TECHMAHINDRA HEALTH INSURANCE POLICY

Transcription

1 TECHMAHINDRA HEALTH INSURANCE POLICY UNDERWRITING DETAILS Insurer: United India Insurance Company Ltd. Policy No. : /48/13/41/ Policy Period Start Date: From hours of March 30, 2014 Policy Period End Date: To Midnight of March 29, 2015 Entry Age limit: 1 day to 90 years. Dependent coverage specifications: Two Dependent Children at the age on the date of entry in the Policy to 21 years provided either or both. 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 higher studies and submit Bonafide Certificate from Institution.3 rd dependent child coverage (in case of twins) can be covered subject to payment of extra-premium. Any one set of parents (parents / parents-in-laws) can be covered under suitable base plan. The set of parents selected in policy period cannot be changed for next two years i.e., for and policy periods as well. TIME FRAMES GUIDELINES FOR CLAIMS Intimation : Cashless Planned : 7days prior to admission Emergency: 24 hrs from date of admission Reimbursement: Planned : 7 days prior to admission Emergency: Within 48 hrs of admission or before date of discharge whichever is earlier Submission: Pre-hospitalization and hospitalization bills: 30 days from date of discharge Post hospitalization bills: 30 days from date of last treatment or 60 days whichever is earlier

2 HEALTH INSURANCE BASE PLANS Plan A: This is 100% company sponsored plan where you will be provided default coverage whereas your spouse and upto two children will be provided coverage subject to enrolment within the window period. Sum Insured will be as per grade. Plan B: This plan provides cover for your dependent parents / parent in laws in addition to spouse and upto two children subject to enrolment within window period. The premium of this plan will be borne by the employee. Please refer to the premium table for the same. Plan C : This plan has been designed for onsite employees only who wish to opt for health insurance coverage for any one set of their parents residing in India. The premium of this plan will be entirely borne by you. Please refer to the premium table for the same and also note that this plan allows coverage of your parents only. PREMIUM TABLE FOR BASE PLANS Base Plan Plan A Plan B Plan C- (For associates at overseas locations only) Members Covered Self+ Spouse+2 children Self+Spouse+2 children+ Parents One set of Parents/In-Laws Only Premium payable by associate s towards Parent/In- Laws Cover Parent/In- Laws Cover Sum Insured Hospitaliz ation U1 To U3 U4 & P1 A To P1B P2A To P2B & E1 To E2 Annual Premium payable by the associate Sum Insured Hospitalizat ion Annual Premium payable by the associate Sum Insured Hospitaliz ation Annual Premium payable by the associate 2 Lakhs 0 3 Lakhs 0 4 Lakhs 0 3 Lakhs 7,255 4 Lakhs 11,081 6 Lakhs 13,868 1 Lakh 7,070 1 Lakh 7,070 1 Lakh 7,070 2 Lakhs 13,195 2 Lakhs 13,195 2 Lakhs 13,195 3 Lakhs 19,792 3 Lakhs 19,792 3 Lakhs 19,792 HEALTH INSURANCE OPTIONAL PLAN: TOP-UP COVER An optional Top-Up cover of additional sum insured is also available in addition to any of the above mentioned base plans. Coverage will be available for you and your family members enrolled under the base plan opted for. The additional premium payable for the same is as per details mentioned below, SUM INSURED OPTIONS (in Rs.) PREMIUM Salient Features of Top-Up Cover The terms and conditions would be exactly as applicable for the basic policy which also comprise of Co-Pay, disease/ ailment wise capping. All sublimit / capping will be applied as per sum insured of base plan. Top-Up Cover will get activated when sum insured / disease /major surgery sublimit is exhausted. Expenses related to Maternity benefit are excluded from the scope of Top-Up Cover. Items deducted under a claim processed under family floater (of base plan) like excess room rent / ICU rent / non payable items / co-payment amount cannot be claimed under Top-Up Cover.

3 SALIENT FEATURES OF BASE PLANS CRITERIA FOR MEDICAL INSTITUTION WHERE THE IN-PATIENT TREATMENT IS CARRIED OUT HOSPITAL A Hospital means any institution established for in-patient care and day care treatment of illness and/or injuries and which has been registered as a Hospital with the local authorities under the Clinical establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under. DAYCARE CENTRE: - Has qualified nursing staff under its employment round the clock. - Has at least 10 in-patient beds in towns having a population of less than 10 lacs and at least 15 in-patient beds in all other places; - Has qualified medical practitioner(s) in charge round the clock; - Has a fully equipped Operation Theatre of its own where surgical procedures are carried out; - Maintains daily records of patients and makes these accessible to the insurance company s authorized personnel. 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. A day care centre means any institution established for day care treatment of illness and/ or injuries or a medical setup within a hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified medical practitioner AND must comply with all minimum criteria as under;- - has qualified nursing staff under its employment - has all qualified medical practitioner(s) in charge - has a fully equipped operation theatre of its own where surgical procedures are carried out. - maintains daily records of patients and will make these accessible to the insurance companies authorised personnel. GENERAL FEATURES Hospitalization expenses in a Hospital/Nursing Home for a minimum period of 24 consecutive hours of inpatient care except for specified procedures/treatments, where such admission could be for a period of less than 24 consecutive hours is covered. Day care expenses are covered for specified procedures as per list. Sublimits mentioned in the policy are applicable per surgery / hospitalization as per base plan sum insured. Pre - hospitalization 30 days from date of admission and post 60 days expenses from the date of discharge are covered except for claims under Maternity Benefit. Each and every claim is subject to 10% co-pay on the admissible total claim amount unless specifically excluded. ROOM RENT AND ICU SERVICES Maximum eligibility for Room rent 1% of base plan sum insured per day Maximum eligibility for ICU rent -- 2% of base plan sum insured per day Room rent / ICU rent includes nursing care, RMO charges, IV Fluids / Blood transfusion / Injection administration charges and similar expenses. Proportionate expenses are not applicable for other expenses as per room eligibility.

4 SPECIAL NOTE Expenses for procedures specified under GIPSA will be payable as per package negotiated by the insurance company in Preferred Provider Network Hospital as applicable in that region subject to policy sublimits. Preferred Provider Network means a network of hospitals which have agreed to a cashless packaged pricing for certain procedures for the insured person. The list is available with the company/tpa and subject to amendment from time to time. Reimbursement of expenses incurred in PPN for the procedures (as listed under PPN package) shall be subject to the rates applicable to PPN package pricing. Expenses beyond the GIPSA package will not be payable on either cashless / reimbursement basis. AMBULANCE SERVICES Expenses necessarily incurred on availing Ambulance services offered by a Hospital or by an Ambulance service provider (operated by a licensed/ authorized service provider and equipped for the transport and paramedical treatment of persons requiring medical attention) for the Insured Member s necessary transportation to the nearest Hospital in case of an Emergency provided that the necessity of the Ambulance transportation is certified by the treating Medical Practitioner. Coverage up to 1000/- per hospitalization. ILLNESS / SURGERY SUBLIMIT S.NO SURGERY NAME SUBLIMIT (% of base plan sum insured) MAX. PAYABLE CO-PAYMENT WAIVER 1 Cataract 10% None 2 Hernia 15% Self, spouse and children 3 Hysterectomy 20% Self, spouse and children 4 Major Surgery (For Grades upto U4, P1a & P1b ) 70% Self, spouse and children 5 Major Surgery (For Grade P2a and above) 75% Self, spouse and children MAJOR SURGERY includes the following, I. Cardiac Surgeries, II. Cancer Surgeries, III. Brain Tumor Surgeries, IV. Pacemaker Implantation, V. Hip Replacement, VI. Knee Joint replacement

5 MATERNITY BENEFIT This includes expenses for treatment arising from or traceable to pregnancy, childbirth, miscarriage,abortion or complications of any of these including caesarean section. 9 month waiting period in respect of maternity claims waived off for all Insured Members. The maximum benefit allowable under this clause will be up to Rs. 50,000/- Sublimits as applicable are as under, Normal Delivery Caesarean section Special features applicable to Maternity Benefit Claim in respect of delivery for only first two children and / or operations associated therewith will be considered in respect of any one Insured. Person covered under the policy or any renewal thereof. Those Insured Persons who are already having two or more living children will not be eligible for this benefit. Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 weeks from the date of conception are not covered. Pre-natal and postnatal expenses are not covered unless admitted in Hospital / Nursing Home and treatment is taken there. Baby covered from day one within the limit of applicable maternity sum insured for well baby care including neonatal jaundice and the limit of the family floater sum insured if the baby has to be hospitalised separately for any other cause or for a life saving treatment, within the same hospital or elsewhere If both husband and wife are separately covered under GMP M/s TechMahindra Ltd., expenses under Maternity benefit will be limited to above mentioned sublimit subject to maximum of Rs.50, 000/-. Maternity benefit expenses have been excluded from scope of Top-Up policy.

6 DAY CARE TREATMENT Day care Treatment refers to medical treatment and or surgical procedure which is i. undertaken under general or local anaesthesia in a hospital/day care centre in less than 24 hours because of technological advancement, and ii. Which would have otherwise required a hospitalisation of more than 24 hours. Treatment normally taken on an outpatient basis is not included in the scope of this definition. 1 Adenoidectomy 19 FESS 2 Appendectomy 20 Haemo dialysis 3 Ascitic/Pleural tapping 21 Fissurectomy / Fistulectomy 4 Auroplasty 22 Mastoidectomy 5 Coronary angiography 23 Hydrocele 6 Coronary angioplasty 24 Hysterectomy 7 Dental surgery 25 Inguinal/ventral/ umbilical/femoral hernia 8 D&C 26 Parenteral chemotherapy 9 Endoscopies 27 Polypectomy 10 Excision of Cyst/granuloma/lump 28 Septoplasty 11 Eye surgery 29 Piles/ fistula 12 Fracture/dislocation excluding hairline fracture 30 Prostrate 13 Radiotherapy 31 Sinusitis 14 Lithotripsy 32 Tonsillectomy 15 Incision and drainage of abcess 33 Liver aspiration 16 Colonoscopy 34 Sclerotherapy 17 Varicocelectomy 35 Varicose Vein Ligation 18 Wound suturing Or any other surgeries/procedures agreed by the TPA/Company which require less than 24 hours hospitalisation and for which prior approval from TPA/Company is mandatory. This condition will also not apply in case of stay in hospital of less than 24 hours provided - a) The treatment is such that it necessitates hospitalisation and the procedure involves specialised infrastructural facilities available in hospitals. b) Due to technological advances hospitalisation is required for less than 24 hours only. c) They are carried out in Day Care Centre networked by TPAs where requirement of minimum number of beds is overlooked but having (i) fully equipped Operation Theatre, (ii) fully qualified Day Care Staff (c) fully qualified Surgeons/Post-Operative attending Doctors. Note : Procedures/treatments usually done in out patient department are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours or carried out in Day Care Centres.

7 POLICY EXCLUSIONS 4.1 Any Pre-existing condition(s) (deleted for M/s TechMahindra Ltd.) 4.2 Any disease other than those stated in clause 4.3 below, contracted by the Insured person during the first 30 days from the commencement date of the policy. (deleted for M/s TechMahindra ) During the first two years of the operation of the policy, the expenses on treatment of specific diseases (deleted for M/s TechMahindra ) 4.3 During the first four years of the operation of the policy, the expenses related to treatment of specific diseases (deleted for M/s TechMahindra ). 4.4 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). 4.5 a. Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident. b. Vaccination or inoculation. c. Change of life or cosmetic or aesthetic treatment of any description such as correction of eyesight., etc, d. Plastic surgery other than as may be necessitated due to an accident or as part of any illness. 4.6 Cost of spectacles and contact lenses, hearing aids. 4.7 Dental treatment or surgery of any kind unless necessitated by accident and requiring hospitalisation. 4.8 Convalescence, general debility; run-down condition or rest cure, Obesity treatment and its complications including morbid obesity, Congenital external disease/defects or anomalies, treatment relating to all psychiatric and psychosomatic disorders; infertility, Sterility (If presenting complaint is infertility Ovarian / Endometriotic Cysts are not payable unless presented as a complaint / lifethreatening complication i.e., ruptured cyst ); Venereal disease, intentional self injury and use of intoxication drugs / alcohol. 4.9 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 and treatment of positive existence of 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 4.12 Injury or Disease directly or indirectly caused by or contributed to by nuclear weapon / materials.

8 4.13 Treatment arising from or traceable to pregnancy, childbirth, miscarriage, abortion or complications of any of these including caesarean section (deleted for M/s TechMahindra ) 4.14 Naturopathy Treatment, acupressure, acupuncture, magnetic therapies, experimental and unproven treatments/ therapies. Treatment including drug Experimental therapy, which is not based on established medical practice in India, is treatment experimental or unproven, Immunomodulator drugs unless FDA approved and Oral Chemotherapy (unless falling under pre and post hospitalization limit following hospitalization) 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, cochlear implant, replacement of battery and /or Leads of Pacemaker, 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 Genetic disorders (ailment related to specific gene defect i.e., Haemophilia,Down s Syndrome Sickle Cell Anaemia, Polycystic kidney disease )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), treatment 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, died charges, baby food, cosmetics, tissue paper, diapers, sanitary pads, toiletry items and similar incidental expenses Any kind of Service charges, Surcharges, Admission Fees/Registration Charges, Luxury Tax and similar charges levied by the hospital 4.21 All non-medical expenses. The detailed list of non-medical expenses (named as Standard Deductibles) is available under Utilities section.