MEDICLAIM INSURANCE POLICY
INDIVIDUAL MEDICLAIM
POLICY
GROUP MEDICLAIM POLICY
whereas the Insurance designated in
the Schedule hereto has by a Proposal and declaration dated as stated in the
Schedule which shall be the basis of this Contract and is deemed to be
incorporated herein, has applied to THE ORIENTAL INSURANCE COMPANY LTD.
(hereinafter called COMPANY) for the insurance hereinafter set forth in respect
of Person(s) named in the Schedule hereto (hereinafter called the INSURED
PERSON) and has paid premium as consideration for such insurance.
NOW THIS POLICY WITNESSES that
subject to the terms, conditions, exclusions and definitions contained herein or
endorsed or otherwise expressed hereon, the Company undertakes that if during
the period stated in the schedule or during the continuance of this policy by
renewal any Insured Person shall contract any disease or suffer from any illness
(hereinafter called INJURY) and if such disease or injury shall require any such
insured person, upon the advice of a duly qualified Physical/Medical
Practitioner (hereinafter called MEDICAL PRACTITIONER) or of (a) duly qualified
Surgeon (hereinafter called SURGEON) to incur a) hospitalization expenses for
medical/surgical treatment at any Nursing Home/Hospital in India as herein
defined (hereafter called HOSPITAL) as an inpatient OR (b) on domiciliary
treatment in India under Domiciliary Hospitalization. Benefits as hereinafter
defined, the Company will pay to the Insured Person the amount of such expenses
as are reasonably and necessarily incurred in respect thereof by or on behalf of
such Insured Person, but not exceeding the sum Insured in aggregate in any
one period of insurance stated in the schedule hereto.
1. In the event of any claim/s
becoming admissible under this Scheme, the Company will pay to the Insured
Person the amount of such expenses as would fall under different heads
mentioned below, and as are reasonably and necessarily incurred thereof by or on
behalf of such Insured Person, but not exceeding the Sum Insured in aggregate
mentioned in the schedule hereto:
A) Room. Boarding Expenses as
provided by the Hospital / Nursing Home
B) Nursing Expenses.
C) Surgeon, Anesthetist Medical
Practitioner, Consultants. Specialists Fees.
D) Anesthesia, Blood, Oxygen,
Operation Theater Charges, Surgical Appliances, Medicines and Drugs, Diagnostic
Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of pacemaker,
Artificial Limbs and costs of Organs and similar expenses.
Note: Company 's liability in
respect of all claims admitted during the period of insurance shall not exceed
the sum Insured per person mentioned in the Schedule.
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2. DEFINITIONS:
2.1 "HOSPITAL/NURSING HOME"
means any institution in India established for indoor care and treatment
of sickness and injuries and which
Either
a) 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.
OR
b) Should comply with minimum
criteria as under :-
i) it should have atleast 15 in-patient Beds.
ii) fully equipped operation theatre of its own wherever surgical operations are
carried out.
iii) fully qualified Nursing staff under its employment round the clock.
iv) fully qualified Doctor(s) should be incharge round the clock.
(N.B *In Class 'C' town condition
of number of beds be reduced to 10)
2.1.1 The term
"HOSPITAL/NURSING HOME" shall not include an establishment which is a
place of rest, a place for the aged, a place for drug-addicts or place of
alcoholics, a hotel or a similar place.
2.2 "SURGICAL
OPERATION" means manual and/or operative procedures for correction of
deformities and defects, repair of injuries, diagnosis and cure of deceases,
relief of suffering and prolongation of life.
2.3 Expenses on Hospitalization
for minimum period of 24 hours are admissible. However, this time limit will not
apply for specific treatment i.e. Dialysis. Chemotherapy, Radiotherapy, Eye
Surgery, Dental Surgery , Lithotripsy (Kidney stone removal), Tonsillectomy
D&C, taken in the Hospital/Nursing Home and Insured is discharged on the
same day, the treatment will be considered to be taken under Hospitalization Benefit.
2.4 DOMICILIARY
HOSPITALIZATION BENEFIT MEANS:
Medical treatment for a period exceeding three days for such
illness/disease/injury which in the normal course would require care and
treatment at a hospital/nursing home but actually taken whilst confined at home
in India under any of the following circumstances namely.
i) The condition of the patient is such that he/she cannot be removed to the
hospital/nursing home or
ii) The patient cannot be removed to hospital/nursing home for lack of accommodation
therein.
Subject however that domiciliary
hospitalization benefits shall not cover:-
i) Expenses incurred for pre and post hospital treatment and
ii) Expenses incurred for treatment for any of the following diseases:
1) Asthma
2) Bronchitis
3) Chronic Nephritis and Nephritic Syndrome
4) Diarrhoea and all type of Dysenteries including Gastroenteritis
5) Diabetes Mellitus and Insipidus
6) Epilepsy
7) Hypertension
8) Influenza, Cough and Cold
9) All Psychiatric or Psychosomatic Disorders
10) Pyrexia of unknown Origin for less than 10 days.
11) Tonsillitis and Upper Respiratory Tract infection including Laryngitis and
Pharingitis
12) Arthritis, Gout and Rheumatism
Note: When treatment such as
dialysis, Chemotherapy, Radiotherapy etc. is taken in the hospital/nursing home
and the Insured is discharged on the same day, the treatment will be considered
to be taken under Hospitalization Benefit section.
Liability of the Company under this
clause is restricted as stated in the Schedule attached hereto.
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3.0 ANY ONE ILLNESS
Any one illness will be deemed to
mean continuous period of illness and it includes relapse within 45 days from
the date of last consultation with the Hospital/Nursing Home where treatment may
has been taken. Occurrence of same illness after a lapse of 45 days as stated
above will be considered as fresh illness for the purpose of this policy.
3.1 PRE-HOSPITALIZATION
Relevant medical expenses incurred
during period upto 30 days prior to hospitalization/domiciliary hospitalization
on disease/illness/injury sustained will be considered as part of claim
mentioned under item 1.0 above.
3.2 POST-HOSPITALIZATION
Relevant medical incurred during
period upto 60 days after Hospitalization/Domiciliary Hospitalization on
disease/illness/injury sustained will be considered as part of claim as
mentioned under item1.0 above.
3.3 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.
3.4 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.
4. EXCLUSIONS:
4.0 The company shall not be
liable to make any payment under this policy in respect of any expenses
whatsoever incurred by any Insured Person in connection with or in respect of:-
4.1 Such diseases which have been in existence at the time of proposing
this insurance. Pre-existing conditions means any injury which existed prior to
the effective date of the insurance. Pre-existing condition also means any
sickness or its symptoms which existed prior to the effective date of this
insurance, whether or not the insured person had knowledge that the symptoms
were relating to the sickness. Complications arising from pre-existing disease
will be considered part of the pre-existing condition.
4.2 Any expenses on hospitalization/domicilary incurred during first 30
days from the date of commencement of insurance cover except in case of injury
arising out of accident.
4.3 During the first year of the operation of insurance cover, the
expenses on treatment of diseases such as Cataract. Benign Pro static Hypertrophy.
Hysterectomy for Menorrahagia or Fibromyoma. Hernia, Hydrocele, Congenital
Internal Diseases, Fistula in anus, Piles, Sinusitis and related disorders are
not payable. If these diseases are pre-existing at the time of proposal they
will not be cove red even during subsequent period of renewal too.
4.4 Injury or disease 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).
4.5 Circumcision unless necessary for treatment of a disease not
excluded hereunder or as may be necessitated due to an accident, Vaccination or
inoculation or change of life or cosmotic or aesthetic treatment of any
description, plastic surgery other than as may be necessitated due to an
accident or as a part of any illness.
4.6 Cost of spectacles and contact lenses, hearing aids.
4.7 Dental treatment or surgery of any kind unless requiring
hospitalization.
4.8 Convalescence, general debility, Run-down condition or test cure, congenital
external disease or defects or anomalies, sterility, venereal disease,
intentional self-injury and use of intoxicating drugs/alcohol.
4.9 All expenses arising out of any condition directly or indirectly
caused to or associated with human T-cell Lymph tropic Virus Type III (II TLB-III)
or Lvmphadinopathy Associated Virus (LAV) or the Mutants Derivative or
variations Deficiency Syndrome or any Syndrome or condition of a similar kind
commonly referred to as AIDS.
4.10 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.
4.11 Expenses on vitamins and tonics unless forming part of treatment for
injury or disease as certified by the attending Physician.
4.11.1 Injury or disease directly caused by or contributed to by nuclear
weapons/materials.
4.12 Treatment arising from or traceable to pregnancy, childbirth
including caesarean section.
4.13 Naturopathy Treatment.
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5.0 CONDITIONS:
5.1 Every notice or
communication to be given or made under this Policy shall be delivered in
writing at the address as shown in the schedule.
5.2 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 terms, provisions, conditions and endorsements
of this policy by the Insured person insofar as they relate to anything to be
done or compiled with by the Insured Person shall be a condition precedent to
any liability of the company to make any payment under this policy. No waiver of
any terms, provisions, conditions and endorsements of this policy shall be valid
unless made in writing and signed by an authorized official of the Company.
5.3 Upon the happening of any event which may give rise to a claim under
this policy notice with full particulars shall be sent to the Company within 7
days from date of death, injury, Hospitalization, Domiciliary Hospitalization.
5.4 Claim must be filed within 30 days from date of discharge from the
hospital.
NOTE: Waiver of this
Condition may be considered 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.
5.5 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.
5.6 Any medical practitioner authorised by the Company shall be
allowed to examine the Insured person in case of any alleged injury or disease
requiring Hospitalization when and so often as the same may reasonably be
required on behalf of the Company.
5.7 The company shall not be liable to make any payment under this policy
in respect of any claim be in any manner fraudulent or supported by any
fraudulent means or device whether by the insured person or by any other person
acting on his behalf.
5.8 If at the time when any claim arises under this policy, there
is in existence any other insurance (other than Cancer Insurance policy in
collaboration with Indian Cancer Society) 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. The benefits under this Policy
shall be in excess of the benefits available under cancer Insurance policy.
5.9 The policy may be renewed by mutual consent. The company shall not
however be bound to give notice that it is due for renewal and the company may
at any time cancel this policy by sending the Insured 30 days notice by
registered letter at the Insured last known address and in such event the
Company shall refund to the Insured a pro-rata premium for the unexpired period
of insurance. The company shall however remain liable for any claim which arose
prior to the date of cancellation. The insured may at any time cancel this
policy and in such event the company shall allow refund of premium at company's
short period rate only (Table given here below) provided no claim has occurred
upto the date of cancellation.
PERIOD ON RISK |
RATE OF PREMIUM TO BE CHARGED |
Upto one month
Upto three month
Upto six months
Exceeding six months |
1/4 of the annual rate
1/2 of the annual rate
3/4 of the annual rate
Full annual rate |
5.10 If the difference shall
arise as to the quantum to be paid under this policy (liability being otherwise
admitted such difference shall be referred to Arbitration in accordance with the
provision of the Indian Arbitration Act, 1940 as amended from time to time and
for the time being in force. It is clearly agreed and understood that no
difference or dispute shall be referable to arbitration as hereinbefore provided
if the company had disputed or not accepted liability under or in respect
of this policy.
5.11 If the company shall disclaim liability to the Insured for any claim
hereunder and if the Insured shall not within 12 calendar months from the date
of receipt of the notice of such disclaimer and intends to recover his claim
from the company then the claim shall for al purposes be recoverable hereunder.
5.12 All medical/surgical treatments under this policy shall have to be
taken in India and admissible claims thereof shall be payable in Indian
currency.
6.0 PAYMENT OF CLAIM
All claims under this policy shall
be payable in Indian currency. All medical treatments for the purpose of this
insurance will have to be taken in India only.
7.0 CUMULATIVE BONUS:
Sum insured under this policy shall
be progressively increased by 5% in respect of each claim free year of
insurance, subject to maximum accumulation of 10 claim free years of insurance.
7.1 In case of a claim under the policy in respect of insured person who
has earned the cumulative bonus the increased percentage will be reduced by 10%
of sum insured at the next renewal. However, basic sum insured will be
maintained and will not be reduced.
N.B.:
1) For existing policy holders ( as date of implementation) the
accrued amount of benefit of cumulative bonus will be added to the Sum insured,
subject to maximum 10 claim free years.
2) Cumulative bonus will be lost if policy is not renewed on the date of
expiry.
Waiver : In exceptional circumstances the seven days extension in period of
renewal is permissible to the entitled for cumulative bonus although the policy
is renewed only subject to Medical Examination and exclusion of diseases.
8.0 COST OF HEALTH CHECKUP
In addition to cumulative bonus, the
insured shall be entitled for reimbursement of cost of medical check-up once at
the end of block of every four 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 amount of average sum insured during the block of four
claims free underwriting years.
IMPORTANT
For Cumulative Bonus and Health Check-up provisions as aforesaid
Both Health check-up and cumulative bonus provisions are applicable only in respect
of continuous insurance without break expecting however. Where in exceptional
circumstances the break in period for a maximum of seven days is approved as a
special case subject to medical examination and exclusion of disease during the
break period. Health check-up benefits will be accrued after completion of four
years continuous claims free insurance.
This prospectus shall form, part of
your proposal form hence please sign as you have noted the contents of this
prospectus.
PREMIUM SCHEDULE |
Sum Insured
OVERALL LIABILITY |
LIMIT OF LIABILITY
FOR DOMICILIARY
HOSPITALITY
|
UPTO 45 YEARS |
46-55 YEARS |
56-65 YEARS |
66-70 YEARS |
71-75 YEARS |
|
RS
|
RS |
RS |
RS |
RS |
RS |
15,000 |
3000
|
175 |
240 |
275 |
310 |
330 |
20,000 |
4000
|
225 |
310 |
355 |
385 |
425 |
25,00 |
5000
|
280 |
380 |
440 |
485 |
530 |
30,000 |
6000
|
300 |
415 |
470 |
525 |
565 |
35,000 |
7000
|
320 |
440 |
500 |
560 |
600 |
40,000 |
8000
|
445 |
615 |
700 |
780 |
835 |
45,000 |
9000
|
500 |
690 |
785 |
880 |
940 |
50,000 |
10000
|
555 |
765 |
870 |
975 |
1045 |
55,000 |
11000
|
615 |
845 |
960 |
1075 |
1150 |
60,000 |
12000
|
645 |
885 |
1010 |
1130 |
1210 |
65,000 |
13000
|
700 |
960 |
1080 |
1225 |
1310 |
70,000 |
14000
|
755 |
1035 |
1175 |
1315 |
1410 |
75,000 |
15000
|
805 |
1110 |
1260 |
1410 |
1510 |
80,000 |
16000
|
860 |
1185 |
1345 |
1505 |
1615 |
85,000 |
17000
|
915 |
1260 |
1430 |
1605 |
1720 |
90,000 |
18000
|
970 |
1335 |
1515 |
1695 |
1820 |
95,000 |
19000
|
1025 |
1410 |
1600 |
1790 |
1920 |
100000 |
20000
|
1075 |
1480 |
1685 |
1885 |
2020 |
105000
to 150000 |
20000 +
15%
|
1075 +
1% |
1480 +
1.40% |
1685 +
1.60 % |
1885 +
1.80 % |
2020 +
2.00% |
155000
to 2000000 |
20000 +
15%
|
1575 +
0.90% |
2180 +
1.30% |
2485 +
1.50% |
2785 +
1.70% |
3020 +
2.00% |
205000
to 3000000 |
35000 +
10 %
|
2025 +
0.80% |
2830 +
1.20% |
3235 +
1.40% |
3635 +
1.60% |
3970 +
1.80% |
INDIVIDUAL
MEDICLAIM POLICY
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Brief Description
:
Mediclaim
Insurance is a cover which takes care of medical expenses following
Hospitalisation/Domiciliary Hospitalisation of the Insured in respect of the
following situations: (A) In case of a sudden illness (B) In case of an accident
(C) In case of any surgery which is required in respect of any disease which has
arisen during the policy period.
Covered Risks :
This cover is a hospitalisation cover and
reimburse the medical expenses incurred in respect of covered disease /surgery
while the insured was admitted in the hospital as an in patient.The cover also
extends to pre- hospitalsation and post- hospitalisation for periods of 30 days
and 60 days respectively
Major Exclusions :
Any pre-existing
disease, any expense incurred
during first 30 days of cover except injury due to accident, all expenses
incurred in respect of any treatment relating to pregnancy and child birth.
Treatment for Cataracts, Benign prostatic hypertrophy, Hysterectomy, Menorrhagia
or Fibromyoma, Hernia, Fitula of anus, Piles, Sinusitis, Asthma, Bronchitis, All
Psychiatric or Psychosomatic disorders are excluded from the scope of the cover
GROUP MEDICLAIM POLICY
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Brief Description
:
Mediclaim
Insurance is a cover which takes care of medical expenses following
Hospitalisation/Domiciliary Hospitalisation of the Insured in respect of the
following situations: (A) In case of a sudden illness (B) In case of an accident
(C) In case of any surgery which is required in respect of any disease which has
arisen during the policy period. The major benefit for taking a Group Mediclaim
policy is that the insured gets a Group discount, hence the premium per person
is lower.
Covered Risks :
This cover is a hospitalisation cover and
reimburse the medical expenses incurred in respect of covered disease /surgery
while the insured was admitted in the hospital as an in patient. The cover also
extends to pre- hospitalsation and post- hospitalisation for periods of 30 days
and 60 days respectively
Major Exclusions :
Any pre-existing
disease, any expense incurred
during first 30 days of cover except injury due to accident, all expenses
incurred in respect of any treatment relating to pregnancy and child birth.
Treatment for Cataracts, Benign prostatic hypertrophy, Hysterectomy, Menorrhagia
or Fibromyoma, Hernia, Fitula of anus, Piles, Sinusitis, Asthma, Bronchitis, All
Psychiatric or Psychosomatic disorders are excluded from the scope of the cover.
For more detail and Application Form CLICK
HERE
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