Individual Mediclaim Policy 2007

(Existing policy holders should continue renewals but this policy is not in force now)

Family:
‘Family’ comprises the insured and any one or more of the following:

Spouse
Eligible Dependent Children above the age of 3 months (maximum two children)
Dependent Parents / Parents in laws (below the age of 60 years)

All members of a family should be covered without any selection. However, Regional Offices can consider exceptional cases on merits.

Discounts:
Family Discount: 10% discount in premium for covering family members

Midterm inclusion is allowed for child attaining the age of 3 months and newly married spouse by charging pro-rata premium for the remaining period of the policy. No family discount if permissible for such mid term inclusion

The proposer can take the policy for dependent brothers and sisters residing with him but they will not eligible for family discount.

Loyalty Discount: The proposer with age less than 40 years is entitled for Loyalty Discount on renewal without break. This discount wili be given when the insured enters the next age band: The Loyalty Discount is 10% of Gross renewal Premium for the family and the same will be withdrawn pennanently when a claim is lodged under the policy
fOLany member of the family.

Sum Insured:
The minimum sum insured per person under the policy is Rs.1 lac and thereafter in multiples of Rs. 25,000/- up to Rs. 3 lacs and thereafter in multiple of Rs.50,000/- up 10 Rs. 5 lacs.

Enhancement of the sum insured can be done at the time of renewal subject to satisfactory pre-acceptance Health Check up, irrespective of age. No enhancement in sum insured shall be allowed to persons above 60 years of age.

Insured Persons suffering from chronic ailments of recurring nature should not be considered for enhancement of the sum insured.

Persons suffering from incurable / chronic diseases needing recurring treatment of any kind, such as renal failure, cancer, Parkinson’s disease, Diabetes Mallitus, type II, etc will not eligible for the Mediclaim Policy (2007)

ZONE 1- MUMBAI                                                                            Premium in Rupees

Once the insured person crosses the age of 70 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 65 years to 70 years.

Cost of Health check up:
The Insured shall be entitled for reimbursement of cost of health check up undel1aken once at the expiry of a block of every four continuous claim Free years of New India’s Policy. The cost so reimbursable shall not exceed 1% of average sum insures excluding cumulative bonus for preceding four years.

Introduction of sub limits:
Room, boarding & nursing expenses as provided by the hospital / nursing home not exceeding 1% of the sum insured (without cumulative bonus) per day or actuals, whichever is less.

Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) not exceeding 2% of the sum insured per day or actuals, whichever is less.

Expenses incurred for Ayurvedic / Homeopathic / Unani treatment is admissible up to 25% of the sum insured, provided the treatment is taken in Government Hospital.

Ambulance Service – 1% of the sum insured or actuals, whichever is less subject to maximum of Rs.2,500/- shall be reimbursed in case patient has to be shifted from residence to hospital for admission in emergency ward or ICU or from one Hospital / Nursing Home to another Hospital / Nursing Home by fully equipped ambulance or better medical facilities.

Pre-existing diseases/condition exclusion: All diseases/injuries/conditions, which are pre-existing when the cover incepts for the first time will be. excluded. Any complication arising from pre-existing disease/ailment/injury will be considered as a part of pre-existing condition.

(a) Exclusion of the condition:
This exclusion will be deleted after four consecutive claims free policy years provided there was no hospitalization for the pre-existing. Disease / ailment / condition / injury during the four years of insurance with our Company.

(b) Compulsory Coverage For Pre-Existing Condition (Diabetes / Hypertension)
The existing conditions of Diabetes (Random Blood sample showing sugar of 150 mg and above) and Hypertension (Blood Pressure showing 140/90 and above) have to be covered compulsorily by payment of additional premium at the rate of 20% of basic premium per each preexisting condition. This additional premium will be payable at every subsequent renewal.

First year Exclusion has been modified as under: (Exclusion 4.3)
Waiting period for specified diseases / ailments / conditions:
At the time of inception of the cover, this policy will not cover the diseases / ailments / conditions for the period mentioned bellow. This exclusion will be deleted after the specified period provided the policy has been continuously renewed with our Company without any break.

Name of Disease / Ailment / Surgery not covered for	Duration
Cataract & age related eye ailments	Two years
Benign Prostate Hypertrophy	Two years
Benign Ear, Nose, Throat disorders	Two years
Hysterectomy for Menorrhagia / Fibromyoma, Myomectomy & Prolapse of uterus	Two years
Hernia of all types	Two years
Piles, Fissure & Fistulae	Two years
Stone in Urinary System	Two years
All internal & external benign tumors, cysts, polyps of any kind including benign breast lumps	Two years
Gastric & /or Duodenal Ulcer	Two years
Hydrocele	Two years
Stone in Gall Bladder & Bile duct excluding malignancy	Two years
Pilonidal Sinus, Sinusitis & related disorders	Two years
Unknown Congenital internal disease / defects	Two years
Non Infective Arthritis	Two years
Gout & Rheumatism	Two years
Hypertension	Two years
Diabetes	Two years
Prolapse Inter Vertebral Disc unless arising from accident	Two years
Skin disorders	Two years
Varicose Veins & Varicose Ulcers	Two years
Joint Replacement due to Degenerative Condition	Four years
Age related Osteoarthritis & Osteoporosis	Four years

Dental Treatment:
All types of dental treatments are excluded except those arising out of
accident.

Hospitalization for Day Care Procedure
The time limit of 24 hours of hospitalization will not be applicable for following surgical procedures

• Service Tax: Applicable
• Policy Conditions & Clauses: MEDICLAIM POLICY 2007 (CLAUSES)  (Download .pdf) 
• Forms: MEDICLAIM POLICY 2007 l PRE INSURANCE HEALTH CHECKUP

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