Revised-Family-Medicare-Policy

KEY BENEFITS
The Policy provides cover on an Individual or Family Floater basis. A separate Sum Insured for each Insured Person is provided under Individual basis while under Family Floater basis, the Sum Insured limit is shared by the whole family of the Insured as specified in the Policy Schedule and Our total liability for the family cannot exceed the Sum Insured in a Policy period. The cover type basis shall be as specified in the Policy Schedule.

Basic Cover:
In-patient Hospitalization
Organ Donor Benefit- When Insured Person is the Donor
Day care Treatment
Road Ambulance Cover
Pre and post-hospitalization expenses
Cost of Health Check-up
Ayurvedic/Homeopathic/Unani treatment
Modern Treatment Methods & Advancement in Technologies
Organ Donor's expenses cover

Optional Cover on additional premium:
Restoration of Sum Insured
Daily Cash Allowance on Hospitalization
Maternity Expenses and New Born Baby Cover

SALIENT FEATURES

ELIGIBILITY:
Any person aged between 18 years and 65 years can take this insurance for himself and his/her family consisting of Self, Spouse and dependent children either on Individual Sum Insured basis or on floater basis. Beyond 65 years, only renewals are allowed.

Dependent children between the age of 91 days and 18 years shall be covered provided either or both parents are covered concurrently. Children above 18 years will continue to be covered along with parents till the age of 26 years, provided they are unmarried/unemployed and dependent. The upper age limit will not apply to mentally challenged children. In the event of children becoming independent, employed, getting married, or attaining age above 26 years, a separate policy can be taken on expiry of the current policy for which continuity benefits will be provided.

Midterm inclusion of family members is allowed at pro-rata premium only in case of:
Newly married spouse within 60 (sixty) days of marriage.
New born baby, between the ages of 91 days to 180 days, born to mother, insured under the policy.

SUM INSURED:
Various options are available as under:
Rs. 3 lacs, 4 lacs, 5 lacs, 6 lacs, 7 lacs, 8 lacs, 9 lacs, 10 lacs, 15 Lacs, 20 Lacs & 25 Lacs.

TERM OF POLICY:
One Year. Renewable annually.

COVERAGE

BASE COVERS
The Policy provides base coverage as described below in this section provided that the expenses are incurred on the written Medical Advice of a Medical Practitioner and are incurred on Medically Necessary Treatment of the Insured Person:

In-patient Hospitalization Expenses Cover
We will pay the Reasonable and Customary Charges for the following Medical Expenses of an Insured Person in case of Medically Necessary Treatment taken during Hospitalization provided that the admission date of the Hospitalization due to Illness or Injury is within the Policy period:

Room, Boarding and Nursing expenses (all inclusive) incurred as provided by the Hospital/Nursing Home upto the limits provided below:



These expenses will include nursing care, RMO charges, IV Fluids/Blood transfusion/injection administration charges and similar expenses.

Charges for accommodation in Intensive Care Unit (ICU)/ Intensive Cardiac Care Unit (ICCU) upto the limits provided below:



The fees charged by the Medical Practitioner, Surgeon, Specialists and anaesthetists treating the Insured Person.
Operation theatre charges.
Anaesthesia, Blood, Oxygen, Surgical Appliances and/ or Medical Appliances, medicines and drugs, Cost of Artificial Limbs, cost of prosthetic devices implanted during surgical procedure like pacemaker, orthopaedic implants, infra cardiac valve replacements, vascular stents, relevant laboratory/ diagnostic tests, X-Ray and such other similar medical expenses related to the treatment.

PROPORTIONATE PAYMENT CLAUSE: In case of admission to a room at rates exceeding the aforesaid limits in Clause V.1. 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.

No payment shall be made under 1 C other than as part of the hospitalization bill. However, the bills raised by Surgeon, Anesthetist directly and not forming part of the hospital bill shall be paid provided a pre-numbered bill/receipt is produced in support thereof, when such payment is made ONLY by cheque/ credit card/debit card or digital/online transfer.

Sub-limit:
Cataract Surgery Limit: Expenses in respect of the Cataract surgeries will be restricted to 10% of Sum Insured subject to maximum of Rs. 50,000/- per eye. This limit is applicable per hospitalisation / surgery.

Mental Illness Cover Limit: In case of following mental illnesses the actual In-patient Hospitalization expenses will be covered upto 25% of Sum Insured subject to a maximum of Rs. 3,00,000 per policy year;
Schizophrenia
Bipolar Affective Disorders
Depression
Obsessive Compulsive Disorders
Psychosis

Day Care Treatment Cover-
We will cover the Medical Expenses incurred on the Insured Person's Day Care Treatment during the Policy Period following an Illness or Injury that occurs during the Policy Period provided that the Medical Expenses are incurred in case of Day Care Treatment or Surgery undertaken for the Illness/ condition covered under Base Cover that requires less than 24 hours Hospitalization due to advancement in technology, including for any procedure which requires a period of specialized observation or care after completion of the procedure undertaken by an Insured Person as Day Care Treatment. All Day Care Treatments as defined in the policy are covered.

Procedures/treatments usually done on out-patient basis are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours or carried out in Day Care Centres. Diagnostic Services are also not covered under this benefit.

Pre-Hospitalization and Post-Hospitalization Expenses
We will cover, on a reimbursement basis, the Insured Person's Pre-hospitalization Medical Expenses incurred due to an Illness or Injury that occurs during the period up to 30 days prior to hospitalization and Post- hospitalization Medical Expenses incurred due to an Illness or Injury that occurs during the period upto 60 days after the discharge from the hospital, subject to a maximum of 10% of Sum Insured.

Ayurvedic/Homeopathic/Unani treatment
We will pay the reasonable & customary Charges incurred as in-patient for an Insured Person in case of Medically Necessary Treatment taken during Hospitalization subject to the limits linked to the Sum Insured, as mentioned in the policy and as also in table of benefits.

Donor Expenses Cover
We will cover the In-patient Hospitalization Medical Expenses incurred for an organ donor's treatment during the Policy Period for the harvesting of the organ donated up to the Sum Insured.

We will not cover:
Pre-hospitalization Medical Expenses or Post-hospitalization Medical Expenses of the organ donor;
Screening expenses of the organ donor;
Costs directly or indirectly associated with the acquisition of the donor's organ;
Transplant of any organ/tissue where the transplant is experimental or investigational;
Expenses related to organ transportation or preservation;
Any other medical treatment or complication in respect of the donor, consequent to harvesting.

Organ Donor Benefit- When Insured Person is the Donor
A lump sum payment of 10% of Sum Insured, to take care of medical and other incidental expenses is payable to the Insured Person donating an organ provided that the donation conforms to the Transplantation of Human Organs Act 1994 (amended) and any other extant Act, Central / State Rules / regulations, as applicable, in respect of transplantation of human organs.

This benefit is subject to the Policy (Family Medicare Policy) having been continuously in force for at least 12 (twelve) months in respect of that Insured Person.

Road Ambulance Cover

We will cover the costs incurred up to:
0.5% of the Sum Insured subject to a maximum of Rs. 2500 per event and

1% of the Sum Insured subject to a maximum of Rs. 5000 per policy period

on transportation of the Insured Person by road Ambulance to a Hospital for treatment in an Emergency following an Illness or Injury which occurs during the Policy Period. The necessity of use of an Ambulance must be certified by the treating Medical Practitioner and becomes payable if a claim has been admitted under Section VI.1 or VI.2 and the expenses are related to the same Illness or Injury.

Cost of Health Check-up
Expenses incurred towards cost of health check-up up to 1% of average Sum Insured of preceding 3 years subject to a maximum of Rs. 5000 per person for policies issued on individual sum insured basis / Rs. 10000 per policy period for policies issued on floater basis for a block of every three claim-free years provided the health check-up is done at network hospitals/diagnostic center authorized by us within a year from the date when it got due and the policy is in force. Payment under this benefit does not form part of the sum insured and will not impact the Bonus.

In case of the policy on floater basis, if a claim is made by any of the Insured Persons, the health check-up benefits will not be available under the policy.

Modern Treatment Methods & Advancement in Technologies:
In case of an admissible claims under Section V.1/ V.2 as applicable, expenses incurred on the following procedures (wherever medically indicated) either as in-patient or as part of day care treatment in a hospital, shall be covered. The claim shall be subject to additional sub-limits indicated against them in the table below:





OPTIONAL COVERS:

Restoration of Sum Insured
If the Basic Sum Insured is exhausted completely or partially due to claims made and paid/ accepted as payable during the Policy Year, then it is agreed that a Restore Sum Insured equal to 100% of the Basic Sum Insured will be automatically and instantly available for the particular Policy Year, provided that:

In case of policies on Individual Sum Insured basis the Restore Sum Insured, will be available to each Insured Person individually and in case of a floater policy, the restore Sum Insured will be available for all Insured Persons on floater basis.

A single claim in a Policy Year cannot exceed the Basic Sum Insured.

Such restored Sum Insured can be utilized only for illness / disease unrelated to the illness / diseases for which claim(s) was / were made.

The Restoration of Sum Insured will be applied only once during a Policy Year for family floater policy. For Policy on Individual Sum Insured basis, the restore facility will be available once to each Insured Person individually in a policy year.
If the Restore Sum Insured is not utilized in a Policy Year, it shall not be carried forward to any subsequent Policy Year.

Automatic Restoration of Basic Sum Insured is available only for Sum Insured options from Rs. 3,00,000 and above.

For persons with age of entry above 60 years in Family Medicare Policy, every admissible claim under this optional cover shall be subject to a Co-payment of 10% on the admissible claim amount

Maternity Expenses and New Born Baby Cover

Maternity Expenses: We shall pay the Medical Expenses incurred as an In-patient for a delivery (including cesarean section) or lawful medical termination of pregnancy during the Policy Period limited to two deliveries or terminations or either during the lifetime of the Insured Person. This benefit is applicable only when the Sum Insured is above Rs. 3 Lacs, and available only to the Insured or his spouse, provided that:
Family Medicare Policy with this optional cover has been continuously in force for a period of minimum 24 months

Those Insured Persons who are already having two or more living children will not be eligible for this benefit

Company's maximum liability per delivery or termination shall be limited to 10% of the Sum Insured as stated in the Schedule subject to a maximum of Rs. 40000 in case of normal delivery and Rs. 60000 in case of cesarean section and in no case shall the Company's liability under this clause exceed 10% of the Sum Insured, in any one Policy Period.

New Born Baby Cover: New born Baby shall be covered from day one up to the age of 90 days and expenses incurred for treatment taken in Hospital as in-patient shall only be payable, provided that: Claim under Maternity clause is admissible under the Policy. Company's liability shall be limited to 10% of the Sum Insured as stated in the Schedule.

In case the 90 days period for the New Born Baby is spread over two Policy Periods, the aggregate liability of the Company, for all claims in respect of the New Born Baby, shall be limited to 10% of the Sum Insured of the Policy under which Maternity claim was admitted.

Special conditions applicable to Maternity Expenses and New Born Baby Cover
These benefits are admissible only if the expenses are incurred in Hospital/Nursing Home as in-patients in India.

Surrogate or vicarious pregnancy is not covered.

Expenses incurred in connection with voluntary medical termination of pregnancy during the first twelve weeks from the date of conception are not covered.

Pre-natal and post-natal expenses are not covered unless admitted in Hospital/Nursing Home and treatment is taken there.

Pre Hospitalization and Post Hospitalization benefits are not available under these two clauses.

Subject to the terms & conditions, the Policy covers New Born Baby beyond 90 days only on payment of requisite premium.

If this Option is in force in respect of the Insured Person, then the relevant part of Exclusion VII.B.7 will be deemed inoperative for the purpose of this Option.

Daily Cash Allowance on Hospitalization
We will pay Daily Cash Allowance 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,

The aggregate of Daily Cash Allowance during the policy period shall not exceed per policy period limits as mentioned in the table above.

Daily Cash Allowance will not be payable for Day Care Procedure claims where the hospitalization is less than 24 hours. Deductible equivalent to the first 24 hours Hospitalization benefit will be levied on each and every Hospitalization during the Policy Period.

EXCLUSIONS

A. WAITING PERIOD - EXCLUSIONS
The Company shall not be liable to make any payment under the policy in connection with or in respect of 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.

Specific Disease/ Procedure Waiting Period
Expenses related to the treatment of the listed Conditions, surgeries/treatments as per Table A and Table B below, shall be excluded until the expiry of 24 months and 48 months respectively of continuous coverage after the date of inception of the first policy with us. 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.

List of specific diseases/procedures:

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.

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.

The exclusions under VII.A.1-3 are subject to portability regulations.

PERMANENT 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:

All expenses caused by or arising from or attributable to foreign invasion, act of foreign enemies, hostilities, warlike operations (whether war be declared or not or while performing duties in the armed forces of any country), civil war, public defence, rebellion, revolution, insurrection, military or usurped power.

All Illness/expenses caused by ionizing radiation or contamination by radioactivity from any nuclear fuel (explosive or hazardous form) or from any nuclear waste from the combustion of nuclear fuel nuclear, chemical or biological attack.

a) Stem cell implantation/Surgery/therapy, harvesting, storage or any kind of Treatment using stem cells except as provided for in Clause VI.10.L above; b) growth hormone therapy.
Congenital External Diseases, Defects or anomalies.

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

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

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 unless as provided for in Base Cover VI.8 above

Investigation & Evaluation
Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded even if the same requires confinement at a Hospital.
Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.

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.

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. For this to be considered a medical necessity, it must be certified by the attending Medical Practitioner.
Vaccination or inoculation of any kind unless it is post animal bite,
Routine eye examinations, cost of spectacles, contact lenses;

Refractive Error - Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres.
a) Cost of hearing aids; including optometric therapy;
b) cochlear implants unless necessitated by an Accident or required intra-operatively.

Dental treatment or surgery of any kind unless necessitated by accident and requiring hospitalization.

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

Any treatment related to sleep disorder or sleep apnoea syndrome
Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof.
Intentional self-inflicted Injury, attempted suicide.

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.

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.

Treatments other than Allopathy and Ayurvedic, Homeopathic & Unani branches of medicine.
Any expenses incurred on Domiciliary Hospitalization
Any expenses incurred on Out-patient treatment (OPD treatment)

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.

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.

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. This is indicative and please refer to Annexure-1 of the Policy for the complete list of non-payable items.

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

Treatments such as 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.