Policy Number /48/11/41/ Policy Period to

Transcription

1 UNITED INDIA INSURANCE COMPANY LIMITED REGISTERED & HEAD OFFICE: 24, WHITES ROAD, CHENNAI HEALTH INSURANCE PROSPECTUS-TECH MAHINDRA Policy Number /48/11/41/ Policy Period to SALIENT FEATURES OF THE POLICY The age of the employees their spouse, dependent parents shall be between 18 to 80 years. Dependent children up to age of 21 years provided either or both parents are covered concurrently, However, children above 21 years will cease to be covered if they are employed / self employed or married. For unmarried and unemployed girls, disabled children without income dependent upon proposer, the age limit of 21 year will not apply. Male child up to 26 years can be covered provided they pursue full time higher studies and submit Bonafide Certificate from the institution. This insurance being a group policy availed by the insured covering their employees and dependents, the benefits thereof would not be available to employees who cease the employment for any reason whatsoever Dependents of the existing employees who are covered under the said policy shall not be included during the currency of the policy except newly-wed spouse and newly born child. In the event of any claim(s) becoming admissible under this scheme, the company will pay through TPA to the Hospital / Nursing Home or the insured person the amount of such expenses falling under different heads mentioned below, 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. ND: A. Room, Boarding and Nursing expenses as provided by the Hospital/Nursing Home not exceeding 1% of the sum insured per day or the actual amount whichever is less. This also includes nursing care, RMO charges, IV Fluids/Blood transfusion/injection administration charges and similar expenses. B. ICU expenses not exceeding 2% of the sum insured per day or actual amount whichever is less. C. Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees D. Anaesthesia, Blood, Oxygen, Operation Theatre Charges, surgical appliances, Medicines & Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Artificial Limbs, cost of prosthetic devices implanted during surgical procedure like pacemaker, orthopaedic implants, infra cardiac valve replacements, vascular stents, relevant laboratory / diagnostic tests, X ray and other medical expenses related to the treatment. E. Hospitalisation expenses (excluding cost of organ) incurred for donor in respect of organ transplant to the insured. Note 1: For Ayurvedic treatment, hospitalisation expenses are admissible only when the treatment is taken as in patient in a Government hospital / Medical college hospital only. Note 2: Pre and Post Hospitalisation expenses payable in respect of each hospitalisation shall be the actual expenses incurred.

2 Note 3: 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 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: It should have at least 15 inpatient beds. Fully equipped operation theatre of its own wherever surgical operations is carried out. Fully qualified Nursing Staff under its employment round the clock. Fully qualified Doctor (s) should be in-charge round the clock. Maintains a daily record for each of its patients. In class 'C' towns condition 2.1 b ( i ) in respect of number of beds be reduced to 10. 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 for alcoholics, a hotel or a similar place. OPD COVERAGE: (Only in case of Plan C & D) Expenses with respect to optical will be restricted to actual or Rs 1100/-per family per policy period or whichever is less. Expenses with respect to dental will be restricted to actual or Rs 1500/-per family per policy period or whichever is less. Expenses not covered under OPD will be Cost of Spectacles, Contact Lens, Hearing Aids, Vaccination, maternity expenses or any such expenses which is not allowed under hospitalization claim due to limit and exclusion. No employee is permissible to opt under this section after closer of window period. Each submitted bills / receipts will be associated with respective supporting documents like doctor s prescription in case of consultation receipt, investigation report and advise for investigation in case of investigation receipt. Bills having overwriting and tempering will not be accepted. HOSPITALIZATION COVERAGE: Expenses in respect of the following specified illnesses will be restricted as detailed below under Hospitalization Benefit: Disease / Procedure Wise Sublimit Disease / Employee having Sum Employee having Sum Procedure Insured below 3Lakhs and Insured 4Lakhs and Above Cataract Actual or 10% of SI or Rs 25000/-whichever is Actual or 10% of SI or Rs 25000/-whichever is Hernia Actual or 15% of SI or Rs 35000/-whichever is Actual or 15% of SI or Rs 35000/-whichever is Hysterectomy Actual or 20% of SI or Rs 50000/-whichever is Actual or 20% of SI or Rs 50000/-whichever is Cardiac Actual or 70% of SI or Rs Actual or 75% of SI or Rs is 2,50,000/-whichever is Brain Tumor Actual or 70% of SI or Rs Actual or 75% of SI or Rs is 2,50,000/-whichever is Pacemaker Actual or 70% of SI or Rs Actual or 75% of SI or Rs Implantation 2,00,000/-whichever is 2,50,000/-whichever is for Sick Sinus Syndrome. Kidney Actual or 70% of SI or Rs Actual or 75% of SI or Rs Transplant and other 2,00,000/-whichever is 2,50,000/-whichever is

3 alike Renal Surgeries. Cancer Actual or 70% of SI or Rs Actual or 75% of SI or Rs is 2,50,000/-whichever is Hip Actual or 70% of SI or Rs Actual or 75% of SI or Rs Transplant 2,00,000/-whichever is 2,50,000/-whichever is Knee Actual or 70% of SI or Rs Actual or 75% of SI or Rs Transplant 2,00,000/-whichever is 2,50,000/-whichever is Major surgeries include cardiac surgeries, brain tumour surgeries, pace maker implantation for sick sinus syndrome, cancer surgeries, hip, knee, joint replacement surgery and organ transplantation. Claims for the above mentioned surgeries where there is sublimit given in the policy cannot be extended in any such condition like two person from the same family or husband and wife both are working in same company and having separate cover in the same policy. Expenses in respect of the maternity benefit will be restricted as detailed below: Total Maternity Limit Normal Delivery LSCS Maternity Expenses Actual or Rs 50000/- which is less. Actual or Rs 40000/- which is less. Actual or Rs 50000/- which is less. Special conditions applicable to maternity expenses benefit extension. i. Claims in respect of deliveries for only first two children and/or operations associated there with, will be considered in respect of any one Insured person covered under the policy or any renewal thereof. Those insured person who are already having two or more living children will not be eligible for this benefit ii. Expenses incurred in connection with voluntary medical termination of pregnancy during the first twelve (12) weeks from the date of conception are not covered. iii. Pre-natal and post-natal expenses are not covered unless admitted in hospital/nursing home and treatment is taken there / pre and post hospitalization benefits are not available under the section of maternity. iv. New born baby, if there is no abnormality and child has developed common ailments like neonatal physiological Jaundice, Cough, Cold, Viral Fever etc with Dr Consultation the same will be covered under normal maternity limit only. v. New born baby if hospitalized separately within the same hospital or any other hospital for any abnormality where hospitalization is required then it will be included in normal family floater coverage, in case of critical illness where the baby needs to be treated separately. Expenses on Hospitalisation for minimum period of 24 hours are admissible. However, this time limit is not applied to specific treatments, such as, Appendectomy Coronary angiographies Coronary angioplasty Dental surgery D&C Eye surgery Fracture/ dislocation excluding hairline fracture Radiotherapy Lithotripsy Incision and drainage of abscess Colonoscopy Haemodialysis Hydrocele Hysterectomy Inguinal/ventral/ umbilical/femoral hernia Parenteral chemotherapy Piles/ fistula Prostrate Sinusitis Tonsillectomy Liver aspiration Sclerotherapy

4 Or any other surgeries / procedures agreed by the TPA/ Company which require less than 24 hours hospitalisation and for which prior approval from TPA is mandatory. 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 hospitalisation benefit section. OPD Expenses Hospitalization Expenses Maternity Pre & Post Hospitalization Expenses Copayment Not Applicable 10% Copayment is waived in case of specified major surgery for self, spouse & children. 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 discharge from the Hospital / Nursing Home where treatment has been taken. Occurrence of the same illness after a lapse of 45 days as stated above will be considered as fresh illness for the purpose of this policy. PRE HOSPITALISATION: Relevant medical expenses incurred during period up to 30 days prior to Hospitalisation on disease / illness / injury sustained will be considered as part of claim as mentioned under item 1.2 above POST HOSPITALISATION: Relevant medical expenses incurred during period up to 60 days after hospitalisation on disease / illness / injury sustained will be considered as part of claim as mentioned under item 1.2 above MEDICAL PRACTITIONER means a person who holds a degree / diploma of a recognised institution and is registered with Medical Council of respective State of India. The term Medical Practitioner includes Physician, Specialist and Surgeon. QUALIFIED NURSE means a person who holds a certificate of recognised Nursing Council and who is employed on recommendation of the attending Medical Practitioner. TPA means a Third Party Administrator who holds a valid License from Insurance Regulatory and Development Authority to act as a THIRD PARTY ADMINISTRATOR and is empanelled by the Company for the provision of health services as specified in the agreement between the Company and TPA. EXCLUSIONS: 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: Injury / 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) 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 cosmetic or aesthetic treatment of any description such as correction of eye sight, etc, plastic surgery other than as may be necessitated due to an accident or as a part of any illness. Cost of spectacles and contact lenses, hearing aids. Dental treatment or surgery of any kind unless necessitated by accident and requiring hospitalisation. Convalescence, general debility; run-down condition or rest cure, Congenital external disease or defects or anomalies, Sterility & infertility, Venereal disease, intentional self injury and use of intoxication drugs / alcohol, obesity treatment and its complications including morbid obesity, treatment relating to all psychiatric and psychosomatic disorders. All expenses arising out of any condition directly or indirectly caused to or associated with Human T-Cell Lymphotropic Virus Type III (HTLB - III) or lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or Variation Deficiency Syndrome or any syndrome or condition of a similar kind commonly referred to as AIDS. Charges incurred at Hospital or Nursing Home primarily for diagnosis x-ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis

5 and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital / Nursing Home Expenses on vitamins and tonics unless forming part of treatment for injury or diseases as certified by the attending physician Injury or Disease directly or indirectly caused by or contributed to by nuclear weapon / materials Naturopathy Treatment, acupressure, acupuncture, experimental and unproven treatments/ therapies External and or durable Medical / Non-medical equipment of any kind used for diagnosis and or treatment including CPAP, CAPD, Infusion pump etc. Ambulatory devices i.e., walker, crutches, Belts, Collars, Caps, Splints, Slings, Braces, Stockings, elastocrepe bandages, external orthopaedic pads, sub cutaneous insulin pump, Diabetic foot wear, Glucometer / Thermometer, alpha / water bed and similar related items etc., and also any medical equipment, which is subsequently used at home etc. Any kind of Service charges, Surcharges, Admission Fees/Registration Charges levied by the hospital. Genetic disorders and stem cell implantation/ surgery Change of treatment from one system of medicine to another unless recommended by the consultant/ hospital under whom the treatment is taken. Treatment for Age Related Macular Degeneration (ARMD), treatments such as Rotational Field Quantum Magnetic Resonance (RFQMR), Enhanced External Counter Pulsation (EECP), etc. All non medical expenses including convenience items for personal comfort such as charges for telephone, television, ayah, private nursing/ barber or beauty services, diet charges, baby food, cosmetics, tissue paper, diapers, sanitary pads, toiletry items and similar incidental expenses. NOTICE OF CLAIM: 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 TPA named in the schedule immediately and in case of emergency Hospitalisation within 24 hours from the time of Hospitalisation / Domiciliary Hospitalisation. All supporting documents relating to the claim must be filed with TPA within 30 days from the date of discharge from the hospital. In case of post-hospitalisation, treatment (limited to 60 days), all claim documents should be submitted within 7 days after completion of such treatment. 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. 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. Payment of claim shall be made through TPA to the Hospital/Nursing Home or the Insured Person as the case may be.