New India Top Up Mediclaim
SALIENT FEATURES OF THE POLICY
- This Policy covers In–Patient Hospitalisation Expenses incurred in India.New India Top Up Mediclaim
- This policy will respond only when the aggregate of all Hospitalisation expenses (except Pre / Post hospitalization expenses) of one or all members of the policy, exceeds the “Threshold” stated in the policy.
- This Policy will respond for each and every Hospitalisation after the Threshold has been exceeded by previous Hospitalisation expenses subject only to the Sum Insured stated in the Policy.
- The Sum Insured is the maximum liability of the company for all members of the policy.
- Thus, this Policy offers protection in excess of any Primary Health Policy/Benefit scheme that the Insured may have.
- If there is any expense in excess of Threshold, receivable from any other entity, the Insured Person has an option to recover it from either that entity or this policy, but not both.
- However, the Sum Insured under the policy will be available over and above any reimbursement received from any other entity if such amounts exceed the Threshold.
WHO CAN TAKE THE POLICY
- Any person fulfilling the eligibility norms given below.
- The person may or may not have any other Health Insurance Policy.
- This policy can be taken in addition to any other Health Insurance Policy.
ELIGIBILITY
The policy can be issued on Individual or Floater Sum Insured basis covering up to 6 members of the family. If the policy is to be issued on Individual Sum Insured basis, then separate document will be issued to each Insured. Family comprises of Self, Legal Spouse, dependent Children and dependent Parents.
Age of Entry:
Proposer : 18 to 65 years.
Other members : 3 month to 65 years.
Proposer : 18 to 65 years.
Other members : 3 month to 65 years.
There is no cover ceasing age in case of renewal.
Children between the age of 3 months and 18 years are covered provided either or both parents are covered concurrently. Children between the age of 18 years and 25 years are covered only if either or both the parents are also covered and they are financially dependent on the parents. But this upper limit is not applicable for Unmarried Daughter and Mentally Challenged Children. Exclusion for treatment related to Psychiatric and Psychosomatic disorder will apply for such Mentally Challenged Children regardless of Continuous Coverage.
Children between the age of 3 months and 18 years are covered provided either or both parents are covered concurrently. Children between the age of 18 years and 25 years are covered only if either or both the parents are also covered and they are financially dependent on the parents. But this upper limit is not applicable for Unmarried Daughter and Mentally Challenged Children. Exclusion for treatment related to Psychiatric and Psychosomatic disorder will apply for such Mentally Challenged Children regardless of Continuous Coverage.
PROCEDURE FOR TAKING A POLICY
The following are to be submitted–- Proposal form duly completed & signed and details of Insured Person/s.
- The details of existing and previous Health Insurance policies in respect of each Insured Person are to be provided without fail in the proposal form along with claim history. Copy of current/expiring policy may be attached.
- Signed copy of Prospectus.
Pre–acceptance health check–ups will be required in the following instances:
- For persons above 50 years of age OR
- For persons with Adverse Medical/claims history.
Note: No Pre–acceptance Health Check–up for persons above 50 years of age, if the person has Health insurance policy from our company and there is no claim for previous two years.
A person is said to have Adverse Medical History if he/she:
- Has / Have undergone more than two hospitalisation in previous two years,
- Is Suffering from incurable/chronic diseases needing recurring treatment of any kind, such as Renal Failure, Cancer, Parkinson’s disease, and Diabetes Mellitus type II
- Is Suffering from Hypertension / Diabetes.
- is not in good health and free from Physical and mental diseases or infirmity or medical complaints
Following are the test to be carried out as pre–acceptance health check–up:
| CBC | ROUTINE URINE |
| BLOOD SUGAR (FASTING & PP) | ECG |
| SGPT | X–RAY CHEST PA VIEW |
| SGOT | PHYSICIAN CHECK–UP |
| CHOLESTEROL | HDL CHOLESTEROL |
| TRIGLYCERIDES | EYE CHECK–UP FOR CATARACT & GLUCOMA |
The above tests will have to be carried out at proposer’s cost. However if the proposal is accepted then 50% of such cost will be reimbursed to the proposer.
The tests have to be taken not more than 30 days prior to the date of submission of the proposal.
TENURE OF THE POLICY
This policy will be valid for a period of one year from the date of inception.
SUM INSURED
The Sum Insured available are:
| Coverage Type | Sum Insured | Threshold |
|---|---|---|
| A | 5,00,000 | 5,00,000 |
| B | 10,00,000 | 5,00,000 |
| C | 15,00,000 | 5,00,000 |
| D | 7,00,000 | 8,00,000 |
| E | 12,00,000 | 8,00,000 |
| F | 17,00,000 | 8,00,000 |
| G | 22,00,000 | 8,00,000 |
"Proposers are advised to exercise care in choosing the amount of Threshold, as such choice will have an impact on benefits available under the Policy such as Room Rent limit, Hospital Cash, Ambulance Charges, and Get Well Benefit."
THRESHOLDS
The following Hospitalisation expenses incurred in respect of all the Insured members shall be considered for determining the Threshold under the Policy:
- The admission in the Hospital should have happened during the policy period.
- The Insured should have been admitted as an inpatient (outpatient treatments are not to be considered).
- The Hospitalisation should be for an Injury or Illness.
- Pre–Hospitalisation and Post–Hospitalisation expenses will not be considered.
ENHANCEMENT OF SUM INSURED AND THRESHOLD
- Enhancement of Sum Insured and Threshold will not be considered during the currency of the Policy.
- Enhancement of Sum Insured and Threshold is available only at the time of renewal.
- Sum Insured can be enhanced only to next band.
- Enhancement of Sum Insured will not be considered for persons
- Over 65 years
- Suffering from Diabetes, Hypertension, any chronic Illness, any recurring Illness, Any Critical Illness.
- who have preferred any claim under this policy in the previous two policy periods.
PAYMENT OF PREMIUM
As per table attached.
PREMIUM COMPUTATION
| New India Top Up Mediclaim Policy– | Eldest member of family is to be considered as Primary Member. |
| All other members of family will be considered as additional members. |
Note: The Proposer may not be the primary member.
DETAILS OF COVERAGE
Hospitalisation Expenses,
- Room Rent, boarding and nursing expenses actually incurred subject to a cap of Rs. 5000 per day for Rs. 5,00,000 Threshold and Rs. 8000 per day for Rs. 8,00,000 Threshold.
- Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) expenses actually incurred subject to a cap of Rs. 10,000 per day for Rs. 5,00,000 Threshold and Rs. 16,000 per day for Rs. 8,00,000 Threshold .
- Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees.
- Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, Cost of Prosthetic devices implanted during surgical procedure like pacemaker, Relevant laboratory / Diagnostic test, X-Ray and other medical expenses related to the treatment.
- Hospitalization expenses (excluding cost of organ) incurred on the donor during the course of organ transplant to the insured person. The Company’s liability towards expenses incurred on the donor and the insured recipient shall not exceed the Sum Insured of the insured person receiving the organ.
- Get Well Benefit of Rs. 5000 for Rs. 5,00,000 Threshold and Rs. 8000 for Rs. 8,00,000 Threshold, will be paid for Any One Illness. This benefit will be payable only for the first four admissible claims under the Policy. This benefit will reduce the Sum Insured.
- Ambulance service expenses actually incurred subject to cap of Rs. 5000 for Rs. 5,00,000 Threshold and Rs. 8000 for Rs. 8,00,000 Threshold. Payment under this benefit will reduce the Sum Insured. Ambulance charges will be paid once for Any One Illness for each Insured.
- Hospital cash will be paid at the rate of Rs. 500 per day for Rs. 5,00,000 Threshold and Rs. 800 per day for Rs. 8,00,000 Threshold; maximum for 10 days for Any One Illness.This benefit will reduce the Sum Insured. Hospital cash will be paid for completion of every 24 hours as a day but not part thereof.
- Payment of any claim relating to Cataract for each eye shall not exceed Rs.50,000/–.
- AYUSH Treatments are payable provided the treatment has been undergone in a government hospital or in any institute recognized by government and/or accredited by Quality Council of India/National Accreditation Board on Health.
Expenses on Hospitalisation for minimum period of 24 hours are admissible. However, this time limit is not applied for some specific treatments like Dialysis, Chemotherapy, Radiotherapy, Eye surgery, Dental Surgery, Lithotripsy (Kidney Stone removal), D & C, Tonsillectomy or where treatment involves technological advances necessitating hospitalisation for less than 24 hours.
No payment shall be made for any Hospitalisation expenses incurred, unless they form part of the Hospital Bill. However, the bills raised by Surgeon, Anaesthetist directly and not included in the Hospital Bill shall be paid, provided a numbered Bill is produced in support thereof, for an amount not exceeding Rs. Ten thousand, where such payment is made in cash and for an amount not exceeding Rs. Twenty thousand, where such payment is made by cheque
Note: Procedures/treatments usually done in outpatient 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.
EXCLUSIONS
- Treatment of any Pre–existing Condition / Disease, until 48 months of Continuous Coverage of such Insured Person have elapsed, from the Date of inception of his/her first Top Up Policy as mentioned in the Schedule.
- Any Illness contracted by the Insured person during the first 30 days of the commencement date of this Policy. This exclusion shall not however, apply if the Insured person has Continuous Coverage for more than twelve months.
- Unless the Insured Person has Continuous Coverage in excess of twenty four months of Top Up Policy, expenses on treatment of the following Illnesses are not payable:
- Unless the Insured Person has Continuous Coverage in excess of forty eight months of Top Up Policy, expenses on treatment of the following Illnesses are not payable:
- Pre and Post Hospitalisation medical expenses.
- Expenses incurred for Naturopathy Treatment, acupressure, acupuncture, magnetic and such other therapies.
- War invasion, Act of foreign enemy, War like operations, Nuclear weapons, ionizing radiation, contamination by radio activity, by any nuclear fuel or nuclear waste or from the combustion of nuclear fuel.
- Circumcision, cosmetic or aesthetic treatment, plastic surgery unless required to treat Injury or Illness.
- Vaccination or inoculation.
- Cost of braces, equipment or external prosthetic devices, non–durable implants, eyeglasses, Cost of spectacles and contact lenses, hearing aids including cochlear implants, durable medical equipment.
- Dental treatment or surgery of any kind except arising out of an Accident.
- Convalescence, general debility, 'Run–down' condition or rest cure, obesity treatment and its complications, treatment relating to all psychiatric and psychosomatic disorders, infertility, sterility, Congenital External Disease, Venereal disease, intentional self–injury and Illness or Injury caused by the use of intoxicating drugs / alcohol.
- Bodily injury or sickness due to wilful or deliberate exposure to danger (except in an attempt to save human life), intentional self–inflicted injury, attempted suicide, arising out of non–adherence to medical advice.
- Treatment of any Bodily injury sustained whilst or as a result of active participation in any hazardous sports of any kind.
- Treatment of any bodily injury sustained whilst or as a result of participating in any criminal act.
- Sexually transmitted diseases, any condition directly or indirectly caused due to or associated with Human T–Cell Lymphotropic Virus Type III (HTLB–III) or lymphotropathy 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.
- Diagnosis, X–Ray or Laboratory examination not consistent with or incidental to the diagnosis of positive existence and treatment of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home.
- Vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician.
- Maternity Expenses, treatment arising from or traceable to pregnancy, miscarriage, abortion or complications except abdominal operation for extra uterine pregnancy (Ectopic Pregnancy), which is proved by submission of Ultra Sonographic Report and Certification by Gynaecologist that it is life threatening one if left untreated.
- Genetic disorders and stem cell implantation / Surgery.
- External and or durable Medical / Non–medical equipment of any kind used for diagnosis and or treatment.
- Domiciliary Hospitalization.
- Unproven / Experimental Treatment.
- Change of treatment from one system to another unless recommended by the consultant / hospital under which the treatment is taken.
- Any kind of Service charges, Surcharges, Admission Fees/Registration Charges levied by the hospital.
- All non–Medical expenses of any kind whatsoever.
- Treatment for Age Related Macular Degeneration (ARMD), drugs such as Avastin or Lucentis or Macugen and other related drugs, treatments such as Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy.
- Treatment taken outside India.
| S.No. | Name of Disease/Ailment/Surgery not covered for |
|---|---|
| 1 | All internal and external benign tumours, cysts, polyps of any kind, including benign breast lumps |
| 2 | Benign ear, nose, throat disorders |
| 3 | Benign prostate hypertrophy |
| 4 | Cataract and age related eye ailments |
| 5 | Congenital Internal Disease. |
| 6 | Diabetes Mellitus |
| 7 | Gastric/ Duodenal Ulcer |
| 8 | Gout and Rheumatism |
| 9 | Hernia of all types |
| 10 | Hydrocele |
| 11 | Hypertension |
| 12 | Non Infective Arthritis |
| 13 | Piles, Fissures and Fistula in anus |
| 14 | Pilonidal sinus, Sinusitis and related disorders |
| 15 | Prolapse inter Vertebral Disc and Spinal Diseases unless arising from accident |
| 16 | Skin Disorders |
| 17 | Stone in Gall Bladder and Bile duct, excluding malignancy |
| 18 | Stones in Urinary system |
| 19 | Treatment for Menorrhagia/Fibromyoma, Myoma and Prolapsed uterus |
| 20 | Varicose Veins and Varicose Ulcers |
| S.No. | Name of Disease/Ailment/Surgery not covered for |
|---|---|
| 1 | Joint Replacement due to Degenerative Condition |
| 2 | Age–related Osteoarthritis & Osteoporosis |
CLAIM PROCEDURE
All claims will be processed and settled by specified Third Party Administrator (TPA) licensed by IRDA.
Intimation of Hospitalisation to be given to the TPA 48 hours before Hospitalisation, for planned Hospitalisation. For emergency Hospitalisation, intimation is to be given within 48 hours from the time of Hospitalisation.
To avail Cashless facility - Pre-authorisation request to be sent or faxed to TPA immediately on admission.
In Reimbursement cases - Insured to intimate TPA about Hospitalisation of Insured Persons immediately on admission. Claim bills to be submitted to TPA within seven days of discharge.
In Reimbursement cases - Insured to intimate TPA about Hospitalisation of Insured Persons immediately on admission. Claim bills to be submitted to TPA within seven days of discharge.
In case of Hospitalisation where the expenses are likely to involve the TPAs of both regular Health Policy and New India Top Up Mediclaim Policy, the intimation/pre-authorisation request with regard to a Hospitalisation is to be given to both the TPAs of these Policies.
In the case of a covered Hospitalisation, the costs of which were not initially estimated to exceed the Threshold but were subsequently found likely to exceed the Threshold, the intimation to the named TPA should be submitted along with a copy of intimation made to the Primary Health Policy TPA/Reimbursement Provider immediately on knowing that the Threshold is likely to be exceeded.
The payment will be made either to Hospital in case of Cashless treatment or to the Proposer/Insured Person in other cases.
The TPA of the regular Health Insurance Policy/Reimbursement Provider will first process the claims and the TPA for this policy will make the balance admissible payments either to the Hospital in the case of cashless settlement or to Insured in case of reimbursement. The Insured has to submit the details of settlement made by the TPA of regular Health Insurance Policy in the case of cashless settlement. In the case of reimbursement, the above details along with photo-copies of bills attested by Primary TPA/Reimbursement Provider are to be submitted to TPA of New India Top Up Mediclaim Policy.
The details of claims lodged and settlement details under regular Health Policy since inception of this policy should be furnished to the TPA of New India Top Up Mediclaim Policy even when the claim is not under the New India Top Up Mediclaim Policy. These documents are to be submitted to the TPA not later than thirty days from the date of discharge from the Hospital.This will enable faster response by the TPA in case of future Hospitalisation requiring the services of this policy.
All claims under this policy shall be payable in Indian currency.
CLAIMS ADJUDICATION
Any Claim which goes beyond the Threshold and Insured makes a claim in this policy, will be adjudicated as examples given below:
| Claim lodged by the Insured | Insured having an Individual policy of 8 Lakhs | Insured having a Top Up of 12 Lakhs with Threshold 8 Lakhs | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Paticulars | Charges | Days | Amount | Sum Insured | 8,00,000 | Threshold | 8,00,000 | ||
| Room Rent | 10,000 | 20 | 2,00,000 | Room Rent (1% of Sum Insured) | 1,60,000 | Room Rent (Maximum Rs. 8000 for opted Threshold of Rs. 8 lakhs) | 1,60,000 | ||
| Surgeon Charges | - | - | 4,00,000 | Surgeon Charges (proportionate on SI) | 3,20,000 | Surgeon Charges (proportionate on SI) | 3,20,000 | ||
| Diagnostics | - | - | 3,20,000 | Diagnostics (proportionate on SI) | 2,56,000 | Diagnostics (proportionate on SI) | 2,56,000 | ||
| Medicines | - | - | 2,50,000 | Medicines (Actual) | 2,50,000 | Medicines (Actual) | 2,50,000 | ||
| Total Cost | - | - | 11,70,000 | - | |||||
| - | Admissible | 9,86,000 | Admissible | 9,86,000 | |||||
| - | Payable under policy | 8,00,000 | Deductible under Top Up | 8,00,000 | |||||
| - | Not Admissible | 1,86,000 | Payable under Top Up | 1,86,000 | |||||
| Insured Incurred | Rs. 11,70,000 | ||||||||
| Total Paid under the Policy | Rs. 8,00,000 | Rs. 1,86,000 | |||||||
| Expense borne by Insured | Rs. 1,84,000 | ||||||||
| Claim lodged by the Insured | Insured having an Individual policy of 5 Lakhs | Insured having a Top Up of 10 Lakhs with Threshold 5 Lakhs | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Paticulars | Charges | Days | Amount | Sum Insured | 5,00,000 | Threshold | 5,00,000 | ||
| Room Rent | 5,000 | 20 | 1,00,000 | Room Rent (1% of Sum Insured) | 1,00,000 | Room Rent (Maximum Rs. 5000 for opted Threshold of Rs. 5 lakhs) | 1,00,000 | ||
| Surgeon Charges | - | - | 4,00,000 | Surgeon Charges (Actual) | 4,00,000 | Surgeon Charges (Actual) | 4,00,000 | ||
| Diagnostics | - | - | 3,20,000 | Diagnostics (Actual) | 3,20,000 | Diagnostics (Actual) | 3,20,000 | ||
| Medicines | - | - | 2,50,000 | Medicines (Actual) | 2,50,000 | Medicines (Actual) | 2,50,000 | ||
| Total Cost | - | - | 10,70,000 | - | |||||
| - | Admissible | 10,70,000 | Admissible | 10,70,000 | |||||
| - | Payable under policy | 5,00,000 | Deductible under Top Up | 5,00,000 | |||||
| - | Not Admissible | 5,70,000 | Payable under Top Up | 5,70,000 | |||||
| Insured Incurred | Rs. 10,70,000 | ||||||||
| Total Paid under the Policy | Rs. 5,00,000 | Rs. 5,70,000 | |||||||
| Expense borne by Insured | Rs. 0 | ||||||||
Insured is not eligible to receive any amount more than the admissible claim. If he goes to a higher Room Rent category than his eligible Room Rent category, the claimed amount will be proportionately deducted and the deducted amount will not be payable even in Top Up. But if he goes to his eligible Room Rent category, the claim will be settled in full without any deductions in the admissible amount.
CANCELLATION
The Company may at any time cancel this Policy on grounds of misrepresentation, fraud, non-disclosure of material fact or non-cooperation by Insured by sending 15 days’ notice by registered letter at the Insured’s last known address and in such event the Company shall not refund any premium.
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 below)provided no claim has occurred up to the date of cancellation however the company shall remain liable for any claim/ claims arising prior to such cancellation.
| PERIOD ON RISK | RATE OF PREMIUM TO BE CHARGED (RETAINED) |
|---|---|
| Up to one month | 1/4th of the annual rate |
| Up to three months | 1/2 of the annual rate |
| Up to six months | 3/4th of the annual rate |
| Exceeding six months | Full annual rate |
TAX REBATE
Tax rebate, as per provision of Income Tax rules, under Section 80-D.
RENEWAL
The Policy may be renewed by mutual consent and in such event the renewal premium shall be paid to the Company on or before the date of expiry of the Policy or of the subsequent renewal thereof and in any case not later than 30 days from the date of expiry of the current policy.
If, during the grace period of 30 days, any Insured Person incurs any Hospitalisation expenses, he shall not be entitled for any claim.
The Company shall not be bound to give notice that such renewal premium is due, provided however that if the Insured shall apply for renewal and remit the requisite premium before the expiry of this policy, renewal shall not be refused, unless the Company has reasonable justification to do so.
A policy that is sought to be renewed after the grace period of 30 days will be underwritten as a Fresh Policy.
Request for increase in Sum Insured at renewals may be considered, after a satisfactory pre-acceptance health check-up.
This Prospectus shall form part of the proposal form. Please sign in token of having noted the contents of Prospectus.
Signature Place:
Name Date:
Name Date:
PREMIUM TABLE
| Threshold (Rs) | Sum Insured (Rs) | Premiums applicable at different ages (excluding tax) | |||
|---|---|---|---|---|---|
| PRIMARY MEMBER | |||||
| 18-44 | 45-54 | 55-60 | 61-65 | ||
| 5,00,000 | 5,00,000 | 1,800 | 2,900 | 4,020 | 6,700 |
| 10,00,000 | 2,800 | 4,500 | 6,300 | 10,500 | |
| 15,00,000 | 3,500 | 5,600 | 8,040 | 13,400 | |
| 8,00,000 | 7,00,000 | 1,600 | 2,500 | 3,840 | 6,400 |
| 12,00,000 | 2,300 | 3,700 | 5,760 | 9,600 | |
| 17,00,000 | 3,000 | 4,700 | 7,440 | 12,400 | |
| 22,00,000 | 3,600 | 5,600 | 8,940 | 14,900 | |
| Threshold (Rs) | Sum Insured (Rs) | Premiums applicable at different ages (excluding tax) | ||||
|---|---|---|---|---|---|---|
| ADDITIONAL MEMBER | ||||||
| 0-17 | 18-44 | 45-54 | 55-60 | 61-65 | ||
| 5,00,000 | 5,00,000 | 700 | 900 | 1,450 | 2,010 | 3,350 |
| 10,00,000 | 1,100 | 1,400 | 2,250 | 3,150 | 5,250 | |
| 15,00,000 | 1,400 | 1,750 | 2,800 | 4,020 | 6,700 | |
| 8,00,000 | 7,00,000 | 600 | 800 | 1,250 | 1,920 | 3,200 |
| 12,00,000 | 900 | 1,150 | 1,850 | 2,880 | 4,800 | |
| 17,00,000 | 1,200 | 1,500 | 2,350 | 3,720 | 6,200 | |
| 22,00,000 | 1,400 | 1,800 | 2,800 | 4,470 | 7,450 | |
Once the Insured Person crosses the age of 65 years, the applicable premium on renewal will be loaded by 2.5% per year. This loading is applicable on premium for the age band of 61 - 65years.
E.g.: Premium for a person aged 69 for SI of 22,00,000 will be 7450 (base premium of 61-65) + (7450 * (2.5%*4)) = 8195
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