Highlights of this Policy
- Cumulative Bonus @25% SI for claim free year with Max 50% of SI.
- Health Check Up for every 3 claim free years.
- New Born Baby cover
- Cataract, up to 20% of Sum Insured or Rs. 50,000, whichever is less, for each eye.
- Ayurvedic / Homeopathic / Unani treatments are covered, up to 25% of the Sum Insured.
- Medical Expenses for Organ transplant are payable.
- Ambulance Charges at the rate of 1% of the Sum Insured.
- Hospital Cash at the rate of 0.1% Sum Insured per day, up to a maximum of 1% Sum Insured.
- For Pre Existing Diseases Waiting period is 48 Months as per clause 4.1 of the policy document.
- For specified diseases waiting period is 24 months as per clause 4.3.1 of the policy document.
- 139 Day Care procedures are covered under this policy.
- Optional Cover I: No Proportionate Deduction
- Optional Cover II: Maternity Expenses Benefit for Sum Insured 5 Lakhs and Above (Maximum of 10% of the average SI of the Insured Person in the preceding three years).
- Optional Cover III: Revision in Limit of Cataract (For 8 Lakhs & above SI revised limit for Cataract will be 10% of the Sum Insured).
- Optional Cover IV: If Voluntary Co-Pay of 20% is chosen then 15% discount on premium will be given on the premium payable for the Insured person.
If the Insured intend to make any claim under this Policy
- Intimate TPA in writing on detection of any Illness/Injury being suffered immediately or forty eight hours before Hospitalization.
- Intimate within twenty four hours from the time of Hospitalization in case of Hospitalization due to medical emergency.
Submit following supporting documents TPA relating to the claim within seven days from the date of discharge from the Hospital.
1. Bill, Receipt and Discharge certificate / card from the Hospital.
2. Cash Memos from the Hospitals (s) / Chemists (s), supported by proper prescriptions.
3. Receipt and Pathological test reports from Pathologist supported by the note from the attending Medical Practitioner / Surgeon recommending such Pathological tests / pathological.
4. Surgeon's certificate stating nature of operation performed and Surgeons' bill and receipt.
5. Attending Doctor's/ Consultant's/ Specialist's / Anesthetist's bill and receipt, and certificate regarding diagnosis.
- 4. In case of Post-Hospitalization treatment (limited to sixty days), submit all claim documents within 7 days after completion of such treatment.
- 5. Provide TPA with authorization to obtain medical and other records from any Hospital, Laboratory or other agency.
The Insured person shall submit to the TPA all original bills, receipts and other documents upon which a claim is based and shall also give the TPA/Us such additional information and assistance as the TPA / We may require.
Any Medical Practitioner authorized by the TPA/Us shall be allowed to examine the Insured Person, at our cost, if We deem Medically Necessary in connection with any claim.
Frequently Asked Questions
1. WHO CAN TAKE THIS POLICY?
All the persons proposed for this Insurance should be between the age of 18 years and 65 years. Children between the age of 3 months and 18 years are covered provided one or both parents are covered concurrently. Children between 18 years to 25 years can be covered provided they are financially dependent on the parents and one or both parents are covered simultaneously. On attaining the age of 18 years or ceasing to be financially dependent on the parents, they can, on renewal take a separate Policy. In such an event the benefits on Continuous Coverage can be ported to the new Policy. The upper age limit will not apply to a mentally challenged children and an unmarried dependent daughter(s). The persons beyond 65 years can continue their Insurance provided they are Insured under the Policy with us without any break.
Midterm inclusion is allowed for newly married spouse by charging pro-rata Premium for the remaining period of the Policy. A New Born Baby, born to an Insured mother, will be covered from date of birth till the expiry of the Policy, without any additional Premium. No coverage for the New Born Baby would be available during subsequent Renewals unless the child is declared for Insurance and covered as an Insured Person.
2. CAN I COVER MY FAMILY MEMBERS IN ONE POLICY?
Yes. You can cover your family members in one policy, with separate Sum Insured for each Insured Person.
The members of the family who could be covered under the Policy are:
- a) Proposer
- b) Proposer's Spouse
- c) Proposer's Children
- d) Proposer's Parents
- e) Proposer's Brother/Sister
- f) Proposer's Ward
- g) Employers can cover their Employees
- Brother/Sister can only be covered when they are financially dependent on the proposer.
- For the relations Employer-Employee/Brother/Sister/Ward 80D certificate shall not be given.
3. WHAT DOES THE POLICY COVER?
This Policy is designed to give You, the Insured, protection against unforeseen Hospitalization expenses.
4. WHAT IS A PRE EXISTING DISEASE?
The term Pre-existing condition/disease is defined in the Policy. It is defined as:
"Any condition, ailment or Injury or related condition(s) for which there were signs or symptoms, and/or were diagnosed, and/or for which medical advice / treatment was received within forty eight months prior to the first policy issued by Us and renewed continuously thereafter."
If You had:
- Signs or symptoms, or
- Been diagnosed or received Medical Advice, or
- Been Treated for any condition or disease within forty eight months prior to the commencement of the first policy with us,
Such a condition or disease shall be considered as Pre-existing. Any Hospitalization arising out of such pre-existing disease or condition is not covered under the Policy until forty eight months of Continuous Coverage have elapsed for the Insured Person.
5. IS PRE-ACCEPTANCE MEDICAL CHECK-UP REQUIRED?
i. Pre-acceptance test is required for all the members entering after the age of 50 for the first time.
ii. However, the condition (i) shall be relaxed to 60 year’s subject to the following conditions:
a. A minimum of 3 persons should be covered in the policy.
b. At least one of the members age should be less than 35 Years.
Irrespective of the (i) & (ii) a person needs to undergo this pre-acceptance medical check-up if he has an adverse medical history. The cost of this check-up will be borne by the proposer. But if the proposal is accepted, then 50% of the cost of this check-up will be reimbursed to the proposer.
Note: Adverse Medical History means a person:
i. Who has undergone more than one Hospitalization in previous two years,
ii. Who is suffering from Critical Illness, Recurring Illness or Chronic Illness?
iii. Is Suffering from Hypertension / Diabetes.
iv. Is not in good health and free from Physical and mental diseases or infirmity or medical complaints.
6. IS HOSPITALISATION ALWAYS NECESSARY TO GET A CLAIM?
Yes. Unless the Insured Person is hospitalized for a condition warranting Hospitalization, no claim is payable under the Policy. The Policy does not cover outpatient treatments.
7. HOW LONG DOES THE INSURED PERSON NEED TO BE HOSPITALISED?
The Policy pays only where the Hospitalization is for more than twenty four hours. But for certain treatments specified in the Policy, period of stay at the Hospital could be less than twenty four hours. Please refer to Clause 2.16 of the Policy for details.
8. WHAT DO I NEED TO DO AFTER I GET HOSPITALISED?
Immediately on Hospitalization or within twenty four hours of such Hospitalization, please intimate the TPA of this fact, with details of Your Policy Number, Name of the Hospital and treatment undertaken. This is an important condition of the Policy that you need to comply with.
9. IS PAYMENT AVAILABLE FOR EXPENSES INCURRED BEFORE HOSPITALISATION?
Yes. Relevant medical expenses incurred before hospitalization for a period of THIRTY days prior to the date of Hospitalization are payable. Relevant medical expenses means expenses related to the treatment of the disease for which the insured is hospitalized.
10. IS PAYMENT AVAILABLE FOR EXPENSES INCURRED AFTER HOSPITALISATION?
Yes. Relevant medical expenses incurred after Discharge from the Hospital for a period of SIXTY days after the date of discharge are payable. Relevant medical expenses means expenses related to the treatment of the disease for which the insured is hospitalized.
11. CAN I GET TREATED ANYWHERE?
Yes, the Policy covers treatment and/or services rendered only in India.
12. IS THERE A LIMIT TO WHAT THE COMPANY WILL PAY FOR HOSPITALISATION?
Yes. We will pay Hospitalization expenses up to a limit, known as Sum Insured. In cases where the Insured Person was Hospitalized more than once, the total of all amounts paid
a) for all cases of Hospitalization,
b) expenses paid for medical expenses prior to Hospitalization,
c) expenses paid for medical expenses after discharge from hospital, and
d) any other payment made under the Policy
shall not exceed the Sum Insured as mentioned in the Schedule.
13. WHAT SUM INSURED SHOULD I CHOOSE?
You are free to choose any Sum Insured ranging from Rs. One Lakh to Fifteen Lakhs. The Premium You pay depends upon Your Age and the Sum Insured chosen. You are free to choose any Sum Insured available in the range specified above. But it is in your own interest to choose the Sum Insured which could satisfy your present as well as future needs, as explained in Point 15 below. Sum Insured of Rs. 4 lakh, 6 lakh and 7 lakh are not available for a fresh Policy and is only available in case of renewal with same Sum insured.
14. HOW LONG IS THE POLICY VALID?
The Policy is valid during the Period of Insurance stated in the Schedule attached to the Policy. It is usually valid for a period of one year from the date of beginning of insurance.
15. IN CASE OF AYURVEDIC TREATMENT, WILL THE ENTIRE AMOUNT BE PAID?
The liability of the company in case of Ayurvedic / Homoeopathic / Unani treatment will be 25% of the Sum Insured provided the treatment is taken in a government Hospital or in any institute recognized by government or accredited by Quality Council Of India or National Accreditation Board on Health, excluding centers for spas, massage and health rejuvenation procedures.
16. CAN THE POLICY BE RENEWED WHEN THE PRESENT POLICY EXPIRES?
Yes. You can, and to get all Continuity benefits under the Policy, you should renew the Policy before the expiry of the present policy. For instance, if Your Policy commences from 2nd October, 2016 date of expiry is usually on 1st October, 2017. You should renew Your Policy by paying the Renewal Premium on or before 1st October 2017.
17. WHAT IS CONTINUITY BENEFIT?
There are certain treatments which are payable only after the Insured Person is continuously covered for a specified period. For example, Cataract is covered only after twenty four months of continuous insurance. If an Insured took a Policy in October, 2008,does not renew it on time and takes a Policy only in December 2009, and renewed it on time in December 2010, any claim for Cataract would not become payable, because the Insured person was not continuously covered for twenty four months. If, he had renewed the Policy in time in October 2009 and then in October 2010, then he would have been continuously covered for twenty four months and therefore his claim for Cataract in the Policy beginning from October 2010 would be payable. For other benefits under the Policy such as cost of health checkup, continuous Insurance is necessary. Therefore, you should always ensure that you pay Your renewal Premium before Your Policy expires.