Presentation on – Group Health Insurance Policy for Registered Dentist of Indian Dental Association only

Broker Partner : Edelweiss Gallagher Insurance Brokers Limited

Coverage

Basic Information

Medical Expenses of Coronavirus Disease (COVID-19) will be covered under this Group Health
Insurance policy

Coverage Type Insurance Company

Individual Sum Insured Universal Sompo

Insured Beneficiary
Indian Dental Association Self, Spouse, Dependent Children,
Associate Staff , Dependent Parent or
Location Parent- in-law
PAN India Age Limit
18years to 65 years

Sum Insured
3 lakh TPA
Universal Sompo in-house TPA
Policy Term – 1
year
Coverage
Claim Admissibility Criteria
Pre-Existing Diseases
Waiting Period
Room Rent Capping
Pre and Post hospitalization
expenses
AYUSH Treatment
Home Care Treatment
Expenses
Ambulance Charges
Claim Intimation/
submission
Mid-term Deletion &
Addition
OPD Cover
Hospital Cash Cover
Co-Morbidity
Member should be tested positive for the COVID- 19 through a government approved diagnostic test in a government authorized diagnostic centre to
be eligible for claim under this policy
Not covered
Expenses related to the treatment of Covid-19 within 14 days from the first policy commencement date shall be excluded.
In case of persons undertaking international travel, expenses related to the treatment of Covid-19 within 14 days from of their date of return to India
shall be excluded
Room Rent, Boarding, Nursing Expenses as provided by the Hospital / Nursing Home – With an upper limit of 1% of Sum Insured & Intensive Care Unit
(ICU) / Intensive Cardiac Care Unit (ICCU) expenses – With an upper limit of 2% of Sum Insured OR As applicable Room Rent / ICU charges mentioned
in the Local Govt notification
Covered upto 15 days prior to Hospitalisation & 30 days after Hospitalisation
The expenses incurred on treatment for Covid-19 under Ayurveda,Yoga and Naturopathy, Unani, Siddha and Homeopathy systems of medicines during
each Policy Year up to the limit of sum insured as specified in the policy schedule in any AYUSH Hospital will be covered
Treatment availed by the Insured Person at home for COVID- 19 on positive diagnosis of COVID- 19 will be cover subjected to:
a) The Medical practitioner advices the Insured person to undergo treatment at home
b) There is a continuous active line of treatment with monitoring of the health status by a medical practitioner for each day through the duration of the
home care treatment
Per hospitalization and per Policy Period: Rs. 2000/-
All reimbursement claims should be intimated to Insurer within 48 hours of Hospitalization and documents of claim should be submitted to the Insurer
within 30 days of discharge. Intimation & Any Queries to be sent to hcm@edelweissfin.com
Deletion of members would be permitted, Premium will refund on pro-Rata basis subjected to no claim in respect of the particular insured Person.
Addition of members would be allowed only for the New Joinee, premium will charged on pro-rata basis
Maximum up to Rs. 3000/- will be covered for Consultations, Prescribed Diagnostics and Prescribed Pharmacy on OPD basis with in the Sum insured
Limit
Maximum up to Rs.1000/-for each 24 hours of continuous hospitalization subject to maximum of 14 days in a policy period will be covered with in the
Sum Insured Limit
Co-Morbidity cover however expenses for treatment of co-morbidity is not covered. For ex. Patient has diabetes then during hospitalisation treatment
to control sugar level will not be paid but treatment of COVID will be paid
Exclusions
Investigation & Expenses related to any admission primarily for diagnostics and evaluation purposes. Any diagnostic expenses which are not related or not incidental to
Evaluation the current diagnosis and treatment

Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:
Rest Cure, Rehabilitation i. 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
and Respite Care either by skilled nurses or assistant or non-skilled persons.
ii. Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.

Dietary supplements and Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals and organic substances
substances unless prescribed by a medical practitioner as part of hospitalization claim or Home care treatment.

Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are treatments,
Unproven Treatments procedures or supplies that lack significant medical documentation to support their effectiveness. However, treatment authorized by the government for
the treatment of COVID-19 shall be covered.
Biological attack or weapons, contributed to, caused by, resulting from or from any other cause or event contributing concurrently or in any other
sequence to the loss, claim or expense. For the purpose of this exclusion:
Biological attack or
Biological attack or weapons means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organisms and/or
weapons
biologically produced toxins (including genetically modified organisms and chemically synthesized toxins) which are capable of causing any Illness,
incapacitating disablement or death
Any expenses incurred on Day Care treatment
Diagnosis /Treatment outside the geographical limits of India
Testing done at a Diagnostic centre which is not authorized by the Government shall not be recognized under this Policy

Other Exclusions Any expenses incurred in respect of inoculations, vaccinations or other preventive treatment.
All covers under this Policy shall cease if the Insured Person travels to any country placed under Travel restriction by the Government of India.

The person who are already affected by Corona Virus / or have suspected quarantine previously will be not covered under this policy
Pre-existing disease

Note: Please refer the policy wordings for complete list of exclusions.
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