National Mediclaim Plus Policy (Individual Plan)

National Mediclaim Plus Policy (Individual Plan)

Policy Details:

This is a high sum insured policy which indemnifies for In-patient treatment expenses (minimum 24 hour hospitalization) and 140+ Day Care Procedures on Cashless/ Reimbursement basis during the policy period with many additional benefits as per plan opted. The expenses incurred should be reasonable, customary and medically necessary

Highlights

1. Sum Insured range Rs.2, 00, 000 to Rs.50, 00,000/-
a. Plan A 9 slabs, 2L to 10L in multiple of 1L
b. Plan B 3 slabs, 15L/ 20L/ 25L
c. Plan C 3 slabs, 30L/ 40L/ 50L
2. Premium is based on age, sum insured and optional covers opted.
3. Entry Age 18 to 65 years
4. Who can be covered Self, Spouse, Dependent or legally adopted children and Parents.
5. Lines of treatment covered Allopathy, Ayurveda and Homeopathy (Up to 100% of SI).
6. Room Rent/ICU charges, Medical practitioners, surgeon, anesthetist, consultants, specialist's fees and other charges as per limits mentioned in the policy.
7. Ambulance (including Air Ambulance) Charges and Organ Donor's expenses covered up to sub-limits mentioned.
8. Pre and Post Hospitalization up to 30 days and 60 days respectively for same disease/illness/injury for which Hospitalization occurred.
9. 12 Modern treatments like Robotic surgery, oral chemotherapies, immunotherapies and etc., are now covered in the policy.
10. Treatment for morbid obesity are now covered after specified waiting periods. (refer policy for complete details)
11. Correction of eyesight, i.e., refractive errors above -7.5 D are now covered after specified waiting periods.
12. Treatment related to participation as a non-professional in hazardous or adventure sports subject sublimit.
13. Mental illness, HIV/AIDS, Genetic disorders are now covered.
14. Cataract surgery as per limits in each plan.
15. Doctor's home visit and nursing care during post hospitalization payable as per limits in each plan.
16. Maternity and New Born Cover (From birth), Vaccination for children as per limits under the policy.
17. Hospital cash benefit & Medical Emergency Reunion as per limits in the policy.
18. Add on covers such as Critical Illness and Out-patient Treatment
19. Cashless Facility available at Network Hospitals Only
20. Pre Negotiated Package rates for specific surgeries/procedure in network hospitals
21. Life Long Renewability
22. Portability (migration) allowed from/to similar products as per IRDAI guidelines.

Covered

Why buy National Mediclaim Plus Policy:

1. High Sum Insured Policy available up to 50 Lakhs.
2. Annual Increase in SI by 5% for each claim free year up to a maximum of 50% of SI opted.
3. Health Check Up facility: Expenses of health check-up once at the end of a block of two (2) policy periods irrespective of claim reported, as per limits in the policy.
4. Discounts for Purchasing policy online, Family, Youth discount 10%
5. Air ambulance, Maternity, Medical emergency re-union, Hospital cash benefit, vaccinations for children
6. Optional covers like
a. Critical Illness Benefit amount per individual - INR 2,00,000/ 3,00,000/ 5,00,000/ 10,00,000/ 15,00,000/ 20,00,000/ 25,00,000 &
b. Outpatient Treatment Limit of cover per individual - INR 2,000/ 3,000/ 4,000/ 5,000/ 10,000.
7. Tax Rebate under Section 80D of Income Tax Act 1961 for the premium paid.

Pre Policy Check Up For Whom -

1. Proposers aged 40 (forty) years and above or
a. opting for SI INR 6,00,000 and above, irrespective of age of the individual
b. opting for Critical Illness optional cover, between the age of 18 (eighteen) years and 65 (sixty five) years

List of Tests/Reports:

1.Physical examination (report to be signed by the Doctor with minimum MD (Medicine) qualification)
2.HbA1c
3.Blood sugar (fasting/ post prandial), HbA1c in some policies
4.Lipid profile
5.Serum creatinine
6.Urine routine and microscopic examination
7.ECG
8.Eye check-up (including retinoscopy)
9.Any other test required by the company and considered necessary

Exclusions

1. Only claims arising out of accidents are payable for the first 30 days of Inception of the Policy
2. All pre-existing diseases included after first thirty six (36) months of Policy
3. 90 days, One, Two and Four Years waiting period for specific diseases.
4. Change-of-Gender Treatments, Cosmetic or Plastic Surgery, Excluded Providers
5. Vitamins, Tonics Drug/alcohol abuse, Self-Inflicted Injury
6. Non Prescription Drug, Home visit charges
7. Dental treatment (unless arising out of accident and requiring hospitalization) and Out Patient Department treatment (OPD treatment)

Claims Procedure

How to report a claim?
For Cashless Facility - available only for policies serviced by a Third Party Administrator (TPA)

1.Check if the hospital falls under the networked hospitals (Preferred provider network/other network Hospitals), as cashless is available only for empaneled network hospitals of the Company/TPA.
2.For planned hospitalization, intimation is to be sent to the TPA/Company in advance (72 hours prior) with details of Name and address of the hospital and condition requiring hospitalization.
3.In case of an emergency hospitalization, intimation is to be sent to the TPA/Company within 24 hours of admission.
4.On admission, a Pre-Authorization Request for cashless will be sent to the TPA by the hospital - duly signed by the insured and Hospital Authorities giving the details of admission, illness, proposed line of treatment and the estimated expenses. Pre and post hospitalization expenses can be claimed separately after treatment.
5.All documents in original are to be submitted within 15 days to TPA, after completion of Post Hospitalization treatment.

For Reimbursement Claims:

1.Written intimation/mail/fax about hospitalization is to be sent to TPA Company within 72 hours of hospitalization in the case of emergency hospitalization and 72 hours prior in case of planned admission.
2.Before leaving the hospital, Discharge Summary, investigation report and other relevant documents (Claim form - Part A & Part B) may be obtained from the hospital authorities. All the documents in original are to be submitted to TPA / Office within 15 days from date of discharge.
3.Pre and post hospitalization expenses can be claimed separately after treatment.
4.All documents in original to be submitted within 15 days after completion of Post Hospitalization treatment.

For Critical Illness Claims:

1.Notice of claim in writing to office within 15 days of diagnosis/procedure
2.Documents shall be submitted, along with the completed claim form, at the Policy issuing office within 30 days from the survival period
3.Medical practitioner's certificate confirming diagnosis of the Critical Illness or undergoing the procedure along with the date of diagnosis or undergoing procedure.
4.Original discharge summary, if any (Certified copy if original not available)
5.Pathological/ radiological/other diagnostic test reports confirming the diagnosis of the Critical Illness.
6.Any other document required by the Company in support of the claim
7.Survival Period (60 days, 90 days and 6 months for specific critical illnesses)

For Out-patient treatment:
1. Claim documents supporting all such outpatient treatments shall be submitted to the TPA/ company twice during the policy period, within 30 (thirty) days of completion of 6 month period.
2. The claim is to be supported with the following original documents
a. All bills, prescriptions from medical practitioner
b. Diagnostic test bills, copy of reports
c. Any other documents required by the company

What are the Documents required (originals)?

1.Duly filled Claim form issued by insurer (Part A & Part B)
2.Original bills, payment receipts, medical history of the patient recorded, discharge certificate/ summary from the hospital etc.
3.Original cash-memo from the hospital (s)/chemist (s) supported by proper prescription
4.Original payment receipt, investigation test reports etc. supported by the prescription from attending medical practitioner
5.Attending medical practitioner's certificate regarding diagnosis and bill receipts etc.
6.Surgeon's original certificate stating diagnosis and nature of operation performed along with bills/receipts etc.
7.Any other document required by company/TPA