What is a pre existing disease?
The term Pre–existing condition/disease is defined in the Policy as Any condition, ailment or Injury or related condition(s) for which there were signs or symptoms, and/or were diagnosed, and/or for which medical advice / treatment was received within forty eight months prior to the first policy issued by Us and renewed continuously thereafter. If You had:
1. Signs or symptoms, or
2. Been diagnosed or received Medical Advice, or
3. Been Treated for any condition or disease within forty eight months prior to the commencement of the first policy with us,
Such a condition or disease shall be considered as Pre–existing. Any Hospitalisation arising out of such pre–existing disease or condition is not covered under the Policy until forty eight months of Continuous Coverage have elapsed for the Insured Person.
Is pre–acceptance medical check–up required?
Pre–acceptance medical check–up is required for all the members entering after the age of 50 years. A person also needs to undergo this pre–acceptance medical check–up if he has an adverse medical history or if the health condition of the person/s to be Insured is such that the office in–charge feels that he / she be subjected to a medical examination. The cost of this check–up will be borne by the proposer. But if the proposal is accepted, then 50% of the cost of this check–up will be reimbursed to the proposer.Pre–acceptance medical check–up shall be conducted at designated centers authorized by Us.
Note: Adverse Medical History means a person:
1. Who has undergone more than one Hospitalisation in previous two years,
2. Who is suffering from Critical Illness, Recurring Illness or Chronic Illness.
3. Is Suffering from Hypertension / Diabetes.
4. Is not in good health and free from Physical and mental diseases or infirmity or medical complaints.
Is hospitalisation always necessary to get a claim?
Yes. Unless the Insured Person is Hospitalised for a condition warranting Hospitalisation, no claim is payable under the Policy. The Policy does not cover outpatient treatments.
Can I get treated anywhere?
Yes, the Policy covers treatment and/or services rendered only in India.
How long is the policy valid?
The Policy is valid during the Period of Insurance stated in the Schedule attached to the Policy. It is usually valid for a period of one year from the date of beginning of insurance.
Is there any grace period for renewal of the policy?
Yes. If Your Policy is renewed within thirty days of the expiry of the previous Policy, then the Continuity Benefits would not be affected. But even if You renew Your Policy within thirty days of expiry of previous Policy, any disease contracted or injuries sustained or Hospitalisation commencing during the break in insurance is not covered. Therefore it is in Your own interest to see that You renew the Policy before it expires.
Can the sum insured be increased at the time of renewal?
We may agree for a request for increase in Sum Insured at the time of renewal. But We are not obliged to agree to this request, if we feel the Person is not in good health. Moreover, for persons aged over 60, such a request could entail subjecting the Person for Medical Examination and other Medical tests. (In case the risk is accepted, 50% of the reasonable cost of Medical Examination would be reimbursed).
Enhancement of Sum Insured is subject to the limits mentioned below:
Age <= 50 years Up to Sum Insured of 15 lakhs without Medical Examination.
Age 51–60 Years By two slabs without Medical Examination
Age 61 – 65 Years By one slab with Medical Examination
Enhancement of Sum Insured will not be considered for:
1. Any Insured Person over 65 years of age.
2. Any Insured Person who had undergone more than one Hospitalisation in the preceding two years.
3. Any Insured Person suffering from one or more of the following Illnesses / Conditions:
1. Any chronic Illness
2. Any recurring Illness
3. Any Critical Illness
Is there any age limit upto which the policy would be renewed?
No. Your Policy can be renewed, as long as You pay the Renewal Premium before the date of expiry of the Policy. There is an age limit for taking a fresh Policy, but there is no age limit for renewal. However, if You do not renew Your Policy before the date of expiry or within thirty days of the date of expiry, the Policy may not be renewed, and only a fresh Policy could be issued, subject to Our underwriting rules. In such cases, it is possible that a fresh Policy could not be issued by Us. It is therefore in Your interest to ensure that Your Policy is renewed before expiry.
Can the insurance company refuse to renew the policy?
We may refuse to renew the Policy only on rare occasions such as fraud, misrepresentation or suppression or non–cooperation being committed by You or any one acting on Your behalf in obtaining insurance or subsequently in relation thereto. If We discontinue selling this Policy, it might not be possible to renew this Policy on the same terms and conditions. In such a case You shall however have the option for renewal under any similar Policy being issued by the Company, provided the benefits payable shall be subject to the terms contained in such other Policy.
In case of revision or modification or withdrawal of the Policy a notice will be provided to You 90 days before such revision or modification or withdrawal. Renewal can also be refused if the Policy is not renewed before expiry of the Policy or within the Grace Period.
Can i make a claim immediately after taking a policy?
Claims for Illnesses cannot be made during the first thirty days of a fresh Insurance policy. However, claims for Hospitalization due to accidents occurring during the first thirty days are payable. There are certain treatments where the waiting period is two years or four years.
What is the third party administrator?
Third Party Administrator (TPA) is a service provider to facilitate service to You for providing Cashless facility for all hospitalizations that come under the scope of Your policy. The TPA also settles reimbursement claims within the scope of the Policy.
What is cashless hospitalisation?
Cashless hospitalization is service provided by the TPA on Our behalf whereby you are not required to settle the hospitalization expenses at the time of discharge from hospital. The settlement is done directly by the TPA on Our behalf. However those expenses which are not admissible under the Policy would not be paid, and You would have to pay such inadmissible expenses to the Hospital. Cashless facility is available only in Networked Hospitals. Prior approval is required from the TPA before the patient is admitted into the Network Hospital. The list of Network Hospitals can also be obtained from the TPA or from their website. You will have full freedom to choose the hospitals from the Network Hospitals and avail Cashless facility on production of proof of Insurance and Your identity, subject to the claim being admissible. The TPA might not agree to provide Cashless facility at a Hospital which is not a Network Hospital. In such cases You may avail treatment at any Hospital of Your choice and seek reimbursement of the claim subject to the terms and conditions of the Policy. In cases where the admissibility of the claim could not be determined with the available documents, even if the treatment is at a Network Hospital, the TPA may refuse to provide Cashless facility. Such refusal may not necessarily mean denial of the claim. You may seek reimbursement of the expenses incurred by producing all relevant documents and the TPA may pay the claim, if it is admissible under the terms and conditions of the Policy.
Can I change hospitals during the course of treatment?
Yes it is possible to shift to another hospital for reasons of requirement of better medical procedure. However, this will be evaluated by the TPA on the merits of the case and as per policy terms and conditions.
How to get reimbursements in case of treatment in non–network hospitals or denial of cashless facility?
In case of treatment in a non–Network Hospital, TPA will reimburse You the amount of bills subject to the conditions of the Policy. You must ensure that the Hospital where treatment is taken fulfills the conditions of definition of Hospital in the Policy. Within twenty four hours of Hospitalisation the TPA should be intimated. The following documents in original should be submitted to the TPA within seven days from the date of Discharge from the Hospital:
• Claim Form duly filled and signed by the claimant
• Discharge Certificate from the hospital
• All documents pertaining to the illness starting from the date it was first detected i.e. Doctor’s consultation reports/history
• Bills, Receipts, Cash Memos from hospital supported by proper prescription
• Receipt and diagnostic test report supported by a note from the attending medical practitioner/surgeon justifying such diagnostics.
• Surgeon’s certificate stating the nature of the operation performed and surgeon’s bill and receipt
• Attending doctor’s / consultant’s / specialist’s / anesthetist’s bill and receipt, and certificate regarding diagnosis
• Details of previous policies if the details are not already with TPA or any other information needed by the TPA for considering the claim.
How to get reimbursement for pre and post hospitalization expenses?
The Policy allows reimbursement of medical expenses incurred before and after admissible Hospitalisation up to a certain number of days. For reimbursement, send all bills in original with supporting documents along with a copy of the discharge summary and a copy of the authorization letter to your TPA. The bills must be sent to the TPA within 7 days from the date of completion of treatment. You must also provide the TPA with additional information and assistance as may be required by the company/TPA in dealing with the claim.
Will the insured get Payments only if included in hospital bill?
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.
Does the policies cover Medical expenses for organ transplant?
If treatment involves Organ Transplant to Insured Person, then We will also pay Hospitalisation Expenses (excluding cost of organ) incurred on the donor, provided Our liability towards expenses incurred on the donor and the insured recipient shall not exceed the aggregate of the Sum Insured and Cumulative Bonus Buffer, if any, of the Insured Person receiving the organ.
What is Day one baby cover?
A New Born Baby is covered for any Illness or Injury from the date of birth till the expiry of this Policy, within the terms of this Policy. Any expense incurred towards post natal care, pre–term or pre–mature care or any such expense incurred in connection with delivery of such New Born Baby would not be covered. Congenital External Anomaly of the New Born Baby is also not covered under the policy. No coverage for the New Born Baby would be available during subsequent renewals unless the child is declared for insurance and covered as an Insured Person.
Can any claim be rejected or refused?
Yes, a claim, which is not covered under the Policy conditions, can be rejected. In case You are not satisfied by the reasons for rejection, you can represent to Us within 15 days of such denial. If You do not receive a response to Your representation or if You are not satisfied with the response, You may write to our Grievance Cell. You also have the right to represent your case to the Insurance Ombudsman. The contact details of the office of the Insurance Ombudsman could be obtained from the IRDAI website.
Can I cancel the policy?
Yes, You can. You will be allowed a period of fifteen days from the date of receipt of the Policy to review the terms and conditions of the Policy and to return the same if not acceptable.
If You have not made any claim during the free look period, You shall be entitled to:
1. A refund of the premium paid less any expenses incurred by Us on medical examination and the stamp duty charges or;
2. where the risk has already commenced and the option of return of the policy is exercised by You, a deduction towards the proportionate risk premium for period on cover or;
3. Where only a part of the risk has commenced, such proportionate risk premium commensurate with the risk covered during such period.
If you choose to cancel the policy after expiry of Free Look Period, the refund would be at our Short Period rate table given below:
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
The refund would be made only if no claim has been made or paid under the Policy.
We may also at any time cancel the Policy on grounds of misrepresentation, fraud, non–disclosure of material fact or non–cooperation by You by sending fifteen days’ notice in writing by Registered A/D to You at the address stated in the Policy. Even if there are several insured persons, notice will be sent to You. On such cancellation, premium corresponding to the unexpired period of Insurance will be refunded, if no claim has been made or paid under the Policy.
Is there any benefit under the income tax act for premium paid for this insurance ?
Yes. Payments made for health insurance in any mode other than cash are eligible for deduction from taxable income as per Section 80 D of the Income Tax Act, 1961. For details, please refer to the relevant Section of the Income Tax Act.
