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Premier Mediclaim Policy

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We welcome You as Our Customer. This document explains how the NEW INDIA PREMIER POLICY could provide value to You. In the document the word ‘You’, ‘Your’ means all the members covered under the Policy. ‘We’, ‘Our’, ‘Us’ means The New India Assurance Co. Ltd.

New India Premier is a Policy designed to cover Hospitalisation expenses of the Persons You wish to cover under this Policy.

WHO CAN TAKE THIS POLICY?

All the persons proposed for this Insurance should be between the age of 18 years and 65 years. Children between the age of 3 months and 18 years are covered provided one or both parents are covered concurrently. Children between 18 years to 25 years can be covered provided they are financially dependent on the parents and one or both parents are covered simultaneously. On attaining the age of 18 years or ceasing to be financially dependent on the parents, they can, on renewal take a separate Policy. In such an event the benefits on Continuous Coverage can be ported to the new Policy. The upper age limit will not apply to a mentally challenged children and an unmarried dependent daughter(s). The persons beyond 65 years can continue their Insurance provided they are Insured under the Policy with us without any break.

Midterm inclusion is allowed for newly married spouse by charging pro-rata Premium for the remaining period of the Policy. A New Born Baby, born to an Insured mother, will be covered from date of birth till the expiry of the Policy, without any additional Premium. No coverage for the New Born Baby would be available during subsequent Renewals unless the child is declared for Insurance and covered as an Insured Person.

CAN I COVER MY FAMILY MEMBERS IN ONE POLICY?

Yes. You and Your entire family can be covered under this Policy. The members of the family who could be covered under the Policy are:

  1. Proposer
  2. Spouse
  3. Dependent Children
  4. Dependent Parents.
Minimum one and maximum six members can be covered in this Policy.

WHAT DOES THE POLICY COVER?

This Policy is designed to give You and Your family, protection against unforeseen Hospitalisation expenses.

WHAT ARE THE PLANS OFFERED IN THIS POLICY?

This Policy has two plans viz:

  1. Plan A: offers Sum Insured of Rs. 15,00,000 and 25,00,000.
  2. Plan B: offers Sum Insured of Rs. 50,00,000 and 100,00,000.
The Sum Insured chosen by You and accepted by Us represents Our maximum liability towards all payments admissible under the Policy in respect of all Insured Persons. Only payment under Critical Care Benefit will not reduce the Sum Insured. All other payments in respect of any admissible claim in respect of any Insured Person shall reduce the Sum Insured.
Please select for the right amount of Sum Insured based upon Your current and future needs. Sum Insured once chosen cannot be increased at the time of Renewal, nor is change from Plan A to Plan B permissible.

IS PRE-ACCEPTANCE MEDICAL CHECK-UP REQUIRED?

Pre-acceptance medical check-up is required for all the members entering after the age of 50 years. A person also needs to undergo this pre-acceptance medical check-up if he has an adverse medical history or if the health condition of the person/s to be Insured is such that the office in-charge feels that he / she be subjected to a medical examination. The cost of this check-up will be borne by the proposer. But if the proposal is accepted, then 100% of the cost of this check-up will be reimbursed to the proposer.

Pre-acceptance medical check-up shall be conducted at designated centers authorized by Us.
Note: Adverse Medical History means a person:

  1. who has undergone more than one Hospitalisation in previous two years,
  2. who is suffering from Critical Illness, Recurring Illness or Chronic Illness.
  3. who has BMI greater than or equal to 32.
  4. who has any Psychiatric and Psychosomatic Disorder.

WHAT ARE THE EXPENSES COVERED UNDER THIS POLCY?

Policy covers following Hospitalisation Expenses:

  1. Room Rent, including boarding and nursing expenses, actually incurred.
  2. Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) expenses, actually incurred.
  3. Surgeon, Anesthetist, Medical Practitioner, Consultants’ Specialist fees.
  4. Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, Cost of Prosthetic devices implanted during surgical procedure like pacemaker, Relevant Laboratory/Diagnostic test, X-Ray and other medical expenses related to the treatment.
  5. All Hospitalisation Expenses (excluding cost of organ, if any) incurred for donor in respect of Organ transplant.
Note: Procedures/treatments usually done in OPD 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 (except specifically mentioned under OPD treatments clause).

WHAT IS HOSPITAL CASH BENEFIT?

This Policy provides for payment of Hospital Cash at the rate of Rs. 2,000 per day for Plan A and Rs. 4,000 per day for Plan B for Any One Illness. This benefit will be given in case of admissible claim only. The benefit is applicable only where Hospitalisation exceeds twenty four consecutive hours.
The total payment for Any One Illness shall be made for maximum 10 days of Hospitalisation. Payment under this clause will reduce the Sum Insured. Hospital Cash will be payable for completion of every 24 hours and not part thereof.

WHAT IS CRITICAL CARE BENEFIT?

If during the Period of Insurance any Insured Person is diagnosed for the first time to be suffering from any Critical Illness as listed below, we will pay Rs. 2,00,000 for Plan A and Rs. 5,00,000 for Plan B as additional benefit i.e. other than the admissible claim amount:

  1. Cancer
  2. First Heart attack of specified severity
  3. Open chest CABG
  4. Open Heart replacement or repair of Heart valves
  5. Coma of specified severity
  6. Kidney failure requiring regular dialysis
  7. Stroke resulting in permanent symptoms
  8. Major organ / bone marrow transplant
  9. Permanent paralysis of limbs
  10. Motor neurone disease with permanent symptoms
  11. Multiple sclerosis with persisting symptoms
Any payment under this clause would be in addition to the Sum Insured and shall not deplete the Sum Insured. This benefit will be paid once in lifetime of any Insured Person. This benefit is not applicable for those Insured Persons for whom it is a Pre-existing Disease.

IN CASE OF AYURVEDIC TREATMENT, WILL THE ENTIRE AMOUNT BE PAID?

The liability of the company in case of Ayurvedic/Homoeopathic/ Unani treatment will be up to 20 % of Sum Insured provided the treatment is taken in a government Hospital or in any institute recognized by government or accredited by Quality Council Of India or National Accreditation Board on Health, excluding centers for spas, massage and health rejuvenation procedures.

WHAT ARE THE AMBULANCE CHARGES PAID UNDER THIS POLICY?

We will pay You the charges incurred towards Ambulance services including Air Ambulance for shifting any Insured Person to Hospital for admission or from one Hospital to another Hospital for better medical facilities maximum up to Rs. 1,00,000 for Any One Illness.
If an Insured Person after the discharge from the Hospital has to be shifted from Hospital to their place of residence in an Ambulance and is not able to travel otherwise, such expenses will also be reimbursed additionally up to Rs. 10,000 for Any One Illness, provided the requirement of an Ambulance is certified by the Medical Practitioner.

DOES THIS POLICY COVER ANY OPD TREATMENTS??

Yes. After every block of two continuous Claim Free Years, all the members covered in this Policy are entitled for OPD coverage of Rs. 5,000 for Plan A and Rs. 10,000 for Plan B cumulatively. The cover can be availed for:

  1. Dental Treatment.
  2. Health Check-up.
  3. Consultation with a Medical Practitioner.
  4. Drugs and Medicines as prescribed by a Medical Practitioner.
  5. Investigations as prescribed by a Medical Practitioner.
The amount will not be carried forward to the next year.
A claim under OPD Treatment clause will also be treated as a claim for determining Claim Free Year.

WHAT IS MATERNITY AND CHILD CARE COVER?

Maternity shall be covered provided the Insured mother has Continuous Coverage of thirty six months in New India Premier Mediclaim Policy. Our liability for expenses incurred towards Maternity, shall be restricted to Rs. 50,000 for Plan A and Rs. 1,00,000 for Plan B.
Special conditions applicable to Maternity and Child Care Benefit:

  1. These benefits are admissible only if the expenses are incurred for the Insured Person in a Hospital as in patient.
  2. Claim under this clause shall not be admissible if, in respect of any Insured Person, two claims for Maternity Expenses have been paid by Us in the preceding / existing New India Premier Mediclaim policies.
    For instance: An Insured person has availed Maternity benefit in 2017, and again in 2018, any subsequent claim for Maternity Benefit will not be available to her.

WHAT IS NEW INDIA BABY COVER?

A New Born Baby is covered for any Illness or Injury from the date of birth till the expiry of this Policy, within the terms of this Policy and Plan opted without additional premium. Congenital External Anomaly of the New Born Baby is not covered under the Policy.
Any expenses incurred towards pre-term or pre-mature care or expenses incurred in connection with delivery of such New Born Baby are not covered under this clause.
No coverage for the New Born Baby would be available during subsequent renewals unless the child is declared for Insurance and covered as an Insured Person.

IS TREATMENT FOR INFERTILITY COVERED IN THIS POLICY?

Yes. We will cover expenses necessarily incurred for treatment of Infertility, including outpatient treatment, subject to a limit of Rs. 1,00,000 for Plan A and Rs. 2,00,000 for Plan B. This limit shall be our maximum liability in respect of all Insured persons. If any claim is payable to any Insured Person under this clause in any particular Policy period, the benefit under this clause shall not be available for any subsequent renewals.
Any payment under this clause shall be paid after the Insured Person has Continuous Coverage of thirty six months under New India Premier Mediclaim Policy.

IS HIV/AIDS COVERED IN THIS POLICY?

Yes. This Policy covers treatment for Sexually Transmitted Diseases, any condition directly or indirectly caused to or associated with Human T-Cell Lymphotropic Virus Type III (HTLB - III) or lymphadenopathy Associated Virus (LAV) or the Mutants Derivative or Variation Deficiency Syndrome or any syndrome or condition of a similar kind commonly referred to as AIDS. Any payment under this Clause shall only be made when the Insured Person was not afflicted with any of these conditions at the time of the proposal, and only when such condition is contracted subsequent to this Insurance, regardless of whether the Insured Person was aware or not of the same. The limit for the above cover will be up to :
Plan A: Rs. 2,00,000 and
Plan B: Rs. 5,00,000
The Insured needs to be admitted as in-patient for more than 24 hours.
Consultation for the above mentioned conditions is available on OPD basis for Rs. 20,000 for Plan A and Rs. 50,000 for Plan B. The OPD limit will be part of the overall limit mentioned above.
Any payment under this clause shall be paid after the Insured Person has Continuous Coverage of thirty six months under New India Premier Mediclaim Policy.

WHAT IS THE MAXIMUM CHARGES PAID FOR TREATMENT OF CATARACT?

Expenses incurred towards cataract shall be paid as per the following limits:
Plan A: Actual charges up to a maximum of Rs. 75,000.
Plan B: Actual charges up to a maximum of Rs. 1,00,000.

ARE PSYCHIATRIC AND PSYCHOSOMATIC DISORDERS COEVRED?

All the Psychiatric and Psychosomatic disorders diagnosed after inception of this Policy will be covered up to 5% of Sum Insured. The Insured needs to be admitted as Inpatient. This treatment will not be covered as a Day-care procedure.

WHICH OBESITY TREATMENTS ARE COVERED IN THIS POLICY?

This cover will be available only for Plan B.
Treatment related to or for obesity is covered where BMI>35 and with co-morbidities mentioned below, up to Rs. 5,00,000

  1. Respiratory: Obstructive sleep apnea, Pickwickian syndrome (obesity hypoventilation syndrome)
  2. Cardiovascular: Coronary artery disease, left ventricular hypertrophy, coronary pulmonale, obesity-associated cardiomyopathy, accelerated atherosclerosis, and pulmonary hypertension of obesity
Any payment under this clause shall be paid after the Insured has:
  1. Continuous Coverage of thirty six months in New India Premier Mediclaim Policy.
  2. Such a treatment is payable only after prior clearance of Medical Practitioner authorized by the Company or TPA mentioned in the Schedule.

SECOND OPINION FOR MAJOR SURGERIES:

In case any Insured Person requires to undergo a Surgery as advised by a Medical Practitioner, then the expenses incurred towards consultation with another Medical Practitioner to seek advice on the surgery shall be payable up to Rs.5,000 for Plan A and up to Rs. 8,000 for Plan B. Cashless facility for availing such second opinion will be provided by the TPA with enlisted Network Providers.

DIETICIAN COUNSELING:

This benefit is applicable only for Plan B.
Dietician counseling can be availed by any Insured Person. The cost of such dietician counseling in respect of all Insured Persons in a policy shall be restricted to a maximum of Rs. 5,000 subject to actuals.

CONCIERGE SERVICE

The services provided will be:

  1. Facilitation of cashless arrangement by the representative of TPA.
  2. Facilitation at the time of discharge by the representative of TPA.
  3. Pick and drop service for all the claim documents, including Pre and Post Hospitalisation bills, by the representative of TPA.
In case of omission by the TPA to arrange to provide this service, Our liability for such omission will be limited to Rs. 5,000 per Hospitalisation.
Conditions:The benefits under this clause shall be applicable only where the Insured Person provides advance notice to TPA as mentioned in the Schedule at least seventy two hours prior to date of Hospitalisation.

DOES IT COVER ALL CASES OF HOSPITALISATION?

No. This Policy does NOT cover ALL cases of Hospitalisation.
The exclusions under the policies are:

  1. Treatment of any Pre-existing Condition/Disease, until thirty six months of Continuous Coverage of such Insured Person have elapsed, from the date of inception of his/her first Policy with Us as mentioned in the Schedule.
  2. Any Illness contracted by the Insured Person during the first 30 days of the commencement date of this Policy. This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve months.
  3. 3.1 Unless the Insured Person has Continuous Coverage in excess of twenty four months, expenses on treatment of the following Illnesses are not payable:
    1. All internal and external benign tumours, cysts, polyps of any kind, including benign breast lumps
    2. Benign ear, nose, throat disorders
    3. Benign prostate hypertrophy
    4. Cardiovascular and Circulatory Disorders
    5. Cataract and age related eye ailments
    6. Diabetes Mellitus
    7. Gastric/ Duodenal Ulcer
    8. Gout and Rheumatism
    9. Hernia of all types
    10. Hydrocele
    11. Hypertension
    12. Non Infective Arthritis
    13. Piles, Fissures and Fistula in anus
    14. Pilonidal sinus, Sinusitis and related disorders
    15. Prolapse inter Vertebral Disc and Spinal Diseases unless arising from accident
    16. Renal Disorders
    17. Skin Disorders
    18. Stone in Gall Bladder and Bile duct, excluding malignancy
    19. Stones in Urinary system
    20. Treatment for Menorrhagia/Fibromyoma, Myoma and Prolapsed uterus
    21. Varicose Veins and Varicose Ulcers
    Note: Even after twenty four months of Continuous Coverage, the above Illnesses will not be covered if they arise from a Pre-existing Condition, until 36 months of Continuous Coverage have elapsed since inception of the first Policy with the Company.

    3.2 Unless the Insured Person has Continuous Coverage in excess of thirty six months with Us, the expenses related to treatment of
    1. Joint Replacement due to Degenerative Condition, and
    2. Age-related Osteoarthritis & Osteoporosis are not payable.
    • Injury / Illness directly or indirectly caused by or arising from or attributable to War, invasion, Act of Foreign enemy, War like operations (whether war be declared or not), nuclear weapon/ ionising radiation, contamination by Radioactive material, nuclear fuel or nuclear waste or from the combustion of nuclear fuel.
      1. Circumcision unless necessary for treatment of an Illness not excluded hereunder or as may be necessitated due to an Accident.
      2. Change of life or cosmetic or aesthetic treatment of any description such as correction of eyesight, etc.
      3. Plastic Surgery other than as may be necessitated due to an Accident or as a part of any Illness.
    • Vaccination and/or inoculation.
    • Cost of braces, equipment or external prosthetic devices, non-durable implants, eyeglasses, Cost of spectacles and contact lenses, hearing aids including cochlear implants, durable medical equipment.
    • Dental treatment or Surgery of any kind unless necessitated by Accident and requiring Hospitalisation, except to the extent provided under Clause 3.1.10.
      • Congenital Internal and External Disease or Defects or anomalies (except to the extent provided under Clause 3.1.5),
      • infertility (except to the extent provided under 3.1.8),
      • Sexually Transmitted Diseases, and any condition directly or indirectly caused to or associated with Human T-Cell Lymphotropic Virus Type III (HTLB - III) or lymphadenopathy Associated Virus (LAV) or the Mutants Derivative or Variation Deficiency Syndrome or any syndrome or condition of a similar kind commonly referred to as AIDS (except to the extent provided under Clause 3.1.11).
      • Treatment relating to any Bodily Injury or Illness sustained whilst or as a result of active participation in any hazardous sports of any kind (except to the extent provided under Clause 3.1.14).
      • Treatment relating to or arising out of all Psychiatric and Psychosomatic disorders (except to the extent provided under Clause 3.2.1).
      • obesity treatment and its complications (except to the extent provided under 3.2.2),
    • Convalescence, general debility, 'Run-down' condition or rest cure, Venereal disease, intentional self-Injury and Illness or Injury caused by the use of intoxicating drugs/alcohol.
    • Bodily Injury due to willful or deliberate exposure to danger (except in an attempt to save human life), intentional self-inflicted Injury, attempted suicide, arising out of non-adherence to medical advice.
    • Treatment of any Injury or Illness sustained whilst or as a result of participating in any criminal act.
    • Charges incurred at Hospital primarily for diagnosis, x-ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any Illness or Injury for which confinement is required at a Hospital. This exclusion shall not apply for any payment under Clause 3.1.10.
    • Expenses on vitamins and tonics unless forming part of treatment for Injury or Illness as certified by the attending physician.
    • Treatment arising from or traceable to pregnancy, childbirth, miscarriage, abortion or complications of any of these including caesarean section, except abdominal operation for extra uterine pregnancy (Ectopic Pregnancy), which is proved by submission of Ultra Sonographic Report and Certification by Gynaecologist that it is life threatening one if left untreated. This exclusion shall not apply for any payment under Clause 3.1.6.
    • Naturopathy Treatment.
    • External and or durable Medical / Non-medical equipment of any kind used for diagnosis and or treatment including CPAP (Continuous Positive Airway Pressure), Sleep Apnea Syndrome (except to the extent provided under Clause 3.2.2) , CPAD (Continuous Peritoneal Ambulatory Dialysis), Oxygen Concentrator for Bronchial Asthmatic condition, Infusion pump etc. Ambulatory devices i.e., walker, crutches, Belts, Collars, Caps, Splints, Slings, Stockings, Elasto crepe bandages, external orthopaedic pads, sub cutaneous insulin pump, Diabetic foot wear, Glucometer / Thermometer, alpha / water bed and similar related items etc., and also any medical equipment, which is subsequently used at home and outlives the use and life of the Insured Person.
    • Genetic disorders and stem cell implantation / Surgery.
    • Domiciliary Hospitalisation.
    • Acupressure, acupuncture, magnetic therapies.
    • Unproven / Experimental Treatment.
    • Any expenses relating to cost of items detailed in Annexure II.
    • Treatment for Age Related Macular Degeneration (ARMD) , treatments such as Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy.

WHAT IS A PRE EXISTING DISEASE?

The term Pre-existing condition/disease is defined in the Policy. It is defined as:
"Any condition, ailment or Injury or related condition(s) for which the Insured Person had:

  1. Signs or symptoms, or
  2. Been diagnosed or received Medical Advice, or
  3. Been treated for any condition or disease,
Within thirty six months prior to the commencement of the first Policy.” Such a condition or disease shall be considered as Pre-existing. Any Hospitalisation arising out of such Pre-existing Disease or condition is not covered under the Policy until the Insured has thirty six months of Continuous Coverage in this Policy.

WHAT IS CONTINUOUS COVERAGE?

When a person is continuously Insured under a New India Premier Mediclaim Policy he is entitled to the benefit of Continuous Coverage. For instance if a person has Continuous Coverage of more than thirty six months, the exclusions relating to treatment of any Pre-existing Condition / Disease will not apply. However, the benefit of Continuous Coverage getting carried over for other Policies will not be available for following Coverage:

  1. OPD Treatments
  2. Maternity and Child Care
  3. Treatment for Infertility
  4. HIV/AIDS
  5. Obesity Treatments

CAN CONTINUOUS COVERAGE FROM OTHER POLICIES BE CARRIED OVER TO NEW INDIA PREMIER MEDICLAIM POLICY?

Continuous Coverage from the following New India Policies can be carried over to the extent of coverage under such previous policies:

  1. Mediclaim 2012
  2. Mediclaim 2007
  3. New India Floater Medicliam Policy
  4. New India Asha Kiran Policy.
You can also carry over the Continuous Coverage, to the extent of cover, from your existing Policy with any other Insurer to New India Premier Mediclaim, subject to IRDA (Protection of Policyholders’ Interest) Regulations, 2002 and guidelines of IRDAI on Portability of Health Insurance Policies, as amended from time to time. In case of change in Sum Insured during such uninterrupted coverage, the lowest Sum Insured would be reckoned for determining Continuous Coverage.
For instance: A person was covered for four years under Mediclaim 2012 for a Sum Insured of Rs. Five lakhs, and carries over this Continuous Coverage to New India Premier Mediclaim in 2017. If there is a claim for a Pre-existing Condition in 2017 for an amount of Rs. Eight lakhs, the claim will be admitted only to the extent of Rs. five lakhs since this is the amount available under Continuous Coverage for more than three years.

IS HOSPITALISATION ALWAYS NECESSARY TO GET A CLAIM?

Yes. Unless the Insured Person is Hospitalised for a condition warranting Hospitalisation, no claim is payable under the Policy.
This shall not be applicable to the treatments taken under OPD cover available under clause 3.1.10.

HOW LONG DOES THE INSURED PERSON NEED TO BE HOSPITALISED FOR MEDICLAIM PURPOSES?

The Policy pays only where the Hospitalisation is for more than twenty four hours. But for certain Day Care Treatments as specified in the Policy, period of stay at the Hospital could be less than twenty four hours. The Day Care Treatments are according to the table given in Point No. 28 below. This shall not be applicable to the treatments taken under Our OPD cover under clause 3.1.10.

WHAT ARE THE DAY CARE TREATMENTS COVERED UNDER THIS POLICY?

Following are the day-care treatments covered under this Policy (treatments done within 24 hours).

1

Stapedotomy

2

Excision And Destruction Of A Lingual Tonsil

3

Stapedectomy

4

Other Operations On The Tonsils And Adenoids

5

Revision Of A Stapedectomy

6

Incision On Bone, Septic And Aseptic

7

Other Operations On The Auditory Ossicles

8

Closed Reduction On Fracture, Luxation Or Epiphyseolysis With Osteosynthesis

9

Myringoplasty (Type -I Tympanoplasty)

10

Suture And Other Operations On Tendons And Tendon Sheath

11

Tympanoplasty (Closure Of An Eardrum Perforation/Reconstruction Of The Auditory Ossicles)

12

Reduction Of Dislocation Under Ga

13

Revision Of A Tympanoplasty

14

Arthroscopic Knee Aspiration

15

Other Microsurgical Operations On The Middle Ear

16

Incision Of The Breast

17

Myringotomy

18

Operations On The Nipple

19

Removal Of A Tympanic Drain

20

Incision And Excision Of Tissue In The Perianal Region

21

Incision Of The Mastoid Process And Middle Ear

22

Surgical Treatment Of Anal Fistulas

23

Mastoidectomy

24

Surgical Treatment Of Haemorrhoids

25

Reconstruction Of The Middle Ear

26

Division Of The Anal Sphincter (Sphincterotomy)

27

Other Excisions Of The Middle And Inner Ear

28

Other Operations On The Anus

29

Fenestration Of The Inner Ear

30

Ultrasound Guided Aspirations

31

Revision Of A Fenestration Of The Inner Ear

32

Sclerotherapy Etc

33

Incision (Opening) And Destruction (Elimination) Of The Inner Ear

34

Incision Of The Ovary

35

Other Operations On The Middle And Inner Ear

36

Insufflation Of The Fallopian Tubes

37

Excision And Destruction Of Diseased Tissue Of The Nose

38

Other Operations On The Fallopian Tube

39

Operations On The Turbinates (Nasal Concha)

40

Dilatation Of The Cervical Canal

41

Other Operations On The Nose

42

Conisation Of The Uterine Cervix

43

Nasal Sinus Aspiration

44

Other Operations On The Uterine Cervix

45

Incision Of Tear Glands

46

Incision Of The Uterus (Hysterotomy)

47

Other Operations On The Tear Ducts

48

Therapeutic Curettage

49

Incision Of Diseased Eyelids

50

Culdotomy

51

Excision And Destruction Of Diseased Tissue Of The Eyelid

52

Incision Of The Vagina

53

Operations On The Canthus And Epicanthus

54

Local Excision And Destruction Of Diseased Tissue Of The Vagina And The Pouch Of Douglas

55

Corrective Surgery For Entropion And Ectropion

56

Incision Of The Vulva

57

Corrective Surgery For Blepharoptosis

58

Operations On Bartholin’S Glands (Cyst)

59

Removal Of A Foreign Body From The Conjunctiva

60

Incision Of The Prostate

61

Removal Of A Foreign Body From The Cornea

62

Transurethral Excision And Destruction Of Prostate Tissue

63

Incision Of The Cornea

64

Transurethral And Percutaneous Destruction Of Prostate Tissue

65

Operations For Pterygium

66

Open Surgical Excision And Destruction Of Prostate Tissue

67

Other Operations On The Cornea

68

Radical Prostatovesiculectomy

69

Removal Of A Foreign Body From The Lens Of The Eye

70

Other Excision And Destruction Of Prostate Tissue

71

Removal Of A Foreign Body From The Posterior Chamber Of The Eye

72

Operations On The Seminal Vesicles

73

Removal Of A Foreign Body From The Orbit And Eyeball

74

Incision And Excision Of Periprostatic Tissue

75

Operation Of Cataract

76

Other Operations On The Prostate

77

Incision Of A Pilonidal Sinus

78

Incision Of The Scrotum And Tunica Vaginalis Testis

79

Other Incisions Of The Skin And Subcutaneous Tissues

80

Operation On A Testicular Hydrocele

81

Cancer Chemotherapy

82

Excision And Destruction Of Diseased Scrotal Tissue

83

Local Excision Of Diseased Tissue Of The Skin And Subcutaneous Tissues

84

Plastic Reconstruction Of The Scrotum And Tunica Vaginalis Testis

85

Other Excisions Of The Skin And Subcutaneous Tissues

86

Other Operations On The Scrotum And Tunica Vaginalis Testis

87

Simple Restoration Of Surface Continuity Of The Skin And Subcutaneous Tissues

88

Incision Of The Testes

89

Free Skin Transplantation, Donor Site

90

Excision And Destruction Of Diseased Tissue Of The Testes

91

Free Skin Transplantation, Recipient Site

92

Unilateral Orchidectomy

93

Revision Of Skin Plasty

94

Bilateral Orchidectomy

95

Other Restoration And Reconstruction Of The Skin And Subcutaneous Tissues

96

Orchidopexy

97

Chemosurgery To The Skin

98

Abdominal Exploration In Cryptorchidism

99

Destruction Of Diseased Tissue In The Skin And Subcutaneous Tissues

100

Surgical Repositioning Of An Abdominal Testis

101

Incision, Excision And Destruction Of Diseased Tissue Of The Tongue

102

Reconstruction Of The Testis

103

Partial Glossectomy

104

Implantation, Exchange And Removal Of A Testicular Prosthesis

105

Glossectomy

106

Other Operations On The Testis

107

Reconstruction Of The Tongue

108

Surgical Treatment Of A Varicocele And A Hydrocele Of The Spermatic Cord

109

Other Operations On The Tongue

110

Excision In The Area Of The Epididymis

111

Incision And Lancing Of A Salivary Gland And A Salivary Duct

112

Epididymectomy

113

Excision Of Diseased Tissue Of A Salivary Gland And A Salivary Duct

114

Reconstruction Of The Spermatic Cord

115

Resection Of A Salivary Gland

116

Reconstruction Of The Ductus Deferens And Epididymis

117

Reconstruction Of A Salivary Gland And A Salivary Duct

118

Other Operations On The Spermatic Cord, Epididymis And Ductus Deferens

119

Other Operations On The Salivary Glands And Salivary Ducts

120

Operations On The Foreskin

121

External Incision And Drainage In The Region Of The Mouth, Jaw And Face

122

Local Excision And Destruction Of Diseased Tissue Of The Penis

123

Incision Of The Hard And Soft Palate

124

Amputation Of The Penis

125

Excision And Destruction Of Diseased Hard And Soft Palate

126

Plastic Reconstruction Of The Penis

127

Incision, Excision And Destruction In The Mouth

128

Other Operations On The Penis

129

Plastic Surgery To The Floor Of The Mouth

130

Cystoscopical Removal Of Stones

131

Palatoplasty

132

Lithotripsy

133

Other Operations In The Mouth

134

Coronary Angiography

135

Transoral Incision And Drainage Of A Pharyngeal Abscess

136

Haemodialysis

137

Tonsillectomy Without Adenoidectomy

138

Radiotherapy For Cancer

139

Tonsillectomy With Adenoidectomy

WHAT DO I NEED TO DO IF A COVERED MEMBER NEEDS TO BE HOSPITALISED?

Upon the happening of any event which may give rise to a claim under the Policy, You need to intimate the TPA named in the schedule with all the details such as name of the Hospital, details of treatment, patient name, Policy number etc.
In case of emergency Hospitalisation, this information needs to be given to the TPA, within 24 hours from the time of Hospitalisation.
This is an important condition which needs to be complied with.

IS TREATMENT FOR HAZARDOUS SPORTS PAYABLE?

Yes. We shall pay expenses incurred towards treatment of any Injury or Illness arising out of the following hazardous sports only:
Bobsledding; Bungee Jumping; Canopying; Hang Gliding; Heli-skiing; Horseback Riding; Jet, Snow, and Water Skiing; Kayaking; Martial Arts; Speed Motorcycling; Mountain Biking; Mountain Climbing (under 14,000 feet); Paragliding; Parasailing; Safari; Scuba Diving, Skydiving; Snowboarding; Snowmobiling; Spelunking; Surfing; Trekking; Whitewater Rafting; Wind Surfing; Zip Lining, Equestrian; Fencing; Archery, Hot Air Ballooning; Underwater Sea-walk; Snorkeling; Rugby.
Our liability under this clause shall not exceed 10% of Sum Insured.
Payment under this clause is admissible only if the expenses are incurred in Hospital as In- Patient / Day Care Treatment in India.

IS PAYMENT AVAILABLE FOR EXPENSES INCURRED BEFORE HOSPITALISATION?

Yes. Medical Expenses incurred sixty days prior to the date of Hospitalisation will be paid provided:

  1. Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalisation was required, and
  2. The In-patient Hospitalisation claim for such Hospitalisation is admissible by Us.
  3. Such Medical Expenses are incurred not earlier than sixty days before the Date of Hospitalisation.

IS PAYMENT AVAILABLE FOR EXPENSES INCURRED AFTER HOSPITALISATION?

Yes. Medical Expenses incurred ninety days after the date of discharge will be paid provided:

  1. Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalisation was required, and
  2. The In-patient Hospitalisation claim for such Hospitalisation is admissible by Us.
  3. Such Medical Expenses are incurred not later than ninety days after the date of discharge from the Hospital.

IS THERE A LIMIT TO WHAT THE COMPANY WILL PAY FOR HOSPITALISATION?

Yes. We will pay Hospitalisation expenses up to a limit, known as Sum Insured. In cases where the Insured Person was Hospitalised more than once, the total of all amounts paid

  1. for all cases of Hospitalisation,
  2. expenses paid for medical expenses prior to Hospitalisation, and
  3. expenses paid for medical expenses after discharge from Hospital
shall not exceed the Sum Insured.
The Sum Insured under the Policy is available for any or all the members covered for one or more claims during the tenure of the Policy.

WHAT SUM INSURED SHOULD I CHOOSE?

You are free to choose any Sum Insured from Rs. 15 lakhs, 25, lakhs, 50 lakhs and 100 lakhs. The premium payable is determined on the following criteria:

  1. The premium for the eldest member of the family. (Premium from Primary Member Premium Table)
  2. Premium for rest of the members to be covered in this Policy. (Premium from Additional Member Premium Table)
  3. Sum Insured
You are free to choose any Sum Insured available as specified above. But it is in your own interest to choose the Sum Insured which could satisfy your present as well as future needs as You cannot enhance Your Sum Insured in this Policy.

HOW LONG IS THE POLICY VALID?

The Policy is valid for a period of one year from the date of inception. The validity of the Policy will be mentioned in the Schedule attached to the Policy. The entire premium for the mentioned period will be payable at the commencement of the Policy period.

WHEN SHOULD I RENEW MY PRESENT POLICY?

In order to get all Continuity benefits under the Policy, you can renew the Policy within thirty days prior to the expiry of the present Policy. For instance, if Your Policy commences from 2nd October, 2011 date of expiry is usually on 1st October, 2012. You can renew Your Policy by paying the Renewal Premium from 1st September 2012 to 1st October 2012.

WHAT IS CONTINUITY BENEFIT?

There are certain treatments which are payable only after the Insured Person is continuously covered for a specified period. For example, Cataract is covered only after twenty four months of Continuous Coverage. If an Insured took a Policy in October, 2016, does not renew it on time and takes a Policy only in December 2017, and renewed it on time in December 2018, any claim for Cataract would not become payable, because the Insured Person was not continuously covered for twenty four months. If, he had renewed the Policy in time in October 2017 and then in October 2018, then he would have been continuously covered for twenty four months and therefore his claim for Cataract in the Policy beginning from October 2018 would be payable. Therefore, you should always ensure that you pay your renewal Premium before Your Policy expires.

IS THERE ANY GRACE PERIOD FOR RENEWAL OF THE POLICY?

Yes. If Your Policy is renewed within thirty days after the expiry of the previous Policy, then the Continuity Benefits would not be affected. But even if You renew Your Policy within thirty days after expiry of previous Policy, any Illness contracted or Injury sustained or Hospitalisation commencing during the break in insurance is not covered. Therefore it is in Your own interest to see that you renew the Policy before it expires.

IS THERE AN AGE LIMIT UPTO WHICH THE POLICY WOULD BE RENEWED?

No. Your Policy can be renewed, as long as you pay the Renewal Premium before the date of expiry of the Policy. There is an age limit for taking a fresh Policy, but there is no age limit for renewal. However, if you do not renew Your Policy before the date of expiry or within thirty days of the date of expiry, the Policy may not be renewed, and only a fresh Policy could be issued, subject to Our underwriting rules. In such cases, it is possible that a fresh Policy could not be issued by Us. It is therefore in your interest to ensure that Your Policy is renewed before expiry.

CAN THE INSURANCE COMPANY REFUSE TO RENEW THE POLICY?

We may refuse to renew the Policy only under instances such as fraud, misrepresentation or non-disclosure of material facts or non-cooperation by You or any one acting on Your behalf in obtaining insurance or subsequently in relation thereto. If we discontinue selling this Policy, it will not be possible to renew this Policy on the same terms and conditions. In such a case you shall, however, have the option for renewal under any similar Policy being issued by the Company as on that date, provided the benefits payable shall be subject to the terms contained in such other Policy.
In case of revision or modification or withdrawal of the Policy a notice will be provided to You 90 days before such revision or modification or withdrawal.
Renewal can also be refused if the Policy is not renewed before expiry of the Policy or within the Grace Period.

CAN I MAKE A CLAIM IMMEDIATELY AFTER TAKING A POLICY?

Claims for Illnesses cannot be made during the first thirty days of a fresh Insurance Policy. However, claims for Hospitalisation due to Accidents occurring even during the first thirty days are payable. There are certain treatments where the waiting period is twelve months and thirty six months are applicable. (Refer Q. No. 22 point 1,2,3 and Q. No. 23 for details)

WHO WILL SETTLE THE CLAIM?

Health claims are generally processed by Third Party Administrator (TPA). TPA is a service provider to facilitate service to you for providing Cashless facility for all Hospitalisation that come under the scope of the Policy. The TPA also processes reimbursement claims within the scope of the Policy. Payment of reimbursement claims will be effected by Us by transfer to Your bank account.

WHAT IS CASHLESS HOSPITALISATION?

Cashless Hospitalisation is service provided by the TPA on Our behalf whereby You are not required to settle the Hospitalisation expenses at the time of discharge from Hospital. The settlement is done directly by the TPA on Our behalf. However those expenses which are not admissible under the Policy would not be paid and You would have to pay such inadmissible expenses to the Hospital. Cashless facility is available only in Network Hospitals. Prior approval is required from the TPA before the patient is admitted into the Network Hospital. You may visit our Website at http://newindia.co.in/listofHospitals.aspx The list of Network Hospitals can also be obtained from the TPA or from their website. You will have full freedom to choose the Hospitals from the Network Hospitals and avail Cashless facility on production of proof of Insurance and Your identity, subject to the claim being admissible. The TPA might not agree to provide Cashless facility at a Hospital which is not a Network Hospital. In such cases You may avail treatment at any Hospital of Your choice and seek reimbursement of the claim subject to the terms and conditions of the Policy. In cases where the admissibility of the claim could not be determined with the available documents, even if the treatment is at a Network Hospital, the TPA may refuse to provide Cashless facility. Such refusal may not necessarily mean denial of the claim. You may seek reimbursement of the expenses incurred by producing all relevant documents and the TPA may pay the claim, if it is admissible under the terms and conditions of the Policy.

CAN I CHANGE HOSPITALS DURING THE COURSE OF MY TREATMENT?

Yes, it is possible to shift to another Hospital for reasons of requirement of better medical treatment. However, this will be evaluated by the TPA on the merits of the case and as per Policy terms and conditions.

HOW TO GET REIMBURSEMENT FOR PRE AND POST HOSPITALISATION EXPENSES?

The Policy allows reimbursement of Medical Expenses incurred before and after admissible Hospitalisation up to a certain number of days. For reimbursement, send all bills in original with supporting documents along with a copy of the discharge summary and a copy of the authorization letter to his/her TPA. The bills must be sent to the TPA within 7 days from the date of completion of treatment. You must also provide the TPA with additional information and assistance as may be required by the TPA in dealing with the claim.

WILL THE ENTIRE AMOUNT OF THE CLAIMED EXPENSES BE PAID?

The entire amount of the claim is payable, if it is within the Sum Insured and is related with the Hospitalisation as per Policy conditions and is supported by proper documents, except the expenses which are excluded. The list of such excluded expenses is attached as Annexure II (LIST OF EXPENSES EXCLUDED ("NON-MEDICAL")) to the Policy.

CAN ANY CLAIM BE REJECTED OR REFUSED?

Yes. A claim, which is not covered under the Policy conditions, can be rejected. Claims may also be rejected in the event of misrepresentation, mis-description or nondisclosure of any material fact/particular. In case You are not satisfied by the reasons for rejection, You can represent to Us within 15 days of such denial. If You do not receive a response to Your representation or if You are not satisfied with the response, You may write to our Grievance Cell, the details of which are provided at our website at http://newindia.co.in/Content.aspx?pageid=73. You may also call our Call Centre at the Toll free number 1800-209-1415, which is available 24x7.
You also have the right to represent Your case to the Insurance Ombudsman. The contact details of the office of the Insurance Ombudsman could be obtained from http://www.irda.gov.in/ADMINCMS/cms/NormalData_Layout.aspx?page=PageNo234&mid=7.2

CAN I CANCEL THE POLICY?

Yes, You can. But the Refund that would be made in case the Policy is cancelled would not be proportionate to the unexpired term of the Policy. Such Refund would be made only if no claim has been made or paid under the Policy, and the Refund would be at our Short Period rate table given below:

Up to one month

1/4th of the annual rate

Up to three months

1/2 of the annual rate

Up to six months

3/4th of the annual rate

Exceeding  six months

Full annual rate

We may also at any time cancel the Policy on grounds of misrepresentation, fraud, non-disclosure of material fact or non-cooperation by You by sending fifteen days’ notice in writing by Registered A/D to You at the address stated in the Policy. Even if there are several Insured Persons, notice will be sent to You.
On such cancellation, other than on grounds of fraud premium corresponding to the unexpired period of Insurance will be refunded, if no claim has been made or paid under the Policy.
Mid-term Deletion of members will be on short scale basis. In case of death of any of the member the refund will pro rata basis, provided there is no claim on that member in the Policy period.

WHAT IS FREE LOOK PERIOD?

The free look period shall be applicable at the inception of first Policy.
You will be allowed a period of 15 days from the date of receipt of the Policy to review the terms and conditions of the Policy and to return the same if not acceptable.
If You have not made any claim during the free look period, then You shall be entitled to:

  1. A refund of the Premium paid less any expenses incurred by Us on medical examination of the Insured Persons and the stamp duty charges or;
  2. Where the risk has already commenced and the option of return of the Policy is exercised by the Policyholder, a deduction towards the proportionate risk Premium for period on cover.

IS THERE ANY BENEFIT UNDER THE INCOME TAX ACT FOR THE PREMIUM PAID FOR THIS INSURANCE?

Yes. Payments made for Health Insurance in any mode other than cash are eligible for deduction from taxable income as per Section 80 D of the Income Tax Act, 1961. For details, please refer to the relevant Section of the Income Tax Act.

IS CONGENITAL DISEASES COVERED IN THE POLICY?

Yes. Congenital Internal Disease or Defects or Anomalies, except those related to Genetic disorders, shall be covered upto Sum Insured, after twenty four months of Continuous Coverage, if it was unknown to You or to the Insured Person at the commencement of such Continuous Coverage. Exclusion for Congenital Internal Disease or Defects or Anomalies would not apply to a New Born Baby during the year of Birth and also subsequent Renewals, if Premium is paid for such New Born Baby and the Renewals are effected before or within thirty days of expiry of the Policy.
Congenital External Disease or Defects or Anomalies shall be covered after thirty six months of Continuous Coverage, but such cover for Congenital External Disease or Defects or Anomalies shall be limited to 10% of the Sum Insured in preceding thirty six months.

HOW MUCH WILL BE REIMBURSED IF THE PERSON HAS MORE THAN ONE POLICY?

If two or more policies are taken by Insured Person during a period from one or more Insurers to indemnify treatment costs, Insured Person shall have the right to require a settlement of his claim in terms of any of the policies.

  1. In all such cases Company shall be obliged to settle the claim as long as the claim is within the limits of and according to the terms of this policy.
  2. If the amount to be claimed exceeds the Sum Insured under a single policy after considering the deductibles or co-pay, Insured Person shall have the right to choose Insurers from whom he wants to claim the balance amount.
  3. Insured Person shall only be indemnified the Hospitalisation costs in accordance with the terms and conditions of the policy.
Note: The Insured Person must disclose such other insurance at the time of making a claim under this Policy.
None of the provisions of this Clause shall apply for payments under Hospital Cash Benefit and Critical Care Benefit.

WHAT WILL HAPPEN TO THE POLICY WHEN THE CHILD / CHILDREN BECOME FINANCIALLY INDEPENDENT AFTER TAKING THE POLICY?

The Company may offer an option to migrate to similar Health Insurance Policy once the child / children become financially independent.

PRIMARY MEMBER
15 L 25L 50L 100L
<20 ₹ 12,519 ₹ 15,399 ₹ 27,953 ₹ 35,243
21-25 ₹ 15,958 ₹ 20,107 ₹ 35,022 ₹ 45,521
26-30 ₹ 16,171 ₹ 20,396 ₹ 35,464 ₹ 46,154
31-35 ₹ 17,767 ₹ 22,540 ₹ 38,773 ₹ 50,852
36-40 ₹ 21,985 ₹ 28,204 ₹ 47,527 ₹ 63,264
41-45 ₹ 25,890 ₹ 32,971 ₹ 56,219 ₹ 74,139
46-50 ₹ 33,803 ₹ 43,308 ₹ 72,114 ₹ 96,168
51-55 ₹ 46,867 ₹ 60,199 ₹ 98,232 ₹ 131,971
56-60 ₹ 63,906 ₹ 82,176 ₹ 132,047 ₹ 178,281
61-65 ₹ 86,147 ₹ 110,321 ₹ 176,701 ₹ 237,877
65-70 ₹ 113,908 ₹ 147,546 ₹ 234,348 ₹ 319,475


SECONDARY MEMBER
15L 25L 50L 100L
<20 ₹ 9,309 ₹ 11,451 ₹ 20,786 ₹ 26,206
21-25 ₹ 11,866 ₹ 14,951 ₹ 26,042 ₹ 33,849
26-30 ₹ 12,025 ₹ 15,166 ₹ 26,370 ₹ 34,320
31-35 ₹ 13,211 ₹ 16,761 ₹ 28,831 ₹ 37,813
36-40 ₹ 16,348 ₹ 20,972 ₹ 35,341 ₹ 47,043
41-45 ₹ 19,252 ₹ 24,517 ₹ 41,804 ₹ 55,129
46-50 ₹ 25,135 ₹ 32,203 ₹ 53,623 ₹ 71,510
51-55 ₹ 34,850 ₹ 44,763 ₹ 73,045 ₹ 98,132
56-60 ₹ 47,520 ₹ 61,105 ₹ 98,189 ₹ 132,568
61-65 ₹ 64,058 ₹ 82,034 ₹ 131,393 ₹ 176,883
65-70 ₹ 84,701 ₹ 109,714 ₹ 174,259 ₹ 237,558

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