health insurance or medical expense insurance schemes have been in existence for a number of years prior to nationalization of insurance business. these policies were granted on a group basis, only to large corporate clients purely on an accommodation basis as claim experience was unsatisfactory.
there was no scheme for individuals and families. this scheme is available both on an individual and group basis.
HOSPITAL/NURSING HOME: means any institution in India established for indoor care and treatment of sickness and injuries and which 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.
MEDICAL PRACTITIONER means a person who holds a degree/diploma of a recognized institution and is registered by Medical Council of respective State of India. The term Medical Practitioner would include Physician, Specialist and Surgeon and shall not include insured person and member of
his family covered under this insurance.
QUALIFIED NURSE means a person who holds a certificate of a recognized nursing Council and who is employed on recommendations of the attending Medical Practitioner.
THIRD PARTY ADMINISTRATOR (T.P.A.)
TPA means a third party administrator as mentioned in the schedule, licensed by the Insurance Regulatory and Development Authority (IRDA) and engaged by the Company for a fee or remuneration for providing “Cashless Service and or reimbursement of claim under Mediclaim Policy to insured persons.
CUSTOMARY & REASONABLE CHARGE: A charge for health care, which is consistent with the prevailing rate in an area or charged in a certain geographical area for identical or similar services.
DAYCARE PROCEDURE means the course of medical treatment / surgical procedure in specialized day care center which enables the insured to be discharged on the same day. The requirement of minimum number of beds will be waived, provided other conditions are met.
CONDITIONS:
Premium Payment: The premium payable under this policy shall be paid in advance. No receipt for premium shall be valid except on the official form of the company signed by a duly authorized official of the Company. The due payment of premium and the observance and fulfillment of the terms,provisions, conditions and endorsements of this policy by the Insured Person in so far as they relate to anything to be done or complied with by the Insured Person shall be a condition precedent to any liability of the Company to make any payment under the Policy. No waiver of any terms, provision, conditions and endorsement of this policy shall be valid unless made in writing and signed by an authorized official of the Company.
Physical Examination: Any Medical Practitioner authorized by the TPA / Company shall be allowed to examine the Insured Person in case of any alleged disease/illness/injury requiring Hospitalization. Non-co-operation by the Insured Person will result into rejection of his/her claim.
Disclaimer of Claim: If The TPA / Company shall disclaim liability to the Insured for any claim hereunder and if the insured shall not, within 12 calendar months from the date or receipt of the notice of such disclaimer notify the TPA / Company in writing that he does not accept such disclaimer and intends to recover his claim from the Company, then the claim shall for all purposes be deemed to have been abandoned and shall not thereafter be recoverable hereunder.
RENEWAL OF POLICY:
(a) The Company sends renewal notice as a matter of courtesy. If the insured does not receive the renewal notice it will not amount to deficiency of service.
(b)The Company shall not be responsible or liable for non-renewal of thepolicy due to non-receipt/delayed receipt of renewal notice or due to any other reason whatsoever.
(c) Decision to accept or reject the coverage of any person at renewal of this insurance shall rest solely with the Company. The Company may at its discretion revise the premium rates and / or the terms and conditions of the policy every year upon renewal thereof. Renewal of this policy is not automatic; premium due must be paid to the Company before the due date.
COST OF HEALTH CHECK UP
In addition to cumulative bonus the Insured shall be entitled for reimbursement of cost of medical check up once at the end of a block of every four consecutive underwriting years provided there are no claims reported during the block. The cost so reimbursable shall not exceed the amount equal to 1% of the average sum Insured under the policies excluding Cumulative Bonus. This benefit will be allowed only when the insurance has been continued with our company for 4 claim free years.
PROCEDURE FOR AVAILING CASHLESS ACCESS SERVICE
Claims in respect of Cashless access services will be through the agreed list of network of hospital / nursing home and is subject to pre-admission authorization. The TPA shall, upon getting the related medical information from the insured person /network provider, verify that the person is eligible to claim under the policy and after satisfying itself will issue a pre-authorization 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 preauthorization in case the insured person is unable to provide the relevant medical details as required by the TPA.
CUMULATIVE BONUS
The Sum Insured under Policy shall be increased by 5% at each renewal in respect of each claim free year of insurance, subject to maximum of 30%. In case of a claim, the cumulative bonus earned shall be withdrawn on renewal of the policy. Cumulative bonus will be lost if policy is not renewed on the date of expiry. In case sum insured under the policy is reduced at the time of renewal, the applicable Cumulative Bonus shall also be reduced in proportion to the sum insured.