Features of 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.