Policy details

The policy covers reimbursement of Hospitalization / Domiciliary Hospitalization expenses for illness, diseases or injury sustained. Expenses on hospitalization for minimum period of 24 hrs are admissible. The cover is restricted to treatments taken in India only. This insurance is available to individuals between the age of 5 years and 75 years. Children between the age of 3 months and 5 years can be covered provided one or both parents are covered concurrently.

A further period of seven days from the date of expiry will be permissible in exceptional cases subject to Health Certificate from Medical Practitioner. Any diseases contracted during the seven days from the date of expiry will be excluded from the date of renewal in addition to other diseases excluded in the expiating policy.

Check Points-

-Exclusions of the Policy
-Group Policy
-Bonus (Low Claim Ratio Discount)
-Malus (High Claim Ratio Loading)
-Mediclaim Policy Sum Insured
-Maternity Expenses Benefit Extension

Exclusions of the Policy

Such diseases which have been in pre-existence at the time of proposing this insurance.

Any expenses on hospitalization incurred during the first 30 days from the commencement period of insurance cover except in case of injury out of accident.

During first year of operation of insurance cover the expenses on treatment of diseases such as Cataract, Benign, Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibro Myoma, Hernia, Hydrocele, Congenitial Internal diseases, Fistula in Anus, Piles, Sinusitis and related disorders circumcision unless necessary for treatment of disease.

Cost of spectacles and contact lenses, hearing aids.

Dental treatment or surgery of any kind unless requiring hospitalization.

Treatment arising from or traceable to pregnancy, childbirth including caesarian section.

AIDs and Naturopathy treatments.

Coverage on hospitalization subject to a minimum of 24 hrs. stay only except in respect of certain specific named treatments viz. DIALYSIS / CHEMOTHERAPY / RADIO THERAPY / EYE SURGERY / DENTAL SURGERY / LITHOTRIPSY, TONSILECTOMY, D & C taken in the hospital and the insured is discharged on the same day.

Group Policy

The Group Mediclaim Policy will be available to any Group / Association / Institution / Corporate Body of more than 50 persons provided it has a central administration point. Each insured should cover all eligible members (insured persons) under one group policy only.

Group Discount

The Group Discount is permissible depending upon the total number of insured persons covered under the Group policy at the inception increase or decrease in the sizes of the group during the currency of the policy is permissible. The final group discount (increase or decrease) will be adjusted on the basis of the size of the group existing on the last day of the policy period provided the policy is renewed for next12 months.

No. of Insured/Group Discount -% Details:

100/15 - 400/20 - 500/25 - 4000/30 - 5000/35 - 15000/40 - 25000/50 - 50000 & Above/66

Bonus (Low Claim Ratio Discount)

Low Claim Ratio Discount as per following scale will be allowed on the total premium at renewal only depending upon the incurred claims ratio for the entire group insured under the Group Policy for the preceding 3 completed years excluding the year immediately preceding the date of renewal. Where the Group Policy has not been in force for 3 completed years, such shorter period of completed years excluding the year immediately preceding the date of renewal will be taken into account.

Incurred Claim Ratio/Discount -% Details:

Not exceeding 60 per cent/5 - Not exceeding 50 per cent/15 - Not exceeding 40 per cent/25 -

Not exceeding 30 per cent/35 - Not exceeding 25 per cent/45

Malus (High Claim Ratio Loading)

The total premium payable at renewal of the group policy will be loaded as per the scale below depending upon the incurred claims ratio for the entire group insured under the Group Policy for the preceding 3 completed years excluding the year immediately preceding the date of renewal.

Where the Group Policy has not been in force for the 3 completed years, such shorter periods of completed years, excluding the year immediately preceding the date of renewal will be taken into account.

Incurred Claim Ratio/Loading -% Details:

Between 80-100 per cent/25 - Between 101-145 per cent/55 - Between 126-150 per cent/90 -

Between 151-175 per cent/120 - Between 176-200 per cent/150 - Over 200 per cent/Cover to be reviewed.

(Incurred claim would mean claims paid plus claims outstanding in respect of the entire group insured under the policy during the relevant period)

Mediclaim Policy Sum Insured

Minimum Rs.15000 with multiples of Rs.5000 thereafter, with maximum sum insured of RS. 3,00,000 is the condition for opting the Mediclaim Policy.


Maternity Expenses Benefit Extension

This is an optional cover which can be obtained on payment of 10% of the total basic premium for all the insured persons under the policy.

The maximum benefit allowable under this clause will be up to Rs.50000 or the sum insured opted by the member of the group whichever is lower.

Conditions:

Benefits are admissible only if the expenses are incurred in Hospital /Nursing
Home as in-patients in India.

Waiting period of 9 months is applicable for payment of any claim relating to normal delivery or caesarian section or abdominal operation for extra uterine pregnancy. The waiting period may be relaxed only in case of delivery, miscarriage or abortion induced by accident or other medical emergency.

Claim in respect of delivery for only first two children and / or operations associated therewith will be considered in respect of any one insured person covered under the policy or any renewal thereof. Those insured persons who are already having two or more living children will not be eligible for this benefit.

Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 weeks from the date of conception are not covered.

Pre-natal and post-natal expenses are not covered unless admitted in Hospital
Nursing Home and treatment is taken there.

• Premium Details