United-Shramik-Seva Policy

KEY BENEFITS
The United Shramik Seva Policy is a Group Health Product for Employer- Employee Groups to take care of the most basic and essential health needs of the employees/ workers in all industrial and commercial establishments, workplaces, offices, etc. and keep them secure.

SALIENT FEATURES

ELIGIBILITY:
All Employer's Employee Groups (including those where Principal covers contractor's/ sub-contractor's employees) with minimum group size of 7 Insured Persons are eligible to take this policy. More specifically, the aim is to target all industrial and commercial establishments, workplaces, offices, etc. so that these organizations can provide medical insurance coverage to their workers. The Policy provides cover on an Individual Sum Insured basis. Employer's Employee Group members aged between 18 years and 65 years are eligible for this insurance.

SUM INSURED:
Five Sum Insured options are available as under: - Rs. 1 lac, 2 lacs, 3 lacs, 4 lacs, 5 Lacs.

Different Sum Insureds can be opted for different grades/ Class of employees. However, within the same Salary Scale/ Grade/ Class/ Designation, the Sum Insured must be equal for all the members.

TERM OF POLICY:
One Year

COVERAGES

Base Cover:
The covers listed below are in-built Policy benefits and shall be available to all Insured Persons in accordance with the procedures set out in this Policy.

Hospitalization
The company shall indemnify medical expenses incurred for Hospitalization of the Insured Person during the Policy period, up to the Sum Insured specified in the policy schedule, for:
Room Rent, Boarding, Nursing Expenses as provided by the Hospital/Nursing Home up to 1% of the sum insured per day.
Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) expenses up to 2% of the sum insured per day.
Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialist Fees whether paid directly to the treating doctor / surgeon or to the hospital.
Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, implants, medicines and drugs, costs towards diagnostics, diagnostic imaging modalities and such similar other expenses.

Other Expenses
Actual expenses incurred on treatment of cataract (including cost of the lens) up to 15% of Sum Insured or Rs. 30,000/-, whichever is lower, per eye during the Policy period.

Dental treatment, necessitated due to injury

Plastic surgery necessitated due to disease or injury

All the day care treatments

Expenses incurred on Road Ambulance subject to a maximum of Rs. 2000/- per hospitalization.

Expenses of Hospitalization for a minimum period of 24 consecutive hours only shall be admissible. However, the time limit shall not apply in respect of Day Care Treatment.

In case of admission to a room at rates exceeding the aforesaid limits in Clause 4.1.i, the reimbursement/payment of all associated medical expenses incurred at the Hospital shall be effected in the same proportion as the admissible rate per day bears to the actual rate per day of Room Rent.

Proportionate Deductions shall not be applied in respect of those hospitals where differential billing is not followed or for those expenses where differential billing is not adopted based on the room category.

AYUSH Treatment
The company shall indemnify medical expenses incurred for inpatient care treatment under Ayurveda, Unani, Siddha and Homeopathy systems of medicines during each Policy Year up to the limit of Rs. 15000 in any AYUSH Hospital.

Pre Hospitalization
The company shall indemnify pre hospitalization medical expenses incurred, related to an admissible hospitalization requiring inpatient care, up to a period of 30 days prior to the date of admissible hospitalization covered under the policy.

Post Hospitalization
The company shall indemnify post hospitalization medical expenses incurred, related to an admissible hospitalization requiring inpatient care, up to 60 days from the date of discharge from the hospital, following an admissible hospitalization covered under the policy.

Modern Treatment Methods & Advancement in Technologies:
The following procedures will be covered (wherever medically indicated) either as inpatient care or as part of day care treatment in a hospital with a co-payment of 20%, up to 50% of Sum Insured, specified in the policy schedule, during the policy period:

Uterine Artery Embolization & HIFU (High intensity focused ultrasound)
Balloon Sinuplasty
Deep Brain stimulation
Oral Chemotherapy
Immunotherapy- Monoclonal Antibody to be given as injection
Intra Vitreal Injections
Robotic Surgeries
Stereotactic radio surgeries
Bronchial Thermoplasty
Vaporization of the Prostate (Green laser treatment or holmium laser treatment)
IONM Intra Operative Neuro Monitoring
Stem Cell Therapy: Hematopoietic stem cells for bone marrow transplant for hematological conditions to be covered.

OPTIONAL COVERS:
Out-patient Treatment Cover: (within the Base Sum Insured)
We will cover the Reasonable and Customary Charges incurred on an out-patient basis for medically required consultations, visit(s) to a doctor, diagnostic tests and pharmacy expenses as per standard medical protocol for any epidemic/ pandemic only up to Rs.5000.
The Benefit payable will be within the Base Sum Insured.
For the purpose of this Cover, Out-patient means an Insured Person who is not hospitalized but who visits a hospital, clinic or associated facility for diagnosis or treatment.
The relevant part of Exclusion 6.29 under the policy will stand deleted for this Option.
All claims under this Benefit can be made as per the process defined under Section 8 of the policy, as applicable.

Daily Cash Allowance on Hospitalization
We will pay Daily Cash Allowance of Rs. 500 per day subject to a maximum of Rs. 7500 per policy period to the Insured Person for every continuous and completed period of 24 hours of Hospitalization, subject to the hospitalization claim being admissible under the policy.
Daily Cash Allowance will not be payable for Day Care Procedure claims where the hospitalization is less than 24 hours. Deductible equivalent to Daily Cash Allowance for the first 24 hours Hospitalization will be levied on each Hospitalization during the Policy Period.
The payment under this benefit is over and above the Base Sum Insured.
All claims under this Benefit can be made as per the process defined under Section 8 of the policy, as applicable.

Benefit Cover for First Diagnosis of Any Epidemic/ Pandemic:
If an Insured Person is First Diagnosed with any Epidemic/ Pandemic during the Period of Cover, then We will pay Rs. 25000 as a lump sum amount, provided that the Illness/disease was first diagnosed after 14 days from the Risk Inception Date.
On the acceptance of a claim under this Benefit, the cover under this Benefit will terminate in relation to the Insured Person.
This Benefit shall be payable subject to the following:

The Insured must have tested positive for the Epidemic/ Pandemic by a Government authorized/ Government designated laboratory in India, appointed for testing of the Epidemic/ Pandemic.
The diagnosis must be confirmed by only those specific test(s) as defined by Government authorities or as per standard medical protocol.
The lab diagnosis must have been performed after the completion of the initial waiting period of 14 days.

No benefit will be payable if the Insured has been quarantined for any suspected epidemic/ pandemic OR diagnosed with any epidemic/ pandemic prior to the risk inception date or within the initial waiting period of 14 days.

The initial waiting period of 14 days will not apply for this Benefit Cover if the Optional Cover for Waiver of Initial Waiting Period of 30 days for any epidemic/ pandemic has been opted for.

The payment under this benefit is over and above the Base Sum Insured.

Waiver of Initial Waiting Period of 30 days for any epidemic/ pandemic:
On payment of additional Premium as mentioned in Schedule, it is hereby agreed and declared that Exclusion no. 5.2 shall not apply for claims arising out of the hospitalization due to any Epidemic/ Pandemic.

Waiver of Co-Payment clause for pre-existing co-morbidities in case of any epidemic/ pandemic:
On payment of additional Premium as mentioned in Schedule, it is hereby agreed and declared that co-payment condition no. 8.5 shall not apply for claims arising out of the hospitalization due to any Epidemic/ Pandemic.

Maternity Benefit Cover:
We will pay a lump sum benefit amount of Rs. 20000 to the female Insured Person above 18 years during the Policy Period for the delivery of a child in a Hospital (including but not limited to cesarean section, vacuum birthing, water birthing, hypnobirthing, midwife birthing).

This Benefit will be available subject to the following:
After a waiting period of 9 months from the Date of Inception of cover for the first time under this policy for the Female Insured Member;
Up to a maximum number of two deliveries;
Payment under this cover will be limited to per event and will be over and above the Base Sum Insured.

We will not be liable to make any payment in respect of the following:
Medical Expenses incurred in respect of the delivery/ termination of pregnancy.
Medical Expenses for ectopic pregnancy, which will be covered under Section 4.1 of the Base Cover Terms and Conditions.
Complications arising as a result of infertility Treatment (assisted conception).

The payment under this benefit is over and above the Base Sum Insured.

EXCLUSIONS
WHAT POLICY DOES NOT COVER:

WAITING PERIOD
The company shall not be liable to make any payment under the policy in connection with or in respect of the following expenses till the expiry of waiting period mentioned below:

Pre-Existing Diseases
Expenses related to the treatment of a pre-existing disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with us.

In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.

If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health Insurance) Regulations, then waiting period for the same would be reduced to the extent of prior coverage.

Coverage under the policy after the expiry of 48 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by us.

First Thirty Days Waiting Period
Expenses related to the treatment of any illness within 30 days from the first policy commencement date shall be excluded except claims arising due to an accident, provided the same are covered.

This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve months.

The within referred waiting period is made applicable to the enhanced sum insured in the event of granting higher sum insured subsequently.

Specific Waiting Period
Expenses related to the treatment of the following listed Conditions, surgeries/treatments shall be excluded until the expiry of 24/48 months of continuous coverage, as may be the case after the date of inception of the first policy with the Insurer. This exclusion shall not be applicable for claims arising due to an accident.

In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.

If any of the specified disease/procedure falls under the waiting period specified for pre-existing diseases, then the longer of the two waiting periods shall apply.

The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a specific exclusion.

If the Insured Person is continuously covered without any break as defined under the applicable norms on portability stipulated by IRDAI, then waiting period for the same would be reduced to the extent of prior coverage.

24 Months Waiting Period
Benign ENT disorders
Tonsillectomy
Adenoidectomy
Mastoidectomy
Tympanoplasty
Hysterectomy
All internal and external benign tumours, cysts, polyps of any kind, including benign breast lumps
Benign prostate hypertrophy
Cataract and age related eye ailments
Gastric/Duodenal Ulcer
Gout and Rheumatism
Hernia of all types
Hydrocele
Non Infective Arthritis
Piles, Fissure and Fistula in anus
Pilonidal sinus, Sinusitis and related disorders
Prolapse inter Vertebral Disc and Spinal Diseases unless arising from accident
Calculi in urinary system, Gall Bladder and Bile duct, excluding malignancy.
Varicose Veins and Varicose Ulcers
Internal Congenital Anomalies

48 Months Waiting Period
Treatment for joint replacement unless arising from accident
Age-related Osteoarthritis & Osteoporosis

EXCLUSIONS
The company shall not be liable to make any payment under the policy, in respect of any expenses incurred in connection with or in respect of:

Investigation & Evaluation
Expenses related to any admission primarily for diagnostics and evaluation purposes.

Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment.

Rest Cure, rehabilitation and respite care
Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:

Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing, dressing, moving around either by skilled nurses or assistant or non-skilled persons.

Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.

Obesity/Weight Control
Expenses related to the surgical treatment of obesity that does not fulfill all the below conditions:

Surgery to be conducted is upon the advice of the Doctor

The surgery/procedure conducted should be supported by clinical protocols

The member has to be 18 years of age or older and
Body Mass Index (BMI);
greater than or equal to 40 or
greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive methods of weight loss:

Obesity-related cardiomyopathy
Coronary heart disease
Severe Sleep Apnoea
Uncontrolled Type2 Diabetes

Change-of-Gender Treatments
Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.

Cosmetic or Plastic Surgery
Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident, Burn(s) or Cancer or as part of medically necessary treatment to remove a direct and immediate health risk to the Insured. For this to be considered a medical necessity, it must be certified by the attending Medical Practitioner.

Hazardous or Adventure sports
Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports, including but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.

Breach of law
Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with criminal intent.

Excluded Providers
Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website/notified to the policyholders are not admissible. However, in case of life threatening situations or following an accident, expenses up to the stage of stabilization are payable but not the complete claim.

Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof.

Treatments received in health hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing home attached to such establishments or where admission is arranged wholly or partly for domestic reasons.

Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals and organic substances unless prescribed by a medical practitioner as part of hospitalization claim or day care procedure.

Refractive Error
Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 diopters.

Unproven Treatments
Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are treatments, procedures or supplies that lack significant medical documentation to support their effectiveness.

Sterility and Infertility
Expenses related to sterility and infertility. This includes:
Any type of sterilization
Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
Gestational Surrogacy
Reversal of Sterilization

Maternity Expenses
Medical treatment expenses traceable to childbirth (including complicated deliveries and cesarean sections incurred during hospitalization) except ectopic pregnancy; Expenses towards miscarriage (unless due to an accident) and lawful medical termination of pregnancy during the policy period.

War (whether declared or not) and war like occurrence or invasion, acts of foreign enemies, hostilities, civil war, rebellion, revolutions, insurrections, mutiny, military or usurped power, seizure, capture, arrest, restraints and detainment of all kinds.

Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from or from any other cause or event contributing concurrently or in any other sequence to the loss, claim or expense. For the purpose of this exclusion:
Nuclear attack or weapons means the use of any nuclear weapon or device or waste or combustion of nuclear fuel or the emission, discharge, dispersal, release or escape of fissile/fusion material emitting a level of radioactivity capable of causing any Illness, incapacitating disablement or death.

Chemical attack or weapons means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing any Illness, incapacitating disablement or death.

Biological attack or weapons means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organisms and/or biologically produced toxins (including genetically modified organisms and chemically synthesized toxins) which are capable of causing any Illness, incapacitating disablement or death.

Any expenses incurred on Domiciliary Hospitalization

Treatment taken outside the geographical limits of India

a) Stem cell implantation/Surgery/therapy, harvesting, storage or any kind of Treatment using stem cells except as provided for in Clause 4.6.L above; b) Growth Hormone Therapy.

Congenital External Diseases, Defects or anomalies.

Circumcision unless necessary for Treatment of an Illness or Injury not excluded hereunder or due to an Accident.

Cost of routine medical examination and preventive health check-up.

a) Cost of hearing aids; including optometric therapy; b) cochlear implants unless necessitated by an Accident or required intra-operatively.

Intentional self-inflicted Injury, attempted suicide

Treatments other than Allopathy and Ayurvedic, Homeopathic & Unani branches of medicine.

Any expenses incurred on Outpatient treatment (OPD treatment)

Unless used intra-operatively, any expenses incurred on prosthesis, corrective devices; External and or durable Medical / Non-medical equipment of any kind used for diagnosis and/or treatment and/or monitoring and/or maintenance and/or support including instruments used in treatment of sleep apnoea syndrome; Infusion pump, Oxygen concentrator, Ambulatory devices, sub cutaneous insulin pump and also any medical equipment, which are subsequently used at home.

Change of treatment from one system of medicine to another system unless recommended by the consultant/ hospital under whom the treatment is taken.

Treatments including Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy, chondrocyte or osteocyte implantation, procedures using platelet rich plasma, Trans Cutaneous Electric Nerve Stimulation; Use of oral immunomodulatory/ supplemental drugs.

Artificial life maintenance including life support machine use, from the date of confirmation by the treating doctor that the patient is in a vegetative state