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| Besides this the employee is also eligible for a group medi-claim policy through ICICI Lombard with whom the company has tied up for the benefit. |
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| The details of the Medi Claim policy is as follows |
| During the policy period, if any Insured Person shall contract any disease or suffer from Any One Illness or sustain any bodily injury through accident, and if such disease, illness, accident or injury shall require any such Insured Person, upon the advice of a Medical Practitioner to incur Hospitalisation or Domiciliary Hospitalisation expenses, the Company will pay to the Insured Person |
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| ** The amount of such expenses as are reasonably and necessarily incurred thereof, by or on behalf of such Insured Person but not exceeding the sum insured for the person as specified. |
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| ****Medical expenses up to 30 days for Pre – hospitalization and upto 60 days for post – hospitalization are also payable |
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| The Company shall not be liable to make any payment under this policy in connection with or in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of: |
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Such diseases, which were pre-existing at the time of proposing this insurance. Misc 04 |
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Any disease other than those stated in Exclusion (3) below, contracted by the Insured Person during the first 30 days from the commencement date of the policy. This exclusion shall not however, apply if in the opinion of Panel of Medical Practitioners constituted by the company for the purpose, the Insured person could not have known of the existence of the Disease or any symptoms or complaints thereof at the time of making the proposal for insurance to the company. |
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The expenses on treatment of diseases, or illness such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagisa or Fibromyoma, Hernia, Hydrocele, Congenital Internal Diseases, Fistula in anus, Piles, Sinusitis and related disorders |
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During the first year of operation of this policy. If these diseases, or illness are pre-existing at the time of proposal, they will not be covered during subsequent renewal of the policy. |
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Diseases, illness, accident or injuries directly or indirectly caused by or arising from or attributable to war, invasion, act of foreign enemy, war like operations (whether war be declared or not). |
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Circumcision whether or not necessitated by vaccination or inoculation or change of life or cosmetic or aesthetic treatment of any description, plastic surgery unless necessary for treatment of a disease not excluded by the terms of the policy or as may be necessitated due to treatment of an accident. |
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The cost of spectacles and contact lenses, hearing aids. |
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Dental treatment or surgery of any kind unless requiring hospitalisation. |
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Convalescence, general debility, run-down condition or rest cure, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self-injury (whether arising from an attempt to suicide or otherwise) and use of intoxicating drugs and/or alcohol |
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All expenses arising out of any condition directly or indirectly caused to or associated with Acquired Immuno Deficiency Syndrome (AIDS) whether or not arising out of HIV, Human T-Cell Lymphotropic Virus Type III (HTLB –III) or Lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome or condition of a similar kind. |
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Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-Ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any diseases, illness or injury whether or not requiring Hospitalisation/Domiciliary Hospitalisation. |
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Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending Medical Practitioner. |
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Diseases, illness, accident or injuries directly or indirectly caused by or contributed to by nuclear weapons/materials or contributed to by or arising from ionising radiation or contamination by radioactivity by any nuclear fuel or from any nuclear waste or from the combustion of nuclear fuel. |
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Treatment arising from or traceable to pregnancy, childbirth including caesarean section. |
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Voluntary medical termination of pregnancy during the first 12 weeks from the date of conception. |
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Naturopathy treatment |
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Claim must be filed within 30 days from the date of completion of treatment. However, the Company may at its absolute discretion consider waiver, of this Condition in extreme cases of hardship where it is proved to the 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. |
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The Insured Person shall obtain and furnish the Company with all original bills, receipts and other documents upon which a claim is based and shall also give the Company such additional information and assistance as the Company may require in dealing with the claim. |
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Any medical practitioner authorised by the Company shall be allowed to examine the Insured Person in case of any alleged diseases, illness, accident or injuries requiring Hospitalisation or Domiciliary Hospitalisation when and so often as the same may reasonably be required on behalf of the Company. |
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If at the time when any claim arises under this policy, there is in existence any other insurance policy whether it be effected by or on behalf of any Insured Person in respect of whom the claim may have arisen covering the same loss, liability, compensation, costs or expenses, the Company shall not be liable to pay or contribute more than its rateable proportion of any loss, liability, compensation, costs or expenses. |
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All medical/surgical treatment under this policy shall have to be taken in India and admissible claims thereof shall be payable in Indian currency. |
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Low Claim Ratio Discount (Bonus): Low Claim Ratio Discount at the 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 Mediclaim Insurance Policy for the preceding 3 completed years excluding the year immediately preceding the date of renewal. In case the Group Mediclaim Insurance 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. |
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High Claim Ratio loading (Malus): The Total Premium payable at renewal of the Group Policy will be loaded at the following scale depending upon the incurred claims ratio for the entire group insured under the Group Mediclaim Insurance Policy for the preceding 3 completed years excluding the year immediately preceding the date of renewal. In case the Group Mediclaim Insurance 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. |
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Extension for maternity benefit under this policy shall be opted only at the inception of this Policy, and not afterwards. |
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Low Claim Ratio Discount (Bonus) or High Claim Ratio Loading (Malus) will be applicable to the Premium at renewal of the Policy depending on the incurred claims Ratio for the entire Group insured. |
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Incurred claim would mean claims paid plus claims outstanding in respect of the entire group insured under the policy during the relevant period. |
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Basis of assessment of the claim shall be as under: |
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The benefit payable shall be such expenses reasonably and necessarily incurred by or on behalf of the Insured Person under the following categories but not exceeding the Sum Insured in respect of such Insured person as specified. |
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Room, and Boarding Expenses as incurred at the Hospital/Nursing Home; |
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Nursing Expenses |
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Fee paid to Medical Practitioner, Surgeon, Anaesthetics, Consultants, and Specialists |
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Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & drugs, Diagnostic Materials and X – Ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial Limbs & Cost of Organs and similar expenses; and /or |
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Pre Hospitalisation and Post Hospitalisation expenses, wherever applicable. |
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| The Insured shall be required to furnish the following for or in support of a claim: |
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Duly completed claim form |
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Bills, receipts and discharge certificate/card from the Hospital |
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Bills from Chemists supported by proper prescription. |
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Test reports and payment receipts. |
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| The procedure for lodging the claim shall be as under: |
| Upon the happening of any event giving rise or likely to give rise to a claim under this policy: |
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The Insured shall give immediate notice thereof in writing to the Company. |
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The Insured shall deliver to the Company, within 30 days from the date of completion of treatment, a detailed statement in writing as per the claim form together with bills, vouchers and any other material particular, relevant to the making of such claim. |
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The Insured shall tender to the Company all reasonable information, assistance and proofs in connection with any claim hereunder. |
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| Method of Payment of the Claim |
| Policy reimburses cost of hospitalisation subject to the Sum Insured under the policy by way of cheque or electronic fund transfer |
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| Extensions |
| Policy can be extended to cover maternity benefits on payment of additional premium. |
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