Individual Mediclaim Policy 2007
(Existing policy holders should continue renewals but this policy is not in force now)
‘Family’ comprises the insured and any one or more of the following:
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.
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enters the next age band: The Loyalty Discount is 10% of Gross renewal Premium for the family and the same will be withdrawn pennanently when a claim is lodged under the policy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.
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
to 5 yrs
|Over 65 yrs
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|
|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|
|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|
All types of dental treatments are excluded except those arising out of
Hospitalization for Day Care Procedure
The time limit of 24 hours of hospitalization will not be applicable for following surgical procedures
|Haemo-Dialysis||– Eye Surgery|
|Parenteral Chemotherapy||– Lithotripsy (Kidney Stone Removal)|
|Dialatation & Curettage (D & C)||– Dental surgery following an accident|
|Hysterectomy||– Coronary Angiography|
|Stones in Gall Bladder, Pancreas & Bile Duct||– Coronary Angioplasty|
|Prostate (TURP)||– Gastrointestinal|
|Appendectomy||– Urinary Tract System|
|Fracture / dislocation excluding hairline fracture||– Inguinal / Ventral / Umbilical / Femoral
|Piles / Fistula||– Anti Rabies Vaccination|
|OR any other Surgeries / Procedures agreed. by TPA / Company which require less than 24 hours hospitalization due to advancement in Medical Technology|
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