National Mediclaim Policy (Individual Plan)

National Mediclaim Policy (Individual Plan)

Policy Details:

This policy indemnifies for In-patient treatment expenses (minimum 24 hour hospitalization) and 140+ Day Care Procedures on Cashless/ Reimbursement basis during the policy period. The expenses incurred should be reasonable, customary and medically necessary.

Highlights:

1. Sum Insured range Rs.1,00,000/- to Rs.10, 00,000/-
2. Entry Age 18 to 65 years
3. Who can be covered - Self, Spouse, Dependent natural or legally adopted children, Parents, Parent-in-laws, Brother up to 25 years, if a bona-fide student and not employed, Sister if not employed, till marriage, new born from 3 months age.
4. Lines of treatment covered - Allopathy, Ayurveda and Homeopathy (Up to 100% of SI)
5. Room Rent/ICU charges, Medical practitioners, surgeon, anesthetist, consultants, specialists fees and other charges as per limits mentioned in the policy.
6. Ambulance Charges and Organ Donor's expenses covered up to sublimit mentioned.
7. Pre and Post Hospitalization up to 45 days and 60 days respectively for same disease/illness/injury for which Hospitalization occurred.
8. 12 Modern treatments like Robotic surgery, oral chemotherapies, immunotherapies and etc., are now covered in the policy.
9. Treatment for morbid obesity are now covered after specified waiting periods. (refer policy for complete details)
10. Correction of eyesight, i.e., refractive errors above -7.5 D are now covered after specified waiting periods.
11. Treatment related to participation as a non-professional in hazardous or adventure sports subject sublimits.
12. Mental illness, HIV/AIDS, Genetic disorders are now covered.
13. Cashless Facility available at Network Hospitals Only through TPA.
14. Pre Negotiated Package rates for specific surgeries/procedure in network hospitals.
15. Life Long Renewability.
16. Portability (migration) allowed from/to similar products as per IRDAI guidelines.

Covered

Why buy NMP:
1. Annual Increase in SI by 5% for each claim free year up to maximum 50% of SI opted.

2. Health Check Up Facility: Expenses of health check-up once at the end of a block of four claim free policy periods @ maximum of 1% of the average sum insured.

3. Online Discounts: 10%

4. Tax Rebate under Section 80D of Income Tax Act 1961 for premium paid.

Pre Policy Check Up For Whom Proposers aged 50 years and above (including dependents) and availing the policy for the first time. List of Tests/Reports:

1.Physical examination (report to be signed by the Doctor with minimum MD (Medicine) qualification)
2.Blood sugar (fasting/ post prandial), HbA1c (for Policies beyond 6 Lakhs)
3.Lipid profile
4.Serum creatinine
5.Urine routine and microscopic examination
6.ECG
7.Eye check-up (including retinoscopy)
8.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 forty eight months (48) 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 Hospitalizations treatment.

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