GROUP MEDICLAIM INSURANCE

Group Mediclaim Insurance
‡ Group Personal Accident policy takes care of an event which relates to an external peril. ‡ What if there is an action of internal peril? The human life is exposed to a peril acting from within. ‡ These are in the nature of action of a bacteria or a virus affecting the normal functions of living. ‡ We call them action of disease crippling the normal life. ‡ When this leads to a necessity of hospitalisation there is a policy to take care of the bills of hospitalisation. ‡ Apart from the action of internal perils there are also possibilities of a severe accident leading to hospitalisation for correcting the affected limb. This also is covered under Mediclaim.

Group Mediclaim Insurance ‡ Scope of cover: ‡ Policy covers reimbursement of hospitalization expenses incurred for diseases contracted or injuries sustained in India. ‡ Medical expenses upto 30 days for Pre ± hospitalization and upto 60 days for post ± hospitalization are also admissible .

.Group Mediclaim Insurance ‡ Main Exclusions ‡ Pre Existing Diseases ( Already Existing diseases ) ‡ Diseases Contracted During first 30 Days ‡ Cost Of Spectacles / Contact Lenses ‡ Dental Treatment ‡ AIDS ‡ Pregnancy ‡ Certain specified diseases during first year of the policy.

5.Group Mediclaim Insurance ‡ Amount Of Cover (Sum Insured) ‡ Choice ± From 50.000/Per Person ‡ Types of Policies ‡ Variety of Policies ± with slight modification in each one .000 to Rs.00.

70 years ( depending upon the company ) .Group Mediclaim Insurance ‡ Premium ‡ Premium chargeable depends upon age of the person and the Amount of Cover selected ‡ Age limit is upto 65.

. The loading applied is termed as Malus.Group Mediclaim Insurance ‡ Bonus / Malus Clause ‡ Good Claims experience ( for insurance company ) provides eligibility for discounts and bad Claims experience attracts loading in the premium.

But it becomes a costly affair for the Company in 2-3 years when there are claims on Maternity account . Premium is higher and not worth it . ‡ Some Policies give Cash per day upto say 1500 / max. Now a days insurance companies are usually refusing this cover unless group size is above 1000 or so . premium is high .Group Mediclaim Insurance ‡ Extension ‡ Basic Policy is for Hospitalisation only . ‡ Group Policy can be extended to cover maternity benefits on payment of additional premium . ‡ Other policies have some other extension . .

illness. . and if such disease. upon the advice of a Medical Practitioner to incur Hospitalisation or Domiciliary Hospitalisation expenses. accident or injury shall require any such Insured Person.Group Mediclaim Insurance ‡ More details: ‡ During the policy period. if any Insured Person shall contract any disease or suffer from Any One Illness or sustain any bodily injury through accident. the Company will pay to the Insured Person. the amount of such expenses as are reasonably and necessarily incurred thereof. by or on behalf of such Insured Person but not exceeding the sum insured for the person as specified.

Group Mediclaim Insurance ‡ Domiciliary Hospitalisation: ‡ The term ³Domiciliary Hospitalisation´ means medical treatment for a period exceeding three days for such illness/disease /injury which in the normal course would require care and treatment at the Hospital/Nursing Home but actually taken whilst confined at home in India under any of the following circumstances namely: ‡ i) The condition of the patient is such that he/she cannot be removed to the Hospital/Nursing home or ‡ Ii) The patient can not be removed to Hospital/ Nursing Home for lack of accommodation therein .

Asthma 2. Cough and Cold 9. Gout and Rheumatism . Epilepsy 7. Arthritis. Tonsillitis and Upper Respiratory Tract Infection including Laryngitis and Pharingitis 12. Bronchitis 3. All Psychiatric or Psychosomatic Disorders 10. Pyrexia of unknown origin for less than 10 days 11. Chronic Nephritis and Chronic Nephritic Syndrome 4. Diarrhoea and all types of Dysenteries including Gastro-enteritis 5.Group Mediclaim Insurance ‡ Domiciliary Hospitalisation does not cover: ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ 1. Influenza. Diabetes Mellitus and Insipidus 6. Hypertension 8.

Group Mediclaim Insurance ‡ Exclusions ‡ Pre existing diseases ‡ Disease contracted during the first 30 days of insurance. expenses on tonics. ‡ Certain disease like cataract hernia etc excluded during the first year /two years of the policy ‡ Cosmetic and aesthetic treatment plastic surgery etc not covered unless essentially associated with a treatment. sterility etc ‡ AIDS. intentional self injury. run down condition. expenses only for diagnostics etc ‡ Outpatient Treatment not requiring Hospitalisation ‡ Naturopathy and Other unrecognised Forms of Treatment ‡ Congenital ( Birth ) Defects . ‡ Cost of spectacles ‡ Dental treatment ‡ General debility.

Anaesthetics. Surgical Appliances. and Boarding Expenses as incurred at the Hospital/Nursing Home. Surgeon. Dialysis. Cost of Pacemaker.Group Mediclaim Insurance ‡ Cover Available for Following : ‡ a) Room. Diagnostic Materials and X ± Ray. wherever applicable . Consultants. and Specialists ‡ d) Anaesthesia. Artificial Limbs & Cost of Organs and similar expenses. and /or e) Pre Hospitalisation (30 Days) and Post Hospitalisation ( 60 Days )expenses. Blood. Chemotherapy. Radiotherapy. Oxygen. Operation Theatre Charges. Medicines & drugs. ‡ b) Nursing Expenses. ‡ c) Fee paid to Medical Practitioner.

Group Mediclaim Insurance ‡ Claim documents Required a) Duly completed claim form b)Bills. receipts and discharge certificate/card from the Hospital c)Bills from Chemists supported by proper prescription. d)Test reports and payment receipts .

. ‡ Third Party Administrator sanctions Treatment Cost to Hospital .Group Mediclaim Insurance ‡ CASHLESS HOSPITALISATION : ‡ Diagnosis by Doctor Advice for Hospitalisation ‡ Contact Hospital on Third Party Administrator¶s List (this is given with card or is available on website of TPA ) & fill up their form ‡ Hospital contacts Third Party Administrator by sending form signed by Doctor over Fax .

. ‡ All Receipts to be supported by Doctor¶s Prescription .GROUP MEDICLAIM INSURANCE Reimbursement if Cashless does not happen for any reason ‡ Documents needed as mentioned earlier .

Receipt shows that the amount has been paid . . Both are not the same and One should always take a receipt for any payment . Receipt ‡ ‡ ‡ ‡ Remember the Difference between Bill & Receipt Bill is the proposed amount for goods or services.Group Mediclaim Insurance Bill vs.

Group Mediclaim Insurance ‡ Definitions ‡ Policy lays down definitions of following terms y y y y y y y y y y Any One illness Domiciliary Hospitalization Hospital/Nursing Home Hospitalization Specified Treatment Medical Practitioner Maternity Expenses Benefit Post Hospitalization Pre Hospitalization Qualified Nurse ‡ Surgical Operation .

.Group Mediclaim Insurance Definition of Hospital / Nursing Home ‡ Must have 15 in patient beds .(in Class C towns it is 10 beds ) ‡ Fully equipped Operation Theatre ‡ Fully Qualified Nursing Staff round the clock ‡ Fully Qualified Doctor round the clock ‡ Or Registered with Local Authorities .

However .Group Mediclaim Insurance General Usually minimum 24 hours stay at Hospital is needed for a valid Claim . Tonsillectomy . Radiation etc . certain surgeries like Laser operation of eye . Which do not need 24 Hours Hospitalisation are also covered . .

Thank You .

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