Basic Coverage’s Health Insurance

Under Health Insurance

Features of Health Insurance Policy

For whom Individual/Family
Sum Insured Rs 50000/- to Rs 200 lakhs for higher sum insured room rent capping and sub limits are not applicable.
Hospitalization & Domiciliary expenses incurred for Illness /Disease /Accidents,
including Room Rent, Boarding Expenses as provided by Hospital/ Nursing Home/ Nursing Expenses.
Fees for Surgeon/ Anesthetist/ Medical Practitioner/ Consultants/ Specialist
Expenses for Anesthesia/Blood/Oxygen/ Operation Theatre charges/ Surgical Appliances/ Medicines & Drug charges/ Diagnostic Materials and X-rays/ Dialysis/ Chemotherapy/ Radiotherapy/ Cost of Pacemaker/ Artificial Limbs and Cost of organ etc.
Pharmacy: Medicines/injunctions other related material
Condition 1 Minimum stay in hospital is 24 hours which can be relaxed for the specific treatments like Dialysis, Chemotherapy, Radiotherapy, Eye surgery, Lithotripsy and Accident etc.
Condition 2 Admission in hospital for diagnostic purpose and no illness is detected then the expenses will not be covered under health insurance policy.

Various Standard Exclusions which may vary from Insurer to
Insurer:

  1. All diseases / injuries which are pre-existing when the cover incepts for the first time.
  2. During the first year/second year (depends upon the insurer) of the operation of the insurance cover, the expenses incurred on treatment of diseases such as cataract, Benign Prostatic, Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal diseases, Fistula in anus, piles, Sinusitis related disorders are not payable and if pre existing can not be covered subsequently also.
  3. An 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).
  4. If the insured is aware of the existence of congenital internal diseases/defects before inception of policy it will be treated as pre-existing.
  5. Circumcision, vaccination, cosmetic/ Plastic surgery, AIDS, STD.
  6. Cost of spectacles and contact lenses, hearing aids.
  7. Dental treatment or surgery of any kind unless requiring hospitalization.
  8. All expenses arising out of any condition directly or indirectly caused to or associated with Human T Cell Lymphotropic Virus Type III or lymphandinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency syndrome or any (HTBB – III) Syndrome or condition of a similar kind commonly referred to as AIDS.
  9. Convalesance, general disability “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.
  10. Naturopathy treatment.
  11. Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-Ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury for which confinement is required at a Hospital/ Nursing Home.
  12. Injury or disease directly or indirectly caused by or contributed to by nuclear weapons.
  13. Treatment arising from or traceable to pregnancy, childbirth including cesarean section.
  14. Expenses on vitamins and tonics unless forming part of the
    treatment for injury or disease as certified by the attending
    Physician.

Claim Procedure

If any Claim arises in health insurance policy and the same can be settled in any of the following ways:

  1. Reimbursement of expenses
  2. Cashless facility for planned Hospitalization
  3. Cashless Facility for emergency hospitalization

Reimbursement of expenses: if a policyholder falls sick and hospitalized in non empanelled hospital then he should follow the following procedure:

  1. Intimation to the insurer/ Third Party Administrator (TPA) along with the name of the person who has fallen sick
  2. Policy number
  3. Name of the hospital
  4. Name of the Doctor
    The above information should be sent with in 7 days of the hospitalization. With in 30 days Final claim form along with the following documents:
  5. Hospital receipts/ original bills
  6. Cash memos
  7. Various reports and tests
  8. Hospital admission and discharge slip
  9. Case History
  10. Any other documents desired by TPA or Hospital

Note: Kindly ensure that you have been admitted to the hospital/nursing home as defined in the policy.

Cashless facility for planned Hospitalization:

  1. The expected expenses to be incurred should be sent to TPA through the agreed list of network hospital
  2. Policy no. & card number should be should be shown to the Hospital
  3. On confirmation from the TPA the treatment can be taken in that hospital.
  4. If expenses increases during the treatment then the hospital will sent revise estimate to the TPA for their approval.
  5. For any post hospitalization treatment the original bills/cash memo can be sent to the TPA after completing the treatment for the reimbursement.

Cashless Facility for emergency hospitalization

  1. A card issued by the insurer should be shown to the hospital
  2. The expected expenses may sent to the TPA for their approval.
  3. For any post hospitalization treatment the original bills/cash memo can be sent to the TPA after completing the treatment for the reimbursement.

Important: Kindly ensure that the Identity card issued by TPA should be easily available with you.

Critical Illness

Coverage’s: It is similar to the standard health insurance policy
but covers selected dieses which affect lifestyle of person. The
critical illnesses are defined in the policy which varies from
insurer to insurer. Examples:

Cancer, First heart attack ,Open chest CABG,,Open heart
replacement or repair of heart valves,Coma of specified severity,
Kidney failure requiring regular dialysis,Stroke resulting in
permanent symptoms, Major organ/bone marrow transplant,Permanent
paralysis of limbs, Motor neuron disease with permanent symptoms,
Multiple sclerosis persisting symptoms, Aplastic anemia, Bacterial
meningitis, Loss of speech, End stage liver disease, Deafness, End-stage lung disease, Fulminant viral hepatitis, Major burns, Muscular dystrophy.

Sum Insured: Rs 2 lakhs to 50 lakhs
Who can be insured: Individual/Family
Hospitalization: Not required, the sum insured is paid on diagnosis by the Doctor
Waiting Period : 3 months if the policy is taken first time
Survival: The policyholder should survive for minimum 30 days otherwise the claim is not payable.

Exclusions:

  1. Critical illnesses diagnosed within first 90 days from the inception of policy
  2. Death within 30 days of diagnosis of critical illness or surgery
  3. Illness due to smoking, tobacco, alcohol or drug intake
  4. Illness occurring due to internal or external congenital disorder
  5. Critical conditions or consequences due to pregnancy or childbirth, including caesarean
  6. HIV/AIDS infection
  7. War, terrorism, civil war, navy or military operations
  8. Any dental care or cosmetic surgery
  9. Infertility treatment
  10. Hormone replacement treatment
  11. Treatment done outside India
  12. Treatment to assist reproduction

Overseas Travel Insurance Policy:

If any person is travelling abroad and he may require any medical assistance which may not be covered under domestic health insurance.

Who can buy?: Person going abroad for studying, Business trip and Pleasure trip

Coverage’s:

Emergency medical treatment and assistance: Overseas travel insurance provides cover in case of any medical assistance required while travelling. Foreign travel insurance covers pre and post hospitalization expenses along with repatriation expenses.

Trip cancellation and trip interruption coverage: International travel insurance provides benefit in case of whole or partial trip cancellation by providing cost of your trip. It also provides coverage if your trip terminates due to any personal or professional reason.

Loss of Baggage: In case of loss or delay of baggage, insurance providers compensate insured by providing full amount of the lost baggage.

Legal liability coverage: International travel insurance provides coverage of legal liability arising from damage to a third party. It covers legal costs in case of involvement in legal suit.

Loss of important travel documents: Overseas travel insurance helps in case of loss of important travel documents like passport, tickets etc. It provides fees to reapply your documents.

Hospital cash: It pays daily allowance to the person in case of hospitalization, either due to sickness or an accident.

Repatriation of remains: It covers expenses incurred in moving the insured person to his/her country of residence.

Hijack distress allowance: Compensation is payable in the event of hijack of the common carrier in which the insured person is travelling. Insurer will pay allowance for each day of the hijack up to the total limits specified in the policy.

Personal accident: If you get hurt or die during trip, insurer will pay amount to compensate you or your loved ones.

Emergency financial assistance: Monetary assistance is provided if the insured loses all or substantial part of his travel funds due to theft, robbery or pilferage.