mediclaim policy (individual) guidelines

7/30/2019 Mediclaim Policy (Individual) Guidelines

1/13

TheOrientalInsuranceCompanyLimited

1

THEORIENTALINSURANCECOMPANYLIMITED,

Regd.Office:OrientalHouse,P.B.No.7037, A25/27,AsafAliRoad,NewDelhi 110002

MEDICLAIMINSURANCEPOLICY(INDIVIDUALS)

1 WHEREAStheinsurednamedintheScheduleheretohasbyaproposalanddeclarationdatedstatedintheSchedule(whichshallbethebasisofthisContractandisdeemedtobeincorporatedherein)hasappliedto

THE ORIENTAL INSURANCE COMPANY LIMITED (hereinafter called the Company) for the insurance

hereinaftersetforthinrespectofpersons(s)namedintheSchedulehereto(hereinaftercalledtheINSURED

PERSON(S))andhaspaidpremiumtotheCompanyasconsiderationforsuch insurancetobeservicedby

ThirdPartyAdministrator(hereinaftercalledtheTPA)ortheCompanyasthecasemaybe.

1.1 NOWTHISPOLICYWITNESSESthatsubjecttotheterms,conditions,exclusions and definitionscontainedherein or endorsed or otherwise expressed hereon, the Company undertakes that, if during the period

stated intheSchedule any insuredPersonshallcontractanydiseaseorsufferfromany illness/ailment/

disease (hereinafter called DISEASE) or sustain any bodily injury through accident (hereinafter called

INJURY)and ifsuchdiseaseor injuryshallrequireupontheadviceofadulyqualifiedPhysician/Medical

Specialist/MedicalPractitioner

(hereinafter

called

MEDICAL

PRACTITIONER)

or

of

aduly

qualified

Surgeon

(hereinafter called SURGEON) to incur (a)hospitalisation expenses for medical/surgicaltreatmentat any

NursingHome/Hospital inIndiaashereindefined(hereinaftercalledHOSPITAL)asan inpatientOR(b)on

domiciliarytreatmentinIndiaunderDomiciliaryHospitalisationBenefitsashereinafterdefined,theTPAwill

paytotheHospitals(onlyiftreatment istakenatNetworkHospital(s)withpriorconsentofTPA)ortothe

insuredperson ifpolicy isservicedbytheTPA.OtherwisetheCompanywillpaytotheInsuredPersonthe

amountofsuchexpenses.Itisapreconditionthattheseexpensesarereasonablyandnecessarilyincurredin

respectthereofbyoronbehalfofsuch insuredpersonbutnotexceedingthesum insured inaggregate in

anyoneperiodofinsurancestatedintheschedulehereto.

1.2 ThepolicyreimbursesthepaymentofHospitalisationand/orDomiciliaryHospitalisationexpensesonlyforillness/diseasescontractedorinjurysustainedbytheInsuredPersons.Intheeventofanyclaimbecoming

admissibleunder

this

policy,

the

TPA

will

pay

to

the

hospital

(only

iftreatment

is

taken

at

network

Hospitals

/ Nursing Homes with prior consent of TPA) or to the insured, if policy is serviced by the TPA or the

Company will reimburse to the Insured person, if the policy is not serviced by the TPA, the amount of

expenses reasonably and necessarily incurred under different heads mentioned below by or on behalf of

suchInsuredPersonnotexceedingtheSum Insured inaggregate inrespectof InsuredPersonasstated in

thescheduleforallclaimsadmittedduringtheperiodofinsurancementionedintheschedule.

FOLLOWINGREASONABLE&CUSTOMARYEXPENSESAREREIMBURSABLEUNDERTHEPOLICY


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a. Room,BoardingandNursingExpensesasprovidedbytheHospital/NursingHomenotexceeding1%oftheSumInsuredorRs.5000/ perdaywhicheverisless.

b. I.C.Unitexpensesnotexceeding2%oftheSumInsuredorRs.10,000/ perdaywhicheverisless.(RoomincludingI.C.U.stayshouldnotexceedtotalnumberofadmissiondays).

c. Surgeon,Anaesthetist,MedicalPractitioner,Consultants,SpecialistsFees.d.

Anaesthesia,

Blood,

Oxygen,

Operation

Theatre

Charges,

Surgical

Appliances,

Medicines

&

Drugs,

Dialysis,

Chemotherapy, Radiotherapy, Artificial Limbs, Cost of Prosthetic devices implanted during surgical

procedurelikepacemaker,RelevantLaboratory/Diagnostictest,XRayetc..

e. Ambulanceservices 1%ofthesum insuredorRs2000/ whichever is lessshallbe reimbursable incasepatienthastobeshiftedfromresidencetohospitalincaseofadmissioninEmergencyWard/I.C.U. orfrom

oneHospital/NursinghometoanotherHospital/NursingHomebyregisteredambulanceonlyforbetter

medicalfacilities.

Note:

1.CompanysLiabilityinrespectofallclaimsadmittedduringthePeriodofinsuranceshallnotexceedtheSum

InsuredperPersonmentionedintheSchedule.

2.Hospitalizationexpensesincurredfordonatinganorganbythedonor(excludingcostof organifany)tothe

insuredpersonduringthecourseoforgantransplantwillalsobepayable.Howeverinanycasetheliabilityof

theCompanywillbelimitedtooverallSumInsuredoftheInsuredPerson.

2 DEFINITIONS:2.1 HOSPITAL/NURSINGHOME:meansany institutioninIndiaestablishedfor indoorcareandtreatment

ofsicknessandinjuriesandwhicheither

a) Isduly licensed andregisteredas a Hospital or Nursing Home with the appropriate authorities and isunderthesupervisionofaregisteredandqualifiedMedicalPractitioner.

OR

b) In areas where licensing and registration facilities with appropriate authorities are not available, theinstitution must be one recognised in locality as Hospital / Nursing Home and should comply with

minimumcriteria

as

under

i. Itshouldhaveatleast15inpatientmedicalbedsincaseofMetrocities,AClasscities&Bclasscitiesor10in patientmedicalbedsincaseofCclasscities.ClassificationofcitiesshallbeasperGovtofIndia

Notificationsissuedinthisrespectfromtimetotime.

ii. Fullyequippedand engaged in providingMedical andSurgical facilitiesalongwithDiagnostic facilitiesi.e.PathologicaltestandXray,E.C.G.etc forthecareandtreatmentof injuredorsickpersonsas in

patient.

iii. Fullyequippedoperationtheatreofitsown,whereversurgicaloperationsarecarriedout.iv. Fullyqualifiednursingstaffunderitsemploymentroundtheclock.v. FullyqualifiedDoctor(s)shouldbephysicallyinchargeroundtheclock.ThetermHospital/NursingHomeshallnotincludeanestablishmentwhichisaplaceofrest,aplaceforthe

aged,aplace

for

drug

addicts

or

aplace

for

alcoholics,

ahotel

or

asimilar

place.

Note:IncaseofAyurvedic/Homeopathic/Unanitreatment,Hospitalisationexpensesareadmissibleonlywhen

thetreatmentistakenasinpatient,inaGovernmentHospital/MedicalCollegeHospital.

2.2SurgicalOperationmeansmanualand/oroperativeproceduresforcorrectionofdeformities/defectsandinjuries,cureofdiseases,reliefofsufferingandprolongationoflife.


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2.3HOSPITALISATIONPERIOD: ExpensesonHospitalisationareadmissibleonlyifhospitalisationisforaminimumperiodof24hours. However,

(A) This time limit will not apply to following specific treatments taken in the Networked Hospital /

NursingHomewheretheInsuredisdischargedonthesameday.Suchtreatmentwillbeconsideredto

betakenunderHospitalisationBenefit.

i. HaemoDialysis,ii.

Parentral

Chemotherapy,

iii. Radiotherapy,iv. EyeSurgery,v. Lithotripsy(kidneystoneremoval),

vi. Tonsillectomy,vii. D&Cviii. Dentalsurgeryfollowinganaccident

ix. Hysterectomyx. CoronaryAngioplasty

xi. CoronaryAngiographyxii. Surgeryof Gallbladder,Pancreasandbileduct

xiii. SurgeryofHerniaxiv. SurgeryofHydrocele.xv. SurgeryofProstrate.

xvi. GastrointestinalSurgery.xvii. GenitalSurgery.

xviii. SurgeryofNose.xix. Surgeryofthroat.xx. SurgeryofAppendix.

xxi. SurgeryofUrinarySystem.xxii. Treatmentoffractures/dislocationexcludinghair linefracture,Contracturereleasesandminor

reconstructiveproceduresoflimbswhichotherwiserequirehospitalisation.

xxiii. ArthroscopicKneesurgery.xxiv. Laproscopictherapeuticsurgeries.xxv. AnysurgeryunderGeneralAnaesthesia.

xxvi. Oranysuchdisease/procedureagreedbyTPA/Companybeforetreatment.(B) Further if the treatment / procedure / surgeries of above diseases are carried out, in Networked

specialised Day Care Centre which is fully equipped with advanced technology and specialised

infrastructurewheretheinsuredisdischargedonthesameday,therequirementofminimumbedswill

beoverlookedprovidedfollowingconditionsaremet.

i. The operation theatre is fully equipped for the surgical operation required in respect of sickness /ailment/injurycoveredunderthepolicy.

ii. DayCarenursingstaffisfullyqualified.iii. The doctor performing the surgery or procedure as well as post operative attending doctors are also

fullyqualifiedforthespecificsurgery/procedure.

(C)Thisconditionofminimum24hoursHospitalisationwillalsonotapplyprovided

I)The treatment is such that it necessitates hospitalisation and the procedure involves specialisedinfrastructuralfacilitiesavailableonlyinhospitals,

BUT

II) Duetotechnologicaladvanceshospitalisationisrequiredforlessthan24hours.AND/OR

iii) SurgicalprocedureinvolvedhastobedoneunderGeneralAnaesthesia.


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ABOVEAREADMISSIBLESUBJECTTOTERMS&CONDITIONSOFTHEPOLICY.

NOTE:PROCEDURES/TREATMENTSUSUALLYDONEINOUTPATIENTDEPARTMENTARENOTPAYABLEUNDER

THEPOLICYEVENIFCONVERTEDTODAYCARESURGERY/PROCEDUREORASINPATIENTINTHEHOSPITAL

FORMORETHAN24HOURS.

2.4

DOMICILIARY

HOSPITALISATION

BENEFIT:

means

Medical

treatment

for

a

period

exceeding

three

days

for

suchillness/disease/injurywhichinthenormalcoursewouldrequirecareandtreatmentatahospital/nursing

homeasinpatientbutactuallytakenwhilstconfinedathomeinIndiaunderanyofthefollowingcircumstances

namely:

i. Theconditionofthepatientissuchthathe/shecannotberemovedtotheHospital/NursingHomeOR

ii. ThepatientcannotberemovedtoHospital/Nursinghomeduetolackofaccommodation inanyhospitalinthatcity/town/village.

SubjecthowevertotheconditionthatDomiciliaryHospitalisationbenefitshallnotcover

a) Expensesincurredforpreandposthospitaltreatmentandb) Expensesincurredfortreatmentforanyofthefollowingdiseases:

i. Asthmaii. Bronchitis,iii. ChronicNephritisandNephriticSyndrome,iv. Diarrhoeaandalltypesof Dysenteriesincluding Gastroenteritis,v. DiabetesMellitusandInsipidus,vi. Epilepsy,vii. Hypertension,viii.Influenza,CoughandCold,ix. AllPsychiatricorPsychosomatic Disorders,x. Pyrexiaofunknownoriginforlessthan10days,xi. TonsillitisandUpperRespiratoryTractinfectionincluding LaryngitisandPharingitis,xii. Arthritis,GoutandRheumatism.

Note:Liability

of

the

Company

under

this

clause

is

restricted

as

stated

in

the

schedule

attached

hereto.

3 OTHERDEFINITIONSANDINTERPRETATIONS:3.1 INSUREDPERSON: MeansPerson(s)namedonthescheduleofthepolicy.3.2 ENTIRE CONTRACT: This policy / proposal and declaration given by the insured constitute the

completecontractofthispolicy.Only Insurermayalterthe termsandconditionsofthispolicy.Any

alteration that may be made by the insurer shall only be evidenced by a duly signed and sealed

endorsementonthepolicy.

3.3 THIRDPARTYADMINISTRATOR (TPA): meansanyCompanywhohasobtained licencefrom IRDAtopractice

as

athird

party

administrator

and

is

appointed

by

the

Company.

3.4 NETWORK HOSPITAL: means hospital that has agreed with the TPA to participate for providingcashlesshealthservicestothe insuredpersons. The list ismaintainedbyandavailablewiththeTPA

andthesameissubjecttoamendmentfromtimetotime.

3.5 HOSPITALISATION PERIOD: The period for which an insured person is admitted in the hospital asinpatientandstaysthereforthesolepurposeofreceivingthenecessaryandreasonabletreatmentfor


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thedisease/ailmentcontracted/injuriessustainedduringtheperiodofpolicy.The minimumperiod

ofstayshallbe24hours

3.6 PREHOSPITALISATION:Relevantmedicalexpenses incurredduringthe periodupto30dayspriortohospitalisation on disease/ illness/ injury sustained will be considered as part of claim mentioned

underitem1.2above.

3.7 POSTHOSPITALISATION: Relevant medical expenses incurred for the period of 60 days afterhospitalisationondisease/illness/injurysustainedwillbeconsideredaspartofclaimmentionedunder

item1.2above.

3.8 MEDICALPRACTITIONER:meansapersonwhoholdsadegree/diplomaofarecognisedinstitutionandisregisteredbyMedical Councilof any Stateof India. The term MedicalPractitioner would include

Physician,SpecialistandSurgeon.

3.9 QUALIFIEDNURSE:meansapersonwhoholdsacertificateofarecognisedNursingCouncil.3.10PREEXISTINGHEALTHCONDITIONORDISEASE:meansanyailment/disease/injuriesthattheperson

issufferingfrom,(treated/untreated,declaredornotdeclared intheproposalform)whiletakinga

policyforthefirsttime.

Furtheranycomplicationsarisingfrompreexistingailment/disease/injurieswillbeconsideredasa

partofthatpreexistinghealthcondition.

3.11INPATIENT:AnInsuredpersonwhoisadmittedtohospitalandstaysforatleast 24hoursforthesolepurposeofreceivingthetreatmentforsufferedailment/illness/disease/injury/accidentduringthe

currencyofthepolicy.

3.12REASONABLE&CUSTOMARYEXPENSES:meansreasonableandcustomarysurgicalmedicaltreatmentexpenseswithinthescopetotreattheconditionforwhichtheinsuredpersonwashospitalized.

3.13CASHLESSFACILITY: meanstheTPAmayauthoriseupontheInsuredsrequestfordirectsettlementofadmissibleclaimasperagreedchargesbetweenNetworkHospitals&theTPA. InsuchcasestheTPA

will directly settleall eligible amounts withthe Network Hospitals andthe Insured Person may not

have to pay any bills after the end of the treatment at Hospital to the extent the claim is covered

underthepolicy.

3.14I .D.CARD: means thecard issued tothe Insured Person by the TPA toavail Cashless facility intheNetworkHospital.

3.15DAYCAREPROCEDURE:meansthecourseofMedicaltreatment/surgicalprocedurelistedat 2.3(A)carried out, in Networked specialised Day Care Centre which is fully equipped with advanced

technology and specialised infrastructure where the insured is discharged on the same day, the

requirementof

minimum

beds

will

be

over

looked

provided

other

conditions

are

met.

3.16LIMITOF INDEMNITY: means theamountstated in the schedule against thenameof each insuredperson which represents maximum liability for any and all claims made during the policy period in

respect of that insured person in respect of that insured person in respect of hospitalization taking

placeduringcurrencyofthepolicy.

3.17ANYONEILLNESS:Anyoneillnesswillbedeemedtomeancontinuousperiodofillnessanditincludesrelapsewithin105daysfromthedateofdischargefromtheHospital/nursinghomefromwherethe


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treatmentwastaken.Occurrenceofthesameillnessafteralapseof105daysasstatedabovewillbe

consideredasfreshillnessforthepurposeofthispolicy.

3.18PERIODOFPOLICY:Thisinsurancepolicyisissuedforaperiodofoneyearasshowninthe schedule.4 EXCLUSIONS:

The

Company

shall

not

be

liable

to

make

any

payment

under

this

policy

in

respect

of

any

expenses

whatsoeverincurredbyanyInsuredPersoninconnectionwithorinrespectof:

4.1 Preexisting health condition or disease or ailment / injuries: Any ailment / disease / injuries / healthconditionwhicharepreexisting(treated/untreated,declared/notdeclaredintheproposalform),when

thecoverinceptsforthefirsttimeareexcludedupto4yearsofthispolicybeinginforcecontinuously.

For the purpose of applying this condition, the date of inception of this Mediclaim policy taken from

Oriental Insurance Company shall be considered, provided the renewals have been continuous and

withoutanybreakinperiod.

Thisexclusionwillalsoapplytoanycomplicationsarisingfrompreexistingailments/diseases/injuries.

Such complications will be considered as a part of the pre existing health condition or disease. To

illustrateifaperson issufferingfromhypertensionordiabetesorbothhypertensionanddiabetesatthe

timeoftakingthepolicy,thenpolicyshallbesubjecttofollowingexclusions.

Diabetes Hypertension Diabetes&Hypertension

DiabeticRetinopathy CerebroVascularaccident DiabeticRetinopathy

DiabeticNephropathy HypertensiveNephropathy DiabeticNephropathy

DiabeticFoot/wound InternalBleed/Haemorrhages DiabeticFoot

DiabeticAngiopathy CoronaryArteryDisease DiabeticAngiopathy

DiabeticNeuropathy DiabeticNeuropathy

Hyper/Hypoglycaemicshocks Hyper/Hypoglycaemicshocks

CoronaryArteryDisease

CerebroVascularaccident

HypertensionNephropathy

InternalBleeds/Haemorrhages

4.2 Any disease other thanthose stated in clause 4.3, contracted by the Insured person during the first30daysfromthecommencementdateofthepolicyexcepttreatmentforaccidentalexternalinjuries.

4.3 During the period of insurance cover, the expenses on treatment of following ailment / diseases /surgeriesforspecifiedperiodsarenotpayableifcontractedand/ormanifestedduringthecurrencyof

thepolicy.

i Benign ENT disorders and surgeries i.e. Tonsillectomy, Adenoidectomy, Mastoidectomy,

Tympanoplastyetc.

1 year

ii Polycysticovariandiseases. 1 year

iii Surgeryofhernia. 2 years

iv Surgeryofhydrocele. 2 years

v NoninfectiveArthritis. 2 years

vi UndescendentTestes. 2 Years

vii Cataract. 2 Years

viii Surgeryofbenignprostatichypertrophy. 2 Years

ix Hysterectomyformenorrhagiaorfibromyomaormyomectomyorprolapseofuterus. 2 Years

x Fissure/Fistulainanus. 2 Years

xi Piles. 2 Years

xii Sinusitisandrelateddisorders. 2 Years


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xiii Surgeryofgallbladderandbileductexcludingmalignancy. 2 Years

xiv Surgeryofgenitourinarysystem excludingmalignancy. 2 Years

xv PilonidalSinus. 2 Years

xvi GoutandRheumatism. 2 Years

xvii Hypertension. 2 Years

xviii Diabetes. 2 Years

xix Calculusdiseases. 2 Years

xx Surgeryforprolapsedintervertebraldiskunlessarisingfromaccident. 2 Years

xxi Surgeryofvaricoseveinsandvaricoseulcers. 2 Years

xxii Congenitalinternaldiseases. 2 Years

xxiii JointReplacementduetoDegenerativecondition. 4 Years

xxiv AgerelatedosteoarthritisandOsteoporosis. 4Years

IfthecontinuityoftherenewalisnotmaintainedwithOrientalInsuranceCompanythensubsequent

coverwillbetreatedasfreshpolicyandclauses4.1.,4.2,4.3willapplyunlessagreedbytheCompany

andsuitableendorsementpassedonthepolicy.

4.4 Injuryor disease directlyor indirectly causedbyorarising from or attributableto War, Invasion, ActofForeignEnemy,Warlikeoperations(whetherwarbedeclaredornot)orbynuclearweapons/materials.

4.5 Circumcision (unless necessary for treatment of a disease not excluded hereunder or as may benecessitated due to any accident), vaccination, inoculationorchange of life or cosmeticorof aesthetic

treatmentofanydescription,plasticsurgeryotherthanasmaybenecessitatedduetoanaccidentorasa

partofanyillness.

4.6 Surgeryforcorrectionofeyesight,costofspectacles,contactlenses,hearingaidsetc.4.7 Anydentaltreatmentorsurgerywhich iscorrective,cosmeticorofaestheticprocedure,fillingofcavity,

root canal including wear and tear etc unless arising from disease or injury and which requires

hospitalisationfortreatment.

4.8 Convalescence,generaldebility,rundownconditionorrestcure,congenitalexternaldiseasesordefectsor anomalies, sterility, any fertility, subfertility or assisted conception procedure, venereal diseases,

intentionalselfinjury/suicide,allpsychiatricandpsychosomaticdisordersanddiseases/accidentdueto

and or use, misuse or abuse of drugs / alcohol or use of intoxicating substances or such abuse or

addictionetc.

4.9 Allexpensesarisingoutofanyconditiondirectlyorindirectlycausedby,orassociatedwithHumanTcellLymphotropic Virus Type III (HTLD III) or Lymohadinopathy Associated Virus (LAV) or the Mutants

Derivative or Variations Deficiency Syndrome or any Syndrome or condition of similar kind commonly

referredtoasAIDS,HIVanditscomplicationsincludingsexuallytransmitteddiseases..

4.10 ExpensesincurredatHospitalorNursingHomeprimarilyforevaluation/diagnosticpurposeswhichisnotfollowed

by

active

treatment

for

the

ailment

during

the

hospitalised

period.

4.11 Expensesonvitaminsandtonicsetcunlessformingpartoftreatmentforinjuryordiseaseascertifiedbytheattendingphysician.

4.12 AnyTreatmentarisingfromortraceabletopregnancy,childbirth,miscarriage,caesareansection,abortionorcomplicationsofanyoftheseincludingchangesinchronicconditionasaresultofpregnancy.


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4.13 Naturopathy treatment, unproven procedure or treatment, experimental or alternative medicine andrelatedtreatmentincludingacupressure,acupuncture,magneticandsuchothertherapiesetc.

4.14 Expenses incurred for investigation or treatment irrelevant to the diseases diagnosed duringhospitalisationorprimaryreasons foradmission.Privatenursingcharges,Referralfeetofamilydoctors,

Outstationconsultants/Surgeonsfeesetc,.

4.15 Geneticaldisordersandstemcellimplantation/surgery.4.16 ExternalandordurableMedical/Nonmedicalequipmentofanykindusedfordiagnosisandortreatment

includingCPAP,CAPD,Infusionpumpetc.,Ambulatorydevicesi.e.walker,Crutches,Belts,Collars,Caps,

splints, slings, braces ,Stockings etc of any kind, Diabetic foot wear, Glucometer / Thermometer and

similarrelateditemsetcandalsoanymedicalequipmentwhichissubsequentlyusedathomeetc..

4.17 All non medical expenses including Personal comfort and convenience items or services such astelephone, television, Aya / barber or beauty services, diet charges, baby food, cosmetics, napkins ,

toiletryitemsetc,guestservicesandsimilarincidentalexpenses orservicesetc..

4.18 Changeoftreatmentfromonepathytootherpathyunlessbeingagreed/allowedand recommendedbytheconsultantunderwhomthetreatmentistaken.

4.19 Treatment of obesity or condition arising therefrom (including morbid obesity) and any other weightcontrolprogramme,servicesorsuppliesetc...

4.20 Any treatment required arising from Insureds participation in any hazardous activity including but notlimited to scuba diving, motor racing, parachuting, hang gliding, rock or mountain climbing etc unless

specificallyagreedbytheInsuranceCompany.

4.21 Anytreatmentreceived inconvalescenthome,convalescenthospital,healthhydro,naturecareclinicorsimilarestablishments.

4.22 Any stay in the hospital for any domestic reason or where no active regular treatment is given by thespecialist.

4.23 OutpatientDiagnostic,MedicalorSurgicalproceduresortreatments,nonprescribeddrugsandmedicalsupplies, Hormone replacement therapy, Sex change or treatment which results from or is in any way

relatedtosexchange.

4.24 Massages,Steambathing,Shirodharaandaliketreatmentunder Ayurvedictreatment.4.25 AnykindofServicecharges,Surcharges,Admissionfees/Registrationchargesetcleviedbythehospital.4.26 Doctorshomevisitcharges,Attendant/Nursingchargesduringpreandposthospitalisationperiod.4.27 Treatmentwhichiscontinuedbeforehospitalizationandcontinuedevenafterdischargeforanailment/

disease/injurydifferentfromtheoneforwhichhospitalizationwasnecessary.

5 CONDITIONS


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5.1 ENTIRE CONTRACT: the policy, proposal form, prospectus and declaration given by the insured shallconstitute thecomplete contractof insurance. Only insurer may alter the terms and conditions ofthis

policy/contract. Anyalterationthatmaybemadebytheinsurershallonlybeevidencedbyadulysigned

andsealedendorsementonthepolicy.

5.2 COMMUNICATION : Every notice or communication to be given or made under this policy shall bedelivered

in

writing

at

the

address

of

the

policy

issuing

office

/

Third

Party

Administrator

as

shown

in

the

Schedule.

5.3 PAYMENTOFPREMIUM:Thepremiumpayableunderthispolicyshallbepaidinadvance.NoreceiptforpremiumshallbevalidexceptontheofficialformoftheCompanysignedbyadulyauthorizedofficialof

thecompany. Theduepaymentofpremiumandtheobservanceandfulfilmentoftheterms,provisions,

conditionsandendorsementsofthispolicybytheInsuredPersoninsofarastheyrelatetoanythingtobe

doneorcompliedwithbytheInsuredPersonshallbeconditionprecedenttoanyliabilityoftheCompany

tomakeanypaymentunderthispolicy.Nowaiverofanyterms,provisions,conditionsandendorsements

ofthispolicyshallbevalid,unlessmadeinwritingandsignedbyanauthorisedofficialoftheCompany.

5.4 NOTICE OF CLAIM: Immediate notice of claim with particulars relating to Policy Number, ID Card No.,Nameofinsuredpersoninrespectofwhomclaim ismade,Natureofdisease/ illness/injuryandName

and Address ofthe attending medical practitioner / Hospital/Nursing Home etc.shouldbegiven to the

Company/TPAwhiletakingtreatmentintheHospital/NursingHomebyFax,Email.Suchnoticeshould

begivenwithin48hoursofadmissionorbeforedischargefromHospital/NursingHome,unlesswaivedin

writing.

5.5 CLAIM DOCUMENTS: Final claim along with hospital receipted original Bills/Cash memos/reports, claimformand listofdocumentsas listedbelowshouldbesubmittedtotheCompany/TPAwithin7daysof

dischargefromtheHospital/NursingHome.

a. Originalbills,receiptsanddischargecertificate/cardfromthehospital.b. MedicalhistoryofthepatientrecordedbytheHospital.c. OriginalCashmemofromthehospital(s)/chemist(s)supportedbyproperprescription.d. Original receipt, pathological and other test reports from a pathologist / radiologist including film etc

supportedbythenotefromattendingmedicalpractitioner/surgeondemandingsuchtests.

e. AttendingConsultants/Anaesthetists/Specialistcertificatesregardingdiagnosisandbill/receiptsetc.f. Surgeons original certificate stating diagnosis and nature of operation performed along with bills /

receiptsetc.

g. AnyotherinformationrequiredbyTPA/InsuranceCompany.Alldocumentsmustbedulyattestedbytheinsuredperson.

Incaseofposthospitalisationtreatment(limitedto60days)allsupportingclaimpapers/documentsas

listedaboveshouldalsobesubmittedwithin7daysaftercompletionofsuchtreatment(upto60daysor

actual period which ever is less ) to the Company / T.P.A. In addition insured should also provide the

Company/TPA

such

additional

information

and

assistance

as

the

Company

/TPA

may

require

in

dealing

withtheclaim.

NOTE:Waiveroftheconditionmaybeconsideredinextremecasesofhardshipwhereitisprovedtothe

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.

OtherwiseCompany/TPAhasarighttorejecttheclaim.

5.6 PROCEDUREFORAVAILINGCASHLESSACCESSSERVICESINNETWORKHOSPITAL/NURSINGHOME:


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i) ClaiminrespectofCashlessAccessServiceswillbethroughtheTPAprovidedadmissionisinalistedhospital in the agreed list of the networked Hospitals / Nursing Homes and is subject to pre

admission authorization. The TPA shall, upon getting the related medical details / relevant

informationfromthe insuredperson/networkHospital/NursingHome,verifythattheperson is

eligible to claim under the policy and after satisfying itself will issue a preauthorisation letter /

guarantee

of

payment

letter

to

the

Hospital

/

Nursing

Home

mentioning

the

sum

guaranteed

as

payable,alsotheailmentforwhichthepersonisseekingtobeadmittedasinpatient.

ii) TheTPAreservestherighttodenypreauthorisationincasethehospital/insuredpersonisunabletoprovidetherelevantinformation/medicaldetailsasrequiredbytheTPA. Insuchcircumstances

denialofCashlessAccessshouldinnowaybeconstruedasdenialofclaim. Theinsuredpersonmay

obtain the treatment as per his/her treating doctors advice and later on submit the full claim

paperstotheTPAforreimbursementwithin7daysofthedischargefromHospital/NursingHome.

iii) Should any information be available to the TPA which makes the claim inadmissible or doubtfulrequiringinvestigations,theauthorisationofcashlessfacilitymaybewithdrawn.Howeverthisshall

bedonebytheTPAbeforethepatientisdischargedfromtheHospital.

5.7REPUDIATION:

A (I): The TPA, if policy is being serviced by them, shall repudiate the claim if not covered / not payable

underthepolicy.TheTPAshallmentionthereasonsforrepudiation inwritingtothe insuredperson. The

insuredpersonshallhavetherighttoappeal/approachthepolicyissuingofficeoftheinsurancecompanyif

he/she feelsthattheclaim ispayable. The insurancecompanysdecision inthisregardwillbe finaland

bindingonTPA.

A( II): Ifpolicy isservicedby InsuranceCompany, in caseofrepudiationofclaim, insuredshallhavethe

righttoappealtotheconcernedRegionalOfficeoftheInsuranceCompany,ifhe/shefeelsthattheclaimis

payable.

B : Ifclaim isrepudiatedbythecompany asperA (1)&A (II)butthe insured feelsthathis/herclaim is

payabletheninsuredpersonshallhavearighttoappeal/approachtheChiefManagerGrievanceCellofthe

Companysituated

at

A

25/27,Asaf

Ali

Road,

New

Delhi

110002.

C: The Central Government has established an office of the Insurance Ombudsman for redressal of

grievancesofuptoRs20lacsrelatedtopersonallinesofinsurances.

5.8 AnymedicalpractitionerauthorisedbytheTPA/CompanyshallbeallowedtoexaminetheInsuredPersonincase of any alleged injury or Disease requiring Hospitalisation when and so often as the same may

reasonablyberequiredonbehalfoftheTPA/Company.

5.9 FRAUD/MISREPRESENTATION/CONCEALMENT: TheCompanyshallnotbe liabletomakeanypaymentunder this policy in respect of any claim if such claim be in any manner intentionally or recklessly or

otherwise misrepresented or concealedornondisclosure of material facts ormaking false statements or

submittingfalls

bills

whether

by

the

Insured

Person

or

Institution

/Organization

on

his

behalf

.Such

action

shallrenderthispolicynullandvoidandallclaimshereundershallbeforfeited. Companymaytakesuitable

legalactionagainsttheInsuredPerson/Institution/OrganizationasperLaw.

5.10 CONTRIBUTION : If at the time when any claim arises under this policy, there is in existence any otherinsurance (other than Cancer Insurance Policy in collaboration with Indian Cancer Society) whether it be

effectedbyoronbehalfofanyInsuredPersoninrespectofwhomtheclaimmayhavearisencoveringthe

same loss, liability,compensation,costsorexpenses,thecompanyshallnotbe liabletopayorcontribute


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11

morethanitsrateableproportionofanyloss,liability,compensation,costsorexpenses. Thebenefitsunder

thispolicyshallhoweverbeinexcessofthebenefitsavailableunderCancerInsurancePolicy.

5.11 CANCELLATION CLAUSE: Company may at any time without assigning any reason cancel this Policy bysendingtheInsured30daysnoticebyregistered letterattheInsureds lastknownaddressand insuchan

eventtheCompanyshallrefundtotheInsuredaproratapremiumforunexpiredPeriodofInsurance. The

Company

shall,

however,

remain

liable

for

any

claim

which

arose

prior

to

the

date

of

cancellation.

The

InsuredmayatanytimecancelthispolicyandinsucheventtheCompanyshallallowrefundofpremiumat

Companysshortperiodrateonly(tablegivenherebelow)providednoclaimhasoccurredduringthepolicy

perioduptodateofcancellation.

PeriodonRisk Rateofpremiumtobecharged

Upto1Month 1/4thoftheannualrate

Upto3Months 1/2oftheannualrate

Upto6Months 3/4thoftheannualrate

Exceeding6months Fullannualrate

5.12 ARBITRATIONCLAUSE:Ifanydisputeordifferenceshallariseastothequantumtobepaidunderthepolicy(liabilitybeingotherwiseadmitted)suchdifferenceshall independentlyofallotherquestionsbe

referredtothedecisionofasolearbitratortobeappointed inwritingbythepartiesor iftheycannot

agree upon a single arbitrator within 30 days of any party invoking arbitration, the same shall be

referredtoapanelofthreearbitrators,comprisingoftwoarbitrators, onetobeappointedbyeachof

the partiestothedispute/differenceandthethird arbitratortobe appointedbysuchtwoarbitrators

andarbitrationshallbeconductedunderand inaccordancewiththeprovisionsoftheArbitrationand

ConciliationAct,1996.

Itisclearlyagreedandunderstoodthatnodifferenceordisputeshallbereferabletoarbitrationasherein

beforeprovided,iftheCompanyhasdisputedornotacceptedliabilityunderorinrespectofthispolicy.

Itisherebyexpresslystipulatedanddeclaredthatitshallbeaconditionprecedenttoanyrightofaction

or suitupon this policy thataward by such arbitrator/ arbitratorsoftheamountofthe lossor damage

shallbe

first

obtained.

5.13 DISCLAIMEROFCLAIM:ItisalsoherebyfurtherexpresslyagreedanddeclaredthatiftheTPA/CompanyshalldisclaimliabilityinwritingtotheInsuredforanyclaimhereunderand suchclaimshallnotwithin

12calendarmonthsfromthedateofsuchdisclaimerhavebeenmadethesubjectmatterofasuitina

court of law, thenthe claimshall for all purposes bedeemed to have been abandoned and shall not

thereafterberecoverablehereunder.

5.14 PAYMENTOFCLAIM:Thepolicycoversillness,diseaseoraccidentalbodilyinjurysustainedbytheinsuredpersonduringthepolicyperiodanywhereinIndiaandallmedical/surgicaltreatmentunderthispolicy

shallhavetobetakeninIndiaandadmissibleclaimsthereofshallbepayableinIndiancurrency.

a) Payment of claim shall be made through TPA to the Hospital / Nursing Home or to the InsuredPersonincasepolicyisservicedthroughTPA.

b) InnonTPAcasetheclaimwillbepaidtotheinsuredpersonbytheInsuranceCompany.6 COST OF HEALTH CHECK : The Insured shall be entitled for reimbursement of cost of Health check up

undertakenonceattheexpiryofablockofevery fourcontinuousclaimfreeunderwritingyearsprovided

therearenoclaimsreportedduringtheblock.Thecostsoreimbursableshallnotexceedtheamountequal

to1%oftheaveragebasicsumInsuredduringtheblockoffourclaimfreeunderwritingyears.


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12

IMPORTANT

HealthCheckupprovisionisapplicableonlyinrespectofcontinuousinsurancewithoutbreak.

7 PERIODOFPOLICY:Thisinsurancepolicyisissuedforaperiodofoneyear.8 RENEWALOFPOLICY:

a) TheCompanyshallnotberesponsibleorliablefornonrenewalofpolicyduetononreceiptordelayed receipt (i.e. After the due date) of the proposal form or of the medical practitioners

reportwhereverrequiredorduetoanyotherreasonwhatsoever.

b) Notwithstandingthis,however,thedecisiontoacceptorreject forcoverageanypersonuponrenewalofthisinsuranceshallrestsolelywiththeCompany. Thecompanymayatitsdiscretion

revisethepremiumratesand/ortheterms&conditionofthepolicyeveryyearuponrenewal

thereof. Renewalofthispolicyisnotautomatic;premiumduemustbepaidbytheproposerto

thecompanybeforetheduedate.

c) The Company normally sends renewal notice but not sending it will not tantamount todeficiencyinservices.

Ifthepolicyistoberenewedforenhancedsuminsuredthentherestrictionsasapplicabletoafreshpolicy

(condition4.1,4.2&4.3willapplytoadditionalsuminsured)asifaseparatepolicyhasbeenissuedforthe

difference,subjecttomedicalcheckupaspernormsoftheCompany.ThecostofMedicalcheckupshallbe

bornebytheinsured.

9 PREACCEPTANCEHEALTHCHECKUP:Anypersonbeyond45yearsofagedesiringtotakeinsurancecoverhastosubmit followingmedicalreports fromauthorisedNetworkDiagnosticCentreoranyothermedical

reports required bythe company in case of fresh proposal and renewalwherethere is a break in policy

period.Thecostshallbebornebytheinsured.

Incaseoffreshproposals,50%costofMedicalCheckupnotexceeding20%ofpremiumchargeableshallbe

reimbursedbytheCompanyafteracceptance.

Age 4555 ABOVE55Years

MEDICAL

TEST

PHYSICALEXAMINATION PHYSICALEXAMINATION

URINE(MICROALBUMIN UREA) URINE(MICROALBUMIN UREA)

GLYCOCYLATED,HAEMOGLOBIN GLYCOCYLATEDHAEMOGLOBIN

ULTRASONOGRAPHY(WHOLEABDOMEN

ANDPELVIS)

ULTRASONOGRAPHY (WHOLE ABDOMEN AND

PELVIS)

ELECTROCARDIOGRAM XRAYBOTHKNEES(ANTEPOSTERIORAND LATREL)

COMPLETEEYETESTINCLUDINDFUNDUS

ETC

COMPLETEEYETESTINCLUDINDFUNDUSETC

STRESSTEST(TMT)

10

SUM

INSURED:

The

Companys

liability

in

respect

of

all

claims

admitted

during

the

period

of

Insurance

shallnotexceedthesuminsuredoptedbytheInsuredperson.MinimumsuminsuredisRs50,000/ andin

multiplesofRs25,000/ uptoRs2,00,000/.BeyondtheSumInsuredofRs.200000/ inmultiplesofRs.

50000/ uptoRs500000/.

11 AUTHORITYTOOBTAINRECORDS:a) The insured person hereby agrees to and authorises the disclosure to the insurer or the TPA or any

other person nominated by the insurer of any and all Medical records and information held by any

Institution / Hospital or Person from which the insured person has obtained any medical or other


13/13


13

treatment to the extent reasonably required by either the insurer or the TPA in connection with any

claimmadeunderthispolicyortheinsurersliabilitythereunder.

b) The insurer and the TPA agree that they will preserve the confidentiality of any documentation andinformationthatcomes into their possessionpursuant to (a) above andwillonlyuse it inconnection

withanyclaimmadeunderthispolicyortheinsurersliabilitythereunder

12

CHANGE

OF

ADDRESS:

Insured

must

inform

the

company

immediately

in

writing

of

any

change

in

the

address.

13 REASONABLE,CUSTOMARYANDNECESSARYEXPENSES:13.1 ForanetworkedhospitalmeanstheratepreagreedbetweenNetworkedHospitalandtheTPA

forsurgical/medicaltreatmentthatisnecessary,customaryandreasonablefortreatingthecondition

forwhichinsuredpersonwashospitalized.

13.2 Foranyotherhospital itshallmeanthecostofsurgical/medicaltreatmentthatisnecessary,customaryandreasonablefortreatingtheconditionforwhich insuredpersonwashospitalizedtothe

extent that such cost does not exceed the reasonable and customary charges for which insured was

hospitalized.

NOTE: Any expenses as mentioned above which are not covered under the policy and / or which are not

reasonable,customaryandnecessary,thesamehavetobebornebytheinsuredpersonhimself.

14 QUALITYOFTREATMENT:The insuredherebyacknowledgesandagreesthatpaymentofanyclaimbyoronbehalfoftheinsurershallnotconstituteonpartoftheinsurancecompanyaguaranteeorassuranceas

tothequalityoreffectivenessofanymedicaltreatmentobtainedbytheinsuredperson,itbeingagreedand

recognized by the policy holder that insurer is not in any way responsible or liable for the availability or

quality of any services (Medical or otherwise) rendered by any institution (including a network hospital)

whetherpreauthorizedornot.

15 IDCARD:ThecardissuedtotheinsuredpersonbytheTPAtoavailcashlessfacilityintheNetworkHospitalonly. Uponthecancellationornonrenewalofthispolicy,allIDcardsshallimmediatelybereturnedtothe

TPAatthepolicyholdersexpenseandthepolicyholderandeach insuredpersonagreestoholdandkeep

harmless,theinsurerandtheTPAagainstanyorallcosts,expenses,liabilitiesandclaims(whetherjustified

ornot)arisinginrespectoftheactualorallegeduse,misuseofsuchIDcardspriortotheirreturn.

16 ADDONBENEFIT:MEDICLAIMWITHOMP:

In case where a person covered under Mediclaim Policy (Individual) goes abroad by taking Orientals

OverseasMediclaimPolicyhis/herMediclaimPolicybecomesinoperativefortheperiodhe/sheisabroad.

Since there is no provision for adjustment/ refund of premium, Mediclaim Policy may be extended by

number of days, the insured person was abroad subject to written request being made by the insured

beforeleavingIndia.

17 IRDAREGULATIONNO.5.:Thispolicyissubjecttoregulation5ofIRDA(ProtectionofPolicyHolderinterest)regulation.

mediclaim policy (individual) guidelines

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