Terms & Conditions of One Year Good Health Policy

Goodhealth Group Mediclaim Policy Clause

1. WHEREAS THE Proposer designated in the Policy Certificate forming part of the Schedule hereto, being a Card member or Account Holder or other customer of CITIBANK, has by a Proposal and declaration, in the mode specified in the Schedule, provided the information in such proposal which shall be the basis of this Contract and is deemed to be incorporated herein, has applied to THE NEW INDIA ASSURANCE COMPANY LTD. (hereinafter called the COMPANY) the Group Good Health Policy purchased by CITIBANK,, for the insurance hereinafter set forth in respect of self and/or Family Members and/or domestic employees named in the Certificate of Insurance forming part of the Schedule hereto (hereinafter called the INSURED PERSON) and has paid premium as consideration for such insurance.

1.1 NOW THIS POLICY WITNESSES that subject to the terms, conditions, exclusions and definitions contained herein or endorsed or otherwise expressed hereon, that if during the period stated in the Schedule or during the continuance of this policy by renewal any Insured Person shall contract any disease or suffer from any illness (hereinafter called ILLNESS) or sustain any bodily injury through ACCIDENT (hereinafter called INJURY) and if such

1.2 ILLNESS or INJURY shall, require any such Insured Person, upon the advice of a duly Registered and qualified Physician/Medical Specialist/Medical Practitioner (hereinafter called MEDICAL PRACTITIONER)) to incur MEDICALLY NECESSARY expenses for medical / surgical treatment at any HOSPITAL in India as herein defined (hereinafter called HOSPITAL) as an INPATIENT during such period, this policy provides for payment to the Insured Person / to the hospital through the THIRD PARTY ADMINISTRATOR, the amount of such incurred expenses as are REASONABLE & CUSTOMARY thereof, in respect of such Insured Person, but not exceeding, in any one period of insurance, the limits indicated under the Table of Benefits subject to the Exclusions / Limits set out herein.

Table of Benefits

Hospitalisation Expenses Limits per Claim
(i) ROOM RENT, Board & Nursing Expenses as provided by the hospital/nursing home. Up to 1% of Sum Insured per day
If admitted into INTENSIVE CARE UNIT Up to 2% of Sum Insured per day
All admissible claims under (i) and (ii) as capped during the policy period Up to 30% of Sum Insured per claim
(ii) Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees Up to 30% of Sum Insured per claim
(iii) Emergency Ambulance charges up to Rs.1000/- anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial Limbs and any medical expenses incurred which is integral part of the operation/treatment Up to 40% of Sum Insured per claim

Note:

  1. PACKAGE CHARGES:
    Hospitalisation expenses incurred for treatment of any one illness under agreed package charges will be restricted to 80% of the actual package charges or the sum insured whichever is less.
  2. ORGAN TRANSPLANT-DONOR’S CLAIM:
    Hospitalization expenses of a person donating an organ during the course of organ transplant will also be payable subject to the above sub limits applicable to the insured person within the overall sum insured of the insured person subject to the admissibility of the insured’s claim under the Policy Terms & Conditions.
  3. LIMIT PER CLAIM:
    The limit per claim would apply to the overall total claim amount including pre and post-hospitalization claims and shall be subject to clause 2.3 pertaining to ANY ONE ILLNESS.
  4. MAXIMUM LIABILITY:
    Company's liability in respect of all claims admitted during the period of Insurance shall not exceed the Sum Insured for the insured person as mentioned in the Policy Certificate, issued to the insured.
  5. NON- ALLOPATHIC / ALTERNATE TREATMENT:
    Insurers may provide coverage to non-allopathic treatments provided the treatment has been undergone in a government hospital or in any institute recognized by government and/or accredited by Quality Council of India / National Accreditation Board on Health.The claims which are otherwise admissible under this Policy for in-patient treatment taken in a Hospital / Nursing Home as defined above will be restricted to 20 % of the Sum Insured subject to maximum limit of Rs.25000/- per claim.
  6. LIMITS FOR SPECIFIED AILMENTS
    In respect of following specified ailments, Company’s liability in respect of each and every claim, as arrived at under the Table of Benefits given above and admitted during the period of insurance, subject to the policy terms, conditions and exclusions, shall not exceed the limits mentioned against the respective specified ailment OR the sum insured available for the insured person, whichever is less:
*Disease/Ailment/Treatment (Refer to 4.3 clause herein) Period for Which Claims not admissible Limits per claim(After the exclusion Period)
1. Total Knee / Hip replacement (due to arthritis, rheumatism and other degenerative disorders) 3 years 50% of the sum insured
2. Cataract 3 years 20% of the sum insured subject to a maximum of Rs.40,000/- per eye
3. Benign Prostatic Hypertrophy 2 years 20% of the sum insured
4. Hysterectomy (Due to fibroids or Menorrhagia) 2 years 20% of the sum insured
5.Hernia 2 years 20% of the sum insured
6. Hydrocele 2 years 20% of the sum insured
7. Congenital Internal Disease/Defect 2 years 20% of the sum insured
8. Fistula in Anus and Piles 2 years 20% of the sum insured
9. Sinusitis & Related Disorders 2 years 20% of the sum insured

*All pre-existing Diseases are excluded for the first four policy years subject to Clause No. 4.1

**In case of cataract and total knee or hip replacements, where two eyes or hips or knees are operated in a single procedure the limit per claim indicated as above will be reckoned at twice these limits.

***Cumulative Bonus allowed, if any, under the policy will also be considered for applying the "Limits" mentioned herein above.

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