbs and cost of Stents and implants

Note: Hospitalization expenses of person donating an organ during 

the course of organ transplant will also be payable subject to the 

sub limits under “4” above applicable to the insured person within 

the overall sum insured of the insured person.

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b. Other benefits

1.  The guardian of the insured will be eligible for deduction under 

Section 80 D of the Income Tax Act 1961 as amended from time to

 time, for the premium paid under this section of the policy subject 

to limits specified in the Income Tax Act.

2.The Policy will be serviced by Third Party Administrators (TPA)

 for hospitalization expenses.

3. Cumulative Bonus

Sum insured under this policy 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.:

a) for existing Mediclaim policy holders (as on date of

 implementation)  of the company the accrued amount of benefit 

of cumulative bonus will be added to the sum insured, subject to

 maximum 10 claim free years.

b) Cumulative Bonus will be lost if policy is not renewed on the

 date of expiry.

However, insured has the option either to avail cumulative bonus or

 claim 5% discount in renewal premium 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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c. Definitions

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

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.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

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.

4.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.

5. Pre Hospitalisation: Relevant Medical Expenses incurred during 

period up to 30 days prior to hospitalisation on disease/illness/injury 

sustained will be considered as part of claim mentioned under item

 1.0 above

6.Post Hospitalisation: Relevant Medical Expenses incurred up to 

60 days after hospitalisation/ domiciliary hospitalisation on 

disease/illness/injury sustained will be considered as part of claim

 mentioned under item 1.0 above

7.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.

8.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.

9.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.

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d.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 :

1. All diseases/injuries, which are pre-existing when the cover

 incepts for the first time.  This exclusion will be deleted after three

 continuous claims free years under this policy.

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 any health insurance scheme with any one 

of the Indian Insurance Companies for a continuous period of

 preceding 12 months without any break.

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 for Menorrhagia orFibromyoma, 

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 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. 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).

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.

6. The cost of spectacles and contact lenses hearing aids.

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.

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.

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.

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.

11. Expenses on vitamins and tonics unless forming part of treatment

 for injury or disease as certified by the attending physician.

12. Injury or disease directly or indirectly caused by or contributed 

to by nuclear weapons/materials.

13. Treatment arising from or traceable to pregnancy childbirth

 including caesarean section.  

14. Naturopathy treatment

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3. Section II & III - Personal Accident to  student and guardian of the student

a. Scope of Cover

If the Insured persons shall sustain any bodily injury resulting solely 

and directly from Accident caused by external violent and visible

 means then the Company shall pay to insured the sum hereinafter 

set forth that is to say

(a)If such injury within twelve calendar months of its occurrence

shall be the sole and direct cause of the death of the Insured persons

 the Capital Sum Insured stated in the Schedule.

(b)If such injury within twelve calendar months of its occurrence 

shall be the sole and direct cause of the total and irrecoverable loss 

of sight of both eyes or total and irrecoverable loss of use of two

 hands or two feet, or of one hand and one foot or of such loss of

 sight of one eye and such loss of use of one hand or one foot, the 

capital sum insured stated in the schedule hereto.

(c)If such injury within twelve calendar months of its occurrence

 shall be the sole and direct cause of the total and irrecoverable

 loss of sight of one eye or total and irrecoverable loss of use of a 

hand or foot, fifty percent to the capital sum insured stated in the 

schedule hereto.

(d)If such injury within twelve calendar months of its occurrence

 shall be the sole and direct cause of permanently totally and 

absolutely disabling the Insured from engaging in being occupied

 with or giving attention to any employment or occupation of any

 description whatsoever the Sum Insured stated in the Schedule.

PROVISOS

Provided always that the Company shall not be liable under this 

Policy for

1.Compensation under more than one of the aforesaid sub-clauses 

(a)  (b)  (c)  or  (d) in respect of the same injury or disablement.

2.Any payment in excess of Sum Insured under the Policy during

 any one period of Insurance.

3.Payment of compensation in respect of injury or disablement 

directly or indirectly arising out of or contributed to be or traceable 

to any disability existing on the date of issue of this policy.

This policy will also cover:

Transport cost of insured’s dead body(death due to accident only) 

to the place of residence subject to a maximum of 2% of the Capital

 Sum Insured or Rs.1000/- whichever is lower. This cover is

 applicable both for Section II & III.

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b.Exclusions

1.Payment of compensation in respect of death of the insured

(a) from intentional self injury, suicide or attempted suicide

(b)whilst under influence of intoxicating liquor or drugs

(c) whilst engaging in Aviation or Ballooning, whilst Mounting into, 

Dismounting from or Travelling in any aircraft other than as a 

passenger (fare paying or otherwise) in any duly licensed standard

 type of aircraft anywhere in the world

(d)directly or indirectly caused by venereal disease or insanity,

(e)arising or resulting from the insured committing any breach of the

 law with criminal intent.

Note:“Standard type of aircraft” means any aircraft duly licensed to 

carry passengers (for hire or otherwise) by appropriate authority

 irrespective of whether such an aircraft is privately owned OR

 chartered OR operated by a regular airline OR whether such an 

aircraft has a single engine or multiple engines.

2.Payment of compensation in respect of death of the insured due to

 or arising out of directly or indirectly connected with or traceable to

 war, invasion, Act of foreign enemy, Hostilities (Whether war be 

declared or not) Civil War, Rebellion, Revolution, Insurrection,

 Mutiny, Military or Usurped Power, Seizure, Capture, Arrests, 

restraints and Detainment of all kings, princes and people of

 whatsoever nation, condition or quality.

3.Payment of compensation in respect of death of the insured:

Directly or indirectly caused by or contributed to by or arising from

 ionising radiations or contamination by radioactivity from any nuclear

 fuel or from any nuclear waste from the combustion of nuclear fuel.

  For the purpose of this exception, combustion shall include any

 self-sustaining process of nuclear fission.

Directly or indirectly caused by or contributed to by or arising from

 nuclear weapon material.

4.Pregnancy Exclusion Clause:  The insurance under this Policy shall

 not extend to cover death or disablement resulting directly or 

indirectly caused by or contributed to by or aggravated to prolonged

 by childbirth or pregnancy or in consequence thereof.

Provided also that due observance and fulfilment of the terms and 

conditions of this Policy (which conditions and all endorsements

 here on are to be read as part of this Policy) shall so far as they 

relate to anything to be done or not to be done by the insured 

 be a condition precedent to any liability of the Company under 

this Policy.

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4. Premium Chart

Group Discount:  This discount will be applicable only on actual number insured. Group Discount Structure will be as under:

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5. Claims Procedure

Section-I

Claims will be settled by the Third Party Administrators (TPA). 

 They will send details of the claims procedure for emergency/

planned hospitalisation.

Documents to be submitted:

1. Claim form

2. First Consultation documents

3. Copy of admission advice

4. Discharge Summary

5. Prescription with bills

6. Test Reports

7. Any other document required by TPA.

The amount payable under this section will be paid to the

 insured person.

Procedure for availing Cashless Access Services in Network 

Hospital/Nursing Home.

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 doctors advice and later on submit the full 

claim papers to the TPA for reimbursement subject to admissibility 

of claims as 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/insured person.

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Section-II & III: 

Claims will be dealt by the Underwriting Office of the company

Documents to be submitted:

1.FIR

2.Death Certificate

3.Post Mortem Certificate wherever required

4.Any other Documents required by Company

Payment of Claim

All claims under this policy shall be payable in Indian currency. 

All medical treatments for the purpose of this insurance will have to

 be taken in India only.

Section-I: Claim will be paid to the guardian.

Section II: In case of PTD- claim will be paid to the guardian.

 In case of Death- Claim  amount will be paid to the nominee

 named in the schedule.

Section III: Claim will be paid to the guardian.