National Parivar Mediclaim Policy PDF
National Parivar Mediclaim Policy PDF
National Parivar Mediclaim Policy PDF
Reach us at:
Call at : (033) 2283 1705/ 1706
Toll free : 1800 120 1430
Fax : (033) 2283 1712
Mail us : website.administrator@nic.co.in
Write to us at : Health Insurance Management Dept.
Head Office
3 Middleton Street
Kolkata
West Bengal
Pin code: 700071
Visit us at : www.nationalinsuranceindia.com
Buy online Policy at : http://niconline.in/
Table of Contents
Clause Page 5.5 Claim Procedure 7
Clause Name
No. No. 5.5.1 Notification of Claim 7
1 Recital Clause 1 5.5.2 Procedure for Cashless Claims 7
2 Operative Clause 1 5.5.3 Procedure for Reimbursement of Claims 8
2.1 Coverage 1 5.5.4 Documents 8
2.1.1 In patient Treatment 1 5.5.5 Claim Settlement 8
2.1.1.1 Limit for Room Charges 1 5.5.6 Services Offered by TPA 8
2.1.1.2 Limit for Cataract Surgery 1 5.5.7 Classification of Zone and Copayment 9
2.1.2 Pre Hospitalisation 1 5.5.8 Treatment Outside Network 9
2.1.3 Post Hospitalisation 1 5.6 Payment of Claim 9
2.1.4 Domiciliary Hospitalisation 2 5.7 Territorial Limit 9
2.1.5 Day Care Procedure 2 5.8 Contribution 9
2.1.6 Ayurveda and Homeopathy 2 5.9 Fraud 9
2.1.7 Organ Donor’s Medical Expenses 2 5.10 Cancellation 10
2.1.8 Hospital Cash 2 5.11 Territorial Jurisdiction 10
2.1.9 Ambulance 2 5.12 Arbitration 10
2.1.10 Anti Rabies Vaccination 2 5.13 Disclaimer 10
2.1.11 Maternity 3 5.14 Renewal of Policy 10
2.1.12 Infertility 3 5.15 Enhancement of Sum Insured 10
2.2 Medical Second Opinion 4 Adjustment of Premium for Overseas Travel
5.16 10
3 Good health incentives 4 Insurance Policy
3.1 No Claim Discount 4 5.17 Portability 10
3.2 Health Check Up 4 Medical Expenses Incurred Under Two Policy
5.18 11
4 Exclusions 4 Years
4.1 Pre-existing Diseases 4 5.19 Withdrawal of Product 11
4.2 First Thirty Days Waiting Period 5 Revision of Terms of the Policy including the
5.20 11
4.3 Specific Waiting Period 5 Premium Rates
4.4 HIV, AIDS, STD 5 5.21 Free Look Period 11
General Debility, Congenital External 5.22 Nomination 11
4.5 5
Anomaly 6 Definition 11
4.6 Sterility, Infertility, Assisted Conception 5 6.1 Accident 11
4.7 Pregnancy 5 6.2 Any one illness 11
4.8 Refractive Error 5 6.3 Alternative treatment 11
4.9 Obesity 5 6.4 Break in Policy 11
4.10 Psychiatric Disorder, Self Inflicted Injury 5 6.5 Cashless facility 11
4.11 Genetic Disorders, Stem Cell Surgery 5 6.6 Condition precedent 11
4.12 Circumcision 5 6.7 Contract 11
4.13 Vaccination or Inoculation 5 6.8 Contribution 11
Cosmetic Treatment, Plastic Surgery, Sex 6.9 Congenital anomaly 11
4.14 6
Change, Hormone Replacement 6.10 Co-payment 11
Massages, Spa, Steam Bath, Naturopathy, 6.11 Day care centre 12
4.15 6
Experimental Treatment 6.12 Day care treatment 12
4.16 Dental Treatment 6 6.13 Dental treatment 12
4.17 Vitamins, Tonics 6 6.14 Diagnosis 12
4.18 Out patientTreatment 6 6.15 Domiciliary hospitalisation 12
Hospitalisation for the Purpose of Diagnosis 6.16 Family 12
4.19 6
and Evaluation 6.17 Floater 12
Treatment in Convalescent Home, Nature 6.18 Grace period 12
4.20 6
Clinic 6.19 Hospital 12
4.21 Drug/alcohol Abuse 6 6.20 Hospitalisation 12
Stay in Hospital which is not Medically 6.21 I D card 12
4.22 6
Necessary. 6.22 Illness 12
Spectacles, Contact Lens, Hearing Aid, 6.23 In-patient Care 12
4.23 6
Cochlear Implants. 6.24 Insured/ Insured person 12
4.24 Equipments 6 6.25 Intensive care unit 13
Expenses notRelated to the Diagnosis and 6.26 Injury 13
4.25 6
Treatment of Illness/ Injury 6.27 Medical advice 13
4.26 Items of Personal Comfort 6 6.28 Medical expenses 13
4.27 Service Charge/ Registration Fee 6 6.29 Medically necessary 13
4.28 Home Visit Charges 6 6.30 Medical practitioner 13
4.29 Treatment not Related to Illness 6 6.31 Network provider 13
4.30 Risky Avocations 6 6.32 Newborn baby 13
4.31 Breach Of Law 77 6.33 Notification of claim 13
4.32 War Group Perils 7 6.34 Non- network 13
4.33 Radioactivity 7 6.35 Out patient treatment 13
5 Conditions 7 6.36 Policy period 13
5.1 Disclosure to Information Norm 7 6.37 Policy year 13
5.2 Condition Precedent to Admission of Liability 7 6.38 Preferred provider network (PPN) 13
5.3 Communication 7 6.39 Pre-existing disease 13
5.4 Physical Examination 7
6.40 Portability 13 8.2 Out patient Treatment 15
6.41 Qualified nurse 13 8.3 Critical Illness 15
6.42 Reasonable and customary charges 14 Table of Benefits I
6.43 Room rent 14 Append
II
6.44 Schedule 14 ix I Day Care Procedure
6.45 Service provider 14 Append
IV
6.46 Surgery 14 ix II Major Illness
6.47 Third Party Administrator (TPA) 14 Append
V
6.48 Unproven/ Experimental treatment 14 ix III Vaccinations for Children
6.49 Waiting period 14 Append
VI
7 Redressal of Grievance 14 ix IV Expenses Generally Excluded
8 Optional Covers 14 Append
IX
8.1 Pre-existing Diabetes / Hypertension 14 ix V Ombudsman Office Details
National Insurance Company Limited
Regd. Office 3, Middleton Street, Post Box 9229, Kolkata 700 071
CIN - U10200WB1906GOI001713 IRDA Regn. No. - 58
Issuing Office
National ParivarMediclaim Policy
1 Recital Clause
Whereas the insured designated in the schedule hereto has by a proposal, dated as stated in the schedule, which shall be the basis
of this contract and is deemed to be incorporated herein, has applied to National Insurance Company Ltd. (hereinafter called the
Company), for the insurance hereinafter set forth, in respect of person(s)/ family members named in the schedule hereto
(hereinafter called the insured persons) and has paid the premium as consideration for such insurance.
2 Operative Clause
The Company undertakes that if during the policy period or during the continuance of the Policy by renewal, any insured person
shall suffer any illness or disease (hereinafter called disease) or sustain any bodily injury due to an accident (hereinafter called
injury) and if such disease or injury shall require any such insured person, upon the advice of a duly qualified medical
practitioner,
a. to be hospitalised for treatment at any hospital/nursing home (hereinafter called hospital),
b. to undergo treatment under Domiciliary Hospitalisation,
the Company shall pay to the hospital or reimburse the insured reasonable, customary and medically necessary expenses,
incurred in India, as defined below, in respect thereof by, or on behalf of such insured person, but not exceeding the sum
insured, being a floater, in respect of all such claims from one or all the insured persons during a policy year and subject to the
terms, exclusions, conditions, definitions contained herein or endorsed or otherwise expressed hereon and limits as shown in the
Table of Benefits.
2.1Coverage
2.1.1 In-patient Treatment
The Company shall pay to the hospital or reimburse the insured up to the sum insured, the medical expenses for:
i. Room charges and intensive care unit charges (including diet charges, nursing care by qualified nurse, RMO charges,
administration charges for IV fluids/blood transfusion/injection), subject to limit as per Section 2.1.1.1
ii. Medical practitioner(s)
iii. Anaesthesia, blood, oxygen, operation theatre charges, surgical appliances
iv. Medicines and drugs
v. Diagnostic procedures
vi. Prosthetics and other devices or equipment if implanted internally during a surgical procedure.
vii. Dental treatment, necessitated due to an injury
viii. Plastic surgery, necessitated due to disease or injury
ix. Hormone replacement therapy, if medically necessary
x. Vitamins and tonics, forming part of treatment for disease/injury as certified by the attending medical practitioner
xi. Circumcision, necessitated for treatment of a disease or injury
2.1.1.1 Limit for Room Charges and Intensive Care Unit Charges
Room charges and intensive care unit charges per day shall be payable up to the limit as shown in the Table of Benefits. The limit
shall not apply if the treatment is undergonefor a listed procedure in a Preferred Provider Network (PPN) as a package.
Note:
Listed procedures and Preferred Provider Network list are dynamic in nature, and will be updated in the Company’s website from
time to time.
Exclusions
Domiciliary hospitalisation shall not cover:
i. Treatment of less than three days
ii. Expenses incurred for pre and post hospitalisation
iii. Expenses incurred for alternative treatment
iv. Expenses incurred for maternity or infertility
v. Expenses incurred for any of the following diseases;
a) Asthma
b) Bronchitis
c) Chronic nephritis and nephritic syndrome
d) Diarrhoea and all type of dysenteries including gastroenteritis
e) Epilepsy
f) Influenza, cough and cold
g) All psychiatric or psychosomatic disorders
h) Pyrexia of unknown origin for less than ten days
i) Tonsillitis and upper respiratory tract infection including laryngitis and pharingitis
j) Arthritis, gout and rheumatism
Exclusions
The Company shall not be liable to make any payment in respect of any expenses incurred in connection with or in respect of
1. Cost of the organ to be transplanted
2. Pre and post hospitalisation expenses, as per Section 2.1.2 and Section 2.1.3, incurred by the organ donor unless the organ
donor is an insured person.
3. Any other medical treatment or complication in respect of the donor, consequent to harvesting
2.1.9 Ambulance
The Company shall reimburse the insured the expenses incurred for ambulance charges for transportation to the hospital, or from
one hospital to another hospital, up to the limit as shown in the Table of Benefits, provided a claim has been admitted under
Section 2.1.1.
Note: Ectopic pregnancy is covered under Section 2.1.1 ‘In-patient treatment’, provided such pregnancy is established by medical
reports.
Exclusions
The Company shall not be liable to make any payment in respect of any expenses incurred in connection with or in respect of
1. Insured and insured persons above forty five years of age.
2. More than one delivery or termination in a policy year.
3. Surrogacy, unless claim is admitted under Section 2.1.12 (Infertility)
4. Pre and post hospitalisation expenses as per Section 2.1.2 and Section 2.1.3, other than pre and post natal treatment.
2.1.12Infertility
The Company shall pay to the hospital or reimburse the insured, in respect of the medical expenses of the insured and his spouse,
if covered by the Policy, for treatment undergone as an in-patient or as a day care treatment, for procedures and/ or treatment of
infertility, provided the Policy has been continuously in force for thirty six months from the inception of the Policy or from the
date of inclusion of the insured person, whichever is later. The medical expenses for either or both the insured person shall be
subject to the limit as shown in the Table of Benefits.
Exclusions
The Company shall not be liable to make any payment in respect of any expenses incurred in connection with or in respect of
1. Insured and insured persons above forty five years of age.
2. Diagnostic tests related to infertility
3. Reversing a tubal ligation or vasectomy
4. Preserving and storing sperms, eggs and embryos
5. An egg donor or sperm donor
6. Experimental treatments
7. Any disease/ injury, other than traceable to maternity, of the surrogate mother.
Conditions
1. Expenses advanced procedures, including IVF, GIFT, ZIFT or ICSI, shall be payable only if the Insured person has been
unable to attain or sustain a successful pregnancy through reasonable, and medically necessary infertility treatment.
2. Maternity expenses of the surrogate mother shall be payable under Section 2.1.11 (Maternity). Legal affidavit regarding
intimation of surrogacy shall be submitted to the Company.
3. Maximum of two claims shall be admissible by the Policy during the lifetime of the insured person if he has no living childand
one claim if the insured has one living child.
4. Any one illness (Definition 6.2) limit shall not apply.
Note
Aggregate of all the benefits under 2.1.1 to 2.1.12 are subject to the Sum Insured opted.
4 Exclusions
The Company shall not be liable to make any payment by the Policy, in respect of any expenses incurred in connection with or in
respect of:
4.7 Pregnancy
Treatment arising from or traceable to pregnancy/childbirth including caesarean section, miscarriage, surrogate or vicarious
pregnancy, abortion or complications thereof including changes in chronic conditions arising out of pregnancy, except as and to
the extent provided for under Section 2.1.11 (Maternity) and Section 2.1.12 (Infertility).
4.9 Obesity
Treatment for obesity or a condition arising there from (including morbid obesity) and any other weight control and management
programme/services/supplies or treatment.
4.11 Genetic Disorders, Stem Cell Surgery (except bone marrow transplant).
4.12 Circumcision
Circumcision,except as and to the extent provided for under Section 2.1.1.xi
4.14 Cosmetic Treatment, Plastic Surgery, Sex Change, Hormone Replacement Therapy
Cosmetic treatment or aesthetic treatment of any description, change of life or sex change operation.
Expenses for plastic surgery, except as and to the extent provided for under Section 2.1.1.viii.
Expenses for hormone replacement therapy, except as and to the extent provided for under Section 2.1.1.ix.
4.24 Equipments
External/durable medical/non-medical equipments/instruments of any kind used for diagnosis/ treatment including CPAP,
CAPD, infusion pump, ambulatory devices such as walker, crutches, belts, collars, caps, splints, slings, braces, stockings,
diabetic foot-wear, glucometer, thermometer and similar related items (as listed in Appendix IV) and any medical equipment
which could be used at home subsequently.
4.25 Expenses not Related to the Diagnosis and Treatment of Disease/ Injury
Irrelevant investigations/treatment, drugs not supported by a prescription, private nursing charges, referral fee to family physician,
outstation doctor/surgeon/consultants’ fees and similar expenses (as listed in Appendix IV).
4.33 Radioactivity
Any disease or injury directly or indirectly caused by or contributed by nuclear weapons/materials or arising from ionising
radiation or contamination by any nuclear fuel or from any nuclear waste or combustion of nuclear fuel.
5 Conditions
5.3 Communication
i. All communication should be made in writing.
ii. For Policies serviced by TPA, ID card, PPN/network provider related issues to be communicated to the TPA at the address
mentioned in the schedule. For claim serviced by the Company, the Policy related issues to be communicated to the Policy
issuing office of the Company at the address mentioned in the schedule.
iii. Any change of address, state of health or any other change affecting any of the insured person, shall be communicated to the
Policy issuing office of the Company at the address mentioned in the schedule
iv. The Company or TPA shall communicate to the insured at the address mentioned in the schedule.
Note:
For claim under Section 2.2 (Medical Second Opinion), notification of claim is not required.
5.5.4 Documents
The claim is to be supported by the following documents in original and submitted within the prescribed time limit.
i. Completed claim form
ii. Bills, payment receipts, medical history of the patient recorded, discharge certificate/ summary from the hospital etc.
iii. Cash-memo from the hospital (s)/chemist(s) supported by proper prescription
iv. Payment receipt, investigation test reports etc. supported by the prescription from the attending medical practitioner
v. Attending medical practitioner’s certificate regarding diagnosis along with date of diagnosis and bill receipts etc.
vi. Certificate from the surgeon stating diagnosis and nature of operation and bills/receipts etc.
vii. For claim under Section 2.1.4 (Domiciliary Hospitalisation) in addition to documents listed above (as applicable), medical
certificate stating the circumstances requiring for Domiciliary hospitalisation and fitness certificate from treating medical
practitioner.
viii. For claim under Section 2.1.11 (Maternity) for surrogacy under Section 2.1.12 (Infertility) in addition to documents listed
above (as applicable), legal affidavit regarding intimation of surrogacy.
ix. Any other document required by Company/TPA
Note
In the event of a claim lodged as per condition 5.8 and the original documents having been submitted to the other insurer, the
Company may accept the documents listed under condition 5.5.4 and claim settlement advice duly certified by the other insurer
subject to satisfaction of the Company.
Waiver
Time limit for notification of claim and submission of documents may be waived in cases where it is proved to the satisfaction of
the Company, that the physical circumstances under which insured person was placed, it was not possible to intimate the
claim/submit the documents within the prescribed time limit.
Where treatment has been taken in a zone, other than the one for which ** premium has been paid, the claim shall be
subject to copayment.
i. Insured paying premium as per Zone I can avail treatment in Zone I, Zone II, Zone III and Zone IV without
copayment
ii. Insured paying premium as per Zone II
a. Can avail treatment in Zone II, Zone III and Zone IV without any copayment
b. Availing treatment in Zone I will be subject to a copayment of 5%
iii. Insured paying premium as per Zone III
a. Can avail treatment in Zone III and Zone IV without any copayment
b. Availing treatment in Zone I will be subject to a copayment of 12.5%
c. Availing treatment in Zone II will be subject to a copayment of 7.5%
iv. Insured paying premium as per Zone IV
a. Can avail treatment in Zone IV without any copayment
b. Availing treatment in Zone I will be subject to a copayment of 22.5%
c. Availing treatment in Zone II will be subject to a copayment of 17.5%
d. Availing treatment in Zone IIIwill be subject to a copayment of 10%
** For premium rates please refer to the Prospectus/ Brochure
Above copayments shall not be applicable on Critical illness & Outpatient treatment optional covers, but shall apply on
Pre existing diabetes and/ or hypertension optional cover.
5.8 Contribution
In the event of a claim arising by the Policy, there is in existence any other policy (other than cancer insurance policy in
collaboration with Indian Cancer Society) effected by the insured person or on behalf of the insured person which covers any
claim in whole or in part made by the Policy then the insured person has the option to select the Policy under which the claim is to
be settled. If the claimed amount, after considering the applicable co payment, exceeds the sum insured under any one policy then
the Company shall pay or contribute not more than its rateable proportion of the claim.
5.9 Fraud
The Company shall not be liable to make any payment under if the sameis in any manner fraudulent or supported by any
fraudulent means or device whether by the insured person or by any other person acting on his behalf.
5.12 Arbitration
i. If any dispute or difference shall arise as to the quantum to be paid by the Policy, (liability being otherwise admitted) such
difference shall independently of all other questions, be referred to the decision of a sole arbitrator to be appointed in writing
by the parties here to or if they cannot agree upon a single arbitrator within thirty days of any party invoking arbitration, the
same shall be referred to a panel of three arbitrators, comprising two arbitrators, one to be appointed by each of the parties to
the dispute/difference and the third arbitrator to be appointed by such two arbitrators and arbitration shall be conducted under
and in accordance with the provisions of the Arbitration and Conciliation Act, 1996.
ii. It is clearly agreed and understood that no difference or dispute shall be referable to arbitration as herein before provided, if
the Company has disputed or not accepted liability under or in respect of the Policy.
iii. It is hereby expressly stipulated and declared that it shall be a condition precedent to any right of action or suit upon the
Policy that award by such arbitrator/arbitrators of the amount of expenses shall be first obtained.
5.13 Disclaimer
If the Company shall disclaim liability for a claim hereunder and if the insured person shall not within twelve calendar months
from the date of receipt of the notice of such disclaimer notify the Company in writing that he/ she does not accept such
disclaimer and intends to recover his/ her claim from the Company, then the claim shall for all purposes be deemed to have been
abandoned and shall not thereafter be recoverable hereunder.
5.17 Portability
In the event of the insured person porting to any other insurer, insured person must apply with details of the Policy and claims to
the insurer where the insured person wants to port, at least forty five days before the date of expiry of the Policy.
Portability shall be allowed in the following cases:
i. all individual health insurance policies issued by non-life insurance companies including family floater policies.
ii. individual members, including the family members covered under any group health insurance policy of a non-life insurance
Company shall have the right to migrate from such a group policy to an individual health insurance policy or a family floater
policy with the same insurer. One year thereafter, the insured person shall be accorded the right to port to another non-life
insurance Company.
5.22 Nomination
The insured is mandatorily required at the inception of the Policy to make a nomination for the purpose of payment of claims by
the Policy in the event of death of the insured. Any change of nomination shall be communicated to the Company in writing and
such change shall be effective only when an endorsement on the Policy is made. In the event of death of any insured person other
than the insured, for the purpose of payment of claims, the default nominee would be the insured. The Policy or the benefits
cannot be assigned.
6 Definition
6.1 Accident means a sudden, unforeseen and involuntary event caused by external, visible and violent means.
6.2 Any one illness means continuous period of illness and it includes relapse within forty five days from the date of last
consultation with the hospital where treatment has been taken.
6.3 Alternative treatment means forms of treatments other than "Allopathy" or "modem medicine" and includes Ayurveda,
Unani, Sidha and Homeopathy in the Indian context.
6.4 Break in Policyoccurs at the end of the existing policy period when the premium due on a given Policy is not paid on or
before the renewal date or within grace period.
6.5 Cashless facility means a facility extended by the insurer to the insured where the payments of the costs of treatment
undergone by the insured in accordance with the Policy terms and conditions, are directly made to the network provider by the
insurer to the extent pre-authorization approved.
6.6. Condition precedent means a Policy term or condition upon which the Company’s liability by the Policy is conditional upon.
6.7 Contract means prospectus, proposal, Policy, and the policy schedule. Any alteration with the mutual consent of the insured
person and the insurer can be made only by a duly signed and sealed endorsement on the Policy.
6.8 Contribution means the right of a Company to call upon other insurers, liable to the same insured, to share the cost of an
indemnity claim on a ratable proportion.
6.9 Congenital anomaly refers to a condition(s) which is present since birth, and which is abnormal with reference to form,
structure or position.
i. which is not in the visible and accessible parts of the body is called Internal congenital anomaly.
ii. which is in the visible and accessible parts of the body is called External congenital anomaly
6.10 Co-payment means a cost-sharing requirement by the Policy that provides that the insured shall bear a specified percentage
of the admissible claim amount. A co-payment does not reduce the Sum Insured.
6.12 Day care treatment means medical treatment, and/or surgical procedure (as listed in Annexure I) which is:
i. undertaken under general or local anesthesia in a hospital/day care centre in less than twenty fourhrs because of technological
advancement, and
ii. which would have otherwise required a hospitalisation of more than twenty four hours.
Treatment normally taken on an out-patient basis is not included in the scope of this definition.
6.13 Dental treatment means a treatment carried out by a dental practitioner including examinations, fillings (where appropriate),
crowns, extractions and surgery excluding any form of cosmetic surgery/implants.
6.14 Diagnosis means diagnosis by a medical practitioner, supported by clinical, radiological, histological and laboratory
evidence, acceptable to the Company.
6.15 Domiciliary hospitalisation means medical treatment for an illness /injury which in the normal course would require care
and treatment at a hospital but is actually taken while confined at home under any of the following circumstances.
i. the condition of the patient is such that he/she is not in a condition to be removed to a hospital, or
ii. the patient takes treatment at home on account of non availability of bed/room in a hospital.
6.16 Family members means spouse, children and parents of the insured, covered by the Policy.
6.17Floater means the sum insured, as mentioned in the Schedule, available to all the insured persons, for any and all claims
made in the aggregate during each policy year.
6.18 Grace period means thirty days immediately following the premium due date during which a payment can be made to renew
or continue the Policy in force without loss of continuity benefits such as waiting period and coverage of pre-existing disease.
Coverage is not available for the period for which no premium is received.
6.19 Hospital means any institution established for in-patient care and day care treatment of disease/ 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 Schedule of Section 56(1) of the said Act, OR complies with all minimum criteria as under:
i. has qualified nursing staff under its employment round the clock;
ii. has at least ten inpatient beds, in those towns having a population of less than ten lacs and fifteen inpatient beds in all other
places;
iii. has qualified medical practitioner (s) in charge round the clock;
iv. has a fully equipped operation theatre of its own where surgical procedures are carried out
v. maintains daily records of patients and shall make these accessible to the Company’s authorized personnel.
6.20Hospitalisationmeans admission in a hospital for a minimum period of twenty four consecutive hours except for specified
procedures/ treatments, where such admission could be for a period of less than twenty four consecutive hours.
6.21 I D card means the card issued to the insured person by the TPA for availing cashless facility in the network provider.
6.22 Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function
which manifests itself during the policy period and requires medical treatment.
i. Acute condition means a disease, illness orinjury that is likely to response quickly to treatment which aims to return the
person to his or her state of health immediately before suffering the disease/ illness/ injury which leads to full recovery.
ii. Chronic condition means a disease, illness, or injury that has one or more of the following characteristics
a) it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and / or tests
b) it needs ongoing or long-term control or relief of symptoms
c) it requires your rehabilitation or for you to be specially trained to cope with it
d) it continues indefinitely
e) it comes back or is likely to come back.
6.23 In-patient caremeans treatment for which the insured person has to stay in a hospital for more than 24 hours for a
covered event.
6.24 Insured/ Insured person means person(s) named in the schedule of the Policy.
6.26 Injury means accidental physical bodily harm excluding disease solely and directly caused by external, violent and visible
and evident means which is verified and certified by a medical practitioner.
6.27 Medical advice means any consultation or advice from a Medical Practitioner including the issue of any prescription or
repeat prescription.
6.28 Medical expenses means those expenses that an insured person has necessarily and actually incurred for medical treatment
on account of disease/ injury on the advice of a medical practitioner, as long as these are no more than would have been payable if
the insured person had not been insured and no more than other hospitals or doctors in the same locality would have charged for
the same medical treatment.
6.29 Medically necessary means any treatment, tests, medication, or stay in hospital or part of a stay in hospital which
i. is required for the medical management of the disease/ injuries suffered by the insured person;
ii. must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or
intensity;
iii. must have been prescribed by a medical practitioner;
iv. must conform to the professional standards widely accepted in international medical practice or by the medical community in
India.
6.30 Medical practitioner means a person who holds a valid registration from the medical council of any state or Medical
Council of India or Council for Indian Medicine or for Homeopathy set up by the Government of India or a State Government and
is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of the licence.
6.31 Network provider means hospitals or health care providers enlisted by the Company or by a TPA and the Company together
to provide medical services to an insured person on payment by a cashless facility.
6.32 Newborn baby means baby born during the policy period and is aged between one day and ninety days, both days inclusive.
6.33 Non- networkmeans any hospital, day care centre or other provider that is not part of the network.
6.34 Notification of claim means the process of notifying a claim to the Company or TPA by specifying the timelines as well as
the address / telephone number to which it should be notified.
6.35 Out-patient treatment means treatment in which the insured person visits a clinic / hospital or associated facility like a
consultation room for diagnosis and treatment based on the advise of a medical practitioner and the insured person is not admitted
as a day care patient or in-patient.
6.36 Policy period means period of one policy year/ two policy years/ three policy years as mentioned in the schedule for which
the Policy is issued.
6.37 Policy year means a period of twelve months beginning from the date of commencement of the policy period and ending on
the last day of such twelvemonth period. For the purpose of subsequent years, policy year shall mean a period of twelve months
commencing from the end of the previous policy year and lapsing on the last day of such twelve-month period, till the policy
period, as mentioned in the schedule.
6.38Preferred provider network (PPN) means a network of hospitals which have agreed to a cashless packaged pricing for
listed procedures for the insured person. The list is available on the website of the Company/TPA and subject to amendment from
time to time. For the updated list please visit the website of the Company/TPA. 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.
6.39 Pre-existing disease means any condition, disease or injury or related conditions for which the insured person had signs or
symptoms and/or was diagnosed and/or received medical advice/treatment within forty eight months prior to the inception of the
Policy.
6.40 Portability means transfer by an individual health insurance policy holder (including family cover) of the credit gained for
pre-existing conditions and time bound exclusions if the policy holder chooses to switch from one insurer to another.
6.41 Qualified nurse means a person who holds a valid registration from the Nursing Council of India or the Nursing Council of
any state in India.
6.43 Room rent means the amount charged by a hospital for the occupancy of a bed on per day (twenty four hours) basis and
shall include associated medical expenses.
6.44 Schedule means a document forming part of the Policy, containing details including name of the insured person, age, relation
of the insured person, sum insured, premium paid and the policy period.
6.45 Service provider means an entity engaged by the Company to provide Medical Second Opinion.
6.46 Surgery means manual and / or operative procedure (s) required for treatment of a disease or injury, correction of
deformities and defects, diagnosis and cure of diseases, relief of suffering or prolongation of life, performed in a hospital or day
care centre by a medical practitioner.
6.47 Third Party Administrator (TPA) means any entity, licenced under the IRDA (Third Party Administrators - Health
Services) Regulations, 2001 by the Authority, and is engaged, for a fee by the Company for the purpose of providing health
services.
6.48 Unproven/ Experimental treatment means treatment, including drug therapy, which is not based on established medical
practice in India, is experimental or unproven.
6.49 Waiting period means a period from the inception of this Policy during which specified diseases/treatment is not covered.
On completion of the period, diseases/treatment shall be covered provided the Policy has been continuously renewed without any
break.
7 Redressal of Grievance
In case of any grievance relating to servicing the Policy, the insured person may submit in writing to the Policy issuing office or
regional office for redressal. If the grievance remains unaddressed, insured person may contact Customer Relationship
Management Dept., National Insurance Company Limited, Chhabildas Towers, 6A, Middleton Street, Kolkata - 700071.
If the insured person is not satisfied, the grievance may be referred to “Health Insurance Management Dept.”, National Insurance
Company Limited, 3 Middleton Street, Kolkata - 700071. For more information on grievance mechanism, and to download
grievance form, visit our website www.nationalinsuranceindia.com
The insured person may also approach the office of Insurance Ombudsman of the respective area/region for redressal of
grievance. The contact details of the Insurance Ombudsman offices have been provided as Appendix V.
8 Optional Covers
Copayment
Claims shall be subject to a co payment on admissible claim amount as mentioned below
i. Insured opting for cover for pre existing diabetes, can avail treatment for diabetes, subject to a copayment of 10%
ii. Insured opting for cover for pre existing hypertension, can avail treatment for hypertension, subject to a copayment of
10%
iii. Insured opting for cover for pre existing diabetes and hypertension, can avail treatment for diabetes or hypertension,
subject to a copayment of 25%
Eligibility
As per the Policy.
Limit of Cover
Sum Insured opted under the policy shall apply.
Policy period
The policy period for the Policy, and the cover should be identical, as mentioned in the schedule.
Tax rebate
The insured can avail tax benefits for the premium paid, under Section 80D of Income Tax Act 1961.
Renewal
The cover can be renewed annually till Exclusion 4.1 applies on diabetes and/or hypertension, with respect to the insured persons.
Eligibility
The cover can be availed by all insured persons as a floater.
Limit of Cover
Limit of cover, available under Outpatient Treatment are INR 2,000/ 3,000/ 4,000/ 5,000/ 10,000, in addition to the sum insured
opted.
Policy Period
The policy period for the Policy, and the cover should be identical, as mentioned in the schedule.
Tax Rebate
The insured person can avail tax benefits for the premium paid, under Section 80D of Income Tax Act 1961.
Renewal
The Outpatient Treatment cover can be renewed annually throughout the lifetime of the insured person.
8.2.1 Exclusions
The Company shall not make any payment under the cover in respect of
i. Treatment other than Allopathy/ Modern medicine, Ayurveda and Homeopathy
ii. * Cosmetic dental treatment to straighten lightens, reshape and repair teeth.
* Cosmetic treatments include veneers, crowns, bridges, tooth-coloured fillings, implants and tooth whitening).
8.2.2 Condition
Claim Amount
i. Any amount payable under the optional covers will not affect the sum insured applicable to Section 2.1 and entitlement
to No Claim Discount (Section 3.1) and Health Check up (Section 3.2).
ii. Any amount payable shall not be subject to copayment.
Claims Procedure
Documents supporting all out-patient treatments shall be submitted to the TPA/ Company twice during the policy period, within
thirty days of completion of six month period.
Documents
The claim has to be supported by the following original documents
i. All bills, prescriptions from medical practitioner
ii. Diagnostic test bills, copy of reports
iii. Any other documents required by the Company
Benefit Amount
Policy Period
The policy period for the Policy, and the cover should be identical, as mentioned in the schedule.
Tax Rebate
No tax benefit is allowed on the premium paid under Critical Illness cover (if opted)
Renewal
The Critical Illness cover can be renewed annually throughout the lifetime of the insured person.
8.3.1 Definition
Critical illness means stroke resulting in permanent symptoms, cancer of specified severity, kidney failure requiring regular
dialysis, major organ/ bone marrow transplant, multiple sclerosis with persisting symptoms an open chest CABG (Coronary
Artery Bypass Graft), permanent paralysis of limbs and blindness.
VIII Blindness
The total and permanent loss of all sight in both eyes.
8.3.2 Exclusions
The Company shall not be liable to make any payment by the Policy if any critical illness and/or its symptoms (and/or the
treatment) which were present at any time before inception of the Policy, or which manifest within a period of ninety days from
inception of the Policy, whether or not the insured person had knowledge that the symptoms or treatment were related to such
critical illness. In the event of break in the Policy, the terms of this exclusion shall apply as new from recommencement of cover
8.3.3 Condition
Claim Amount
i. Any amount payable under the optional covers will not affect the sum insured applicable to Section 2.1 and entitlement
to No Claim Discount (Section 3.1) and Health Check up (Section 3.2).
ii. Any amount payable shall not be subject to copayment.
Notification of Claim
In the event of a claim, the insured person/insured person’s representative shall intimate the Company in writing by letter, e-mail,
fax providing all relevant information relating to the critical illness within fifteen days of diagnosis of the critical illness.
Claims Procedure
Documents as mentioned above, supporting the diagnosis shall be submitted to the Company within sixty days from the date of
diagnosis of the critical illness.
Documents
The claim has to be supported by the following original documents
i. Doctor’s certificate confirming diagnosis of the critical illness along with date of diagnosis.
ii. Pathological/other diagnostic test reports confirming the diagnosis of the critical illness.
iii. Any other documents required by the Company
Cessation of Cover
1 upon payment of the benefit amount on the occurrence of a critical illness the cover shall cease and no further claim shall be
paid for any other critical illness during the policy year.
2 On renewal, no claim shall be paid for a critical illness for which a claim has already been made
Note:
i. Day care treatment will include above day care procedures
ii. Any surgery/procedure (not listed above) which due to advancement of medical science requires hospitalisation for less than 24 hours will require prior
approval from Company/TPA.
iii. The standard exclusions and waiting periods are applicable to all of the above day care procedures / surgeries depending on the medical condition /
disease under treatment. Only 24 hours hospitalisation is not mandatory.
The list is as per the standard list of excluded expenses stipulated by IRDA in Guidelines in Standardization in Health Insurance,
dated 20.02.2013.