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he Policy covers reimbursement of Hospitalization Expenses for Illness/ Injury sustained.
Salient features of the Policy
COVERAGE: The Policy covers reimbursement of Hospitalization Expenses for Illness/ Injury sustained.
In event of any claim being admissible, following Reasonable and Customary expenses are reimbursable under the policy:
Room, Boarding Expenses as provided by the hospital including Nursing charges, not exceeding 1% of Sum Insured per day.
Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) expenses, not exceeding 2% of the sum insured per day.
Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees.
Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines &Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial Limbs & Cost of Organs and similar expenses.
Pre-hospitalization medical charges up to 30 days period.
Post-hospitalization medical charges up to 60 days period.
SUB-LIMIT CLAUSE
The amounts payable under 2.3 and 2.4 shall be at the rate applicable to the entitled room category. In case of admission to a room/ICU/ICCU at rates exceeding the limits as mentioned under 2.1 and 2.2, the reimbursement/payment of all other expenses incurred at the Hospital, with the exception of cost of medicines, shall be affected in the same proportion as the admissible rate per day bears to the actual rate per day of room rent/ICU/ICCU charges.
No payment shall be made under 2.3 other than as part of the hospitalization bill.
However, the bills raised by Surgeon, Anesthetist directly and not included in the hospitalization bill may be reimbursed in the following manner:
a. The reasonable, customary and Medically Necessary Surgeon fee and Anesthetist fee would be reimbursed, limited to the maximum of 25% of Sum Insured. The payment shall be reimbursed provided the insured pays such fee(s) through cheque and the Surgeon / Anesthetist provides a numbered bill. Bills given on letter-head of the Surgeon, Anesthetist would not be entertained.
b. Fees paid in cash will be reimbursed up to a limit of Rs. 10,000/- only, provided the Surgeon/Anesthetist provides a numbered bill.
LIMIT ON PAYMENT FOR CATARACT: Company's liability for payment of any claim relating to Cataract shall be limited to Actual or maximum of Rs.24000 (inclusive of all charges, excluding service tax), for each eye, whichever is less.
AYUSH: Expenses incurred for Ayurvedic/Homeopathic/Unani Treatment are admissible up to 25% of the sum insured provided the treatment for Illness and accidental injuries, is taken in a Government hospital or in any institute recognized by Government and /or accredited by Quality Council Of India / National Accreditation Board on Health, excluding centers for spas, massage and health rejuvenation procedures.
Ambulances services- 1.0 % of the sum insured or actual, whichever is less, subject to maximum of Rs. 2,500/- in case patient has to be shifted from residence to hospital for admission in Emergency Ward or ICU or from one Hospital to another Hospital by fully equipped ambulance for better medical facilities.
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.
Covered Up to 60 days
Post-hospitalization medical charges up to 60 days period
Covered Up to 30 days
Pre-hospitalization medical charges up to 30 days period
1 % of the sum insured or actual
1 % of the sum insured or actual, whichever is less, subject to maximum of Rs. 2,500/- in case patient has to be shifted from residence to hospital for admission in Emergency Ward or ICU or from one Hospital to another Hospital by fully equipped ambulance for better medical facilities
Covered up to 25% of the sum insured
Expenses incurred for Ayurvedic/Homeopathic/Unani Treatment are admissible up to 25% of the sum insured provided the treatment for Illness and accidental injuries, is taken in a Government hospital or in any institute recognized by Government and /or accredited by Quality Council Of India / National Accreditation Board on Health, excluding centers for spas, massage and health rejuvenation procedures
Covered limited to Actual
Company's liability for payment of any claim relating to Cataract shall be limited to Actual or maximum of Rs.24000 (inclusive of all charges, excluding service tax), for each eye, whichever is less.
Covered
Family Covered in this Policy
Covered 1% of Sum Insured per day
Room, Boarding Expenses as provided by the hospital including Nursing charges, not exceeding 1% of Sum Insured per day.
