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.

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.

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