Annexure – III
Memoranda attached to and forming part of Policy
M/s.V.A. Tech Wabag Limited,
This Policy shall be subject to the following:
1. Cashless Facility: This Policy is extended to provide Cashless Facility (through TPA – Third Party Administrator)
Cashless facility shall mean:
· In hospitals where cashless facility is available, provided pre-admission authorization is taken in writing from TPA in which case, the Insured Person need not settle the eligible expenses at the hospital. The TPA will pay the bills to the hospital directly.
· TPAs will provide 24-hour helpline and will provide free ambulance referral facility.
· TPAs will be guided by TPA regulations of IRDA.(Insurance Regulatory Development Authority)
· For Hospitalisation at other hospitals, claim settlement will be on reimbursement basis.
2. Exclusions waivers
Exclusion No.1 (Pre-existing Exclusion), Exclusion No. 2 (30 Days Waiting Period), and Exclusion No. 3 (First Year Exclusions) stand deleted for all Insured Persons including all persons enrolled subsequent to the date of inception of the policy.
3. Maternity Treatment Charges Benefit Extension
This Policy is extended to cover Maternity Treatment Charges subject to the following:
Ø The maximum limit under this Extension is limited to Rs.50, 000/- per Insured Person.
Ø A waiting period of 9 months shall apply to Insured Persons enrolled subsequent to the date of inception of this cover.
Ø This Benefit shall apply only to expenses incurred in Hospital/Nursing Home as an In-Patient in India.
Ø Claims in respect of delivery for only first two children and/or operations associated therewith will be considered in respect of any Insured Person covered under the Policy or any renewal thereof. Those Insured Persons who are already have two or more living children are not eligible for this Benefit.
Ø Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 weeks from the date of conception are not covered.
Ø Pre-natal and post-natal expenses are covered only if the Insured Person is treated as an In–Patient in a Hospital/Nursing Home.
Ø The Company shall reimburse the actual cost incurred (subject otherwise, to the limit described above under this Extension) in respect of:
· Abnormal presentation
· Ectopic pregnancy
· Miscarriage
· Missed abortion
· Still birth
· Post-partum haemorrhage
· Retained placental membrane
Ø No refund shall be allowed in the event of the Insured canceling this Benefit during currency of the Policy.
Subject otherwise to the terms, Conditions, Exclusions and limitations of the Policy.
GENERAL RULES
HEALTH PREMIUM PLATINUM INSURANCE POLICY
INTRODUCTION
This is your Policy, explaining your insurance protection in detail. Your premium has been based upon the information shown in Your Policy Schedule. Please check your Policy Schedule to ensure that the details we hold are correct.
If after reading your Policy, you have any questions, please contact your Policy issuing office.
THE INSURANCE CONTRACT
1. The Policy is evidence of the contract between you (the Insured) and us (the Company).
2. The Proposal or any information supplied by you shall be incorporated in and be the basis of the contract.
3. The Policy, the Schedule and any Endorsement are to be read as one document and any word or expression used with a specific meaning in any of them shall have the same meaning wherever it appears.
4. Provided that you pay the premium for all the Insured Persons in the category intended to be insured under this Policy and we receive and accept it, we shall provide the insurance described in the Policy.
5. The terms and Conditions that appear in the Policy or in any Endorsement are part of the contract and must be complied with. Failure to comply may result in the claim being denied.
PERSONS WHO CAN BE INSURED
Ø Unless otherwise agreed this Policy is available to any group / association / institution / corporate body of more than 100 persons whose age group is between 91 days and 75 years. The Policy shall be issued in the name of the group/association/corporate body (called Insured) with Schedule of names of the members/employees including his/her Eligible Family Members (called Insured Persons) forming part of the Policy
Ø Eligible Family Members means
o Spouse - Spouse means your married partner who resides with you
o Dependent Children - Dependent Children means all your unmarried children, stepchildren or legally adopted children and
1. Who are over 90 days and under 18 years of age
2. Financially dependent on you
3. Who permanently reside with you
o Dependent Parents.
Words with special meaning:
Commencement Date
The date shown in the Schedule or the date from which an Insured Person was included under this Policy.
Company/We/Us/Our/Insurer
Royal Sundaram Alliance Insurance Company Limited
Endorsement
Endorsement means written evidence of an agreed change to your Policy including increase or decrease in the Period of Insurance, extent and nature of the cover.
Hospital/Nursing Home:
Hospital/Nursing Home means any institution in India established for indoor care and treatment of sickness and injuries and which
Either
Ø Has been registered either as a Hospital or Nursing Home with the local authorities and is under the supervision of a registered and qualified Medical Practitioner.
or
Ø Should comply with minimum criteria as under:
Ø It should have atleast 20 In -Patient beds.
Ø Fully equipped operation theatre of its own wherever surgical operations are carried out.
Ø Fully qualified Nursing Staff under its employment round the clock.
(N.B.* In Class `C’ town condition of number of beds be reduced to 15).
The term Hospital/Nursing Home shall not include an establishment which is a place of rest, a place for the aged, a place for drug – addicts or place for alcoholics, a hotel or a similar place.
Insured Person:
Anybody shown on the Schedule as insured by this Policy.
In-patient:
An Insured Person who is admitted to hospital and stays for at least 24 hours for the sole purpose of receiving treatment.
Medical Practitioner:
Medical Practitioner means a person who holds a degree/diploma of a recognised institution and is registered by Medical council of respective State of India. The term Medical Practitioner would include Physician, Specialist and Surgeon.
Period of Insurance
Period of Insurance of Insurance means the period shown in the Schedule and any further period, for which you have paid and we have received and accepted your premium
Pre-Hospitalisation
Relevant medical expenses incurred during period upto 30 days prior to Hospitalisation but not prior to the effective date of this Policy on disease/illness/injury sustained shall be considered as part of claim.
Post - Hospitalisation
Relevant medical expenses incurred during period upto 60 days after Hospitalisation including all expenses incurred beyond the expiry date of this Policy on disease/illness/injury sustained shall be considered as part of claim
Qualified Nurse:
Qualified Nurse means a person who holds a certificate of a recognised Nursing Council and who is employed on recommendation of the attending Medical Practitioner.
Surgical Operation:
“Surgical Operation” means manual and/or operative procedures for correction of deformities and defects, repair of injuries, diagnosis and cure of diseases, relief of suffering and prolongation of life.
THE BENEFITS
This Policy covers reimbursement of hospitalisation expenses only for the illness/diseases contracted or injury sustained by the Insured Person during the Period of Insurance stated in the Schedule or during the continuance of this Policy by renewal except due to exclusions mentioned in the Policy. For a claim to be admitted under this Policy the Insured Person should be hospitalised as an In-Patient for a minimum period of 24 hours. In the event of any claim becoming admissible under the Policy the Company shall pay to the Insured/Insured Person the amount of such expenses as would fall under different heads mentioned below as are reasonably and necessarily incurred in respect thereof anywhere in India by or on behalf of such Insured/Insured Person, but not exceeding Sum Insured for that Insured Person as stated in the Schedule for all claims admitted during the Period of Insurance mentioned in the Schedule.
Expenses reimbursed under the Policy
1. Room, Boarding Expenses as provided by the Hospital/Nursing Home.
2. Nursing Expenses.
3. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialist Fees.
4. Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines and Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial Limbs and Cost of Organs and similar expenses.
5. Pre-Hospitalisation (30 days prior to hospitalization) and Post-Hospitalisation (60 days after discharge) as defined above.
For the following specific treatments no In-Patient hospitalization is required:
1. Cataract is excluded during the first year for an Insured Person and is covered only from the second year.
2. Lithotripsy (Kidney stone removal)
3. Tonsillectomy
4. Eye Surgery
5. D & C
6. Any other disease specified from time to time.
EXCLUSIONS
The Company shall not be liable to make any payment under this Policy in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of:
1. Pre-existing conditions - Such conditions which have been in existence at the time of proposing this insurance. Preexisting condition means any injury which existed prior to the effective date of this insurance. Pre-existence condition also means any sickness or its symptoms which existed prior to the effective date of this insurance, whether or not the Insured Person had knowledge that the symptoms were relating to the sickness. Complications arising from pre-existing disease shall be considered part of that pre-existing condition.
Provided however that if the Policy is extended to cover Pre-existing conditions, the waiver of this exclusion shall not apply to those Conditions, which occur prior to the effective date of cover for that Insured Person under this scheme with any other Indian Insurance Companies.
2. Any disease contracted by the Insured Person during the first 30 days from the commencement date of the Policy.
This Exclusion shall not apply if, in the opinion of panel of Medical Practitioners constituted by the Company for the purpose, the Insured Person could not have known of the existence of the Disease or any symptoms or complaints thereof at the time of making the proposal for insurance to the Company.
3. During the first year of the operation of the Policy the expenses on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Fistula in anus, Piles, Sinusitis and related disorders are not payable. If these diseases are pre-existing at the time of proposal they shall not be covered even during subsequent period or renewal too.
4. Injury or disease directly or indirectly caused by or arising from or attributable to War, Invasion, Act of Foreign Enemy, Warlike operations (whether war be declared or not).
5. Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due an accident.
6. Any treatment relating to change of life.
7. Treatment arising from or traceable to pregnancy, childbirth including Caesarean section. (This exclusion shall not apply if the Policy is extended to cover maternity expenses.).
8. Any fertility, sub-fertility or assisted conception operation.
9. The cost of spectacles, contact lenses and hearing aids.
10. Dental treatment or surgery of any kind unless requiring hospitalization.
11. Convalescence, general debility, `Run-down’ condition or rest cure, congenital external/internal disease or defects or anomalies, sterility, venereal disease, intentional self-injury.
12. All expenses arising out of 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 variations Deficiency Syndrome or any Syndrome or condition of a similar kind commonly referred to as AIDS.
13. Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home as defined.
14. Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending Physician.
15. Injury or Disease directly or indirectly caused by or contributed to by nuclear weapons/materials or radioactive contamination
16. Any claim or expense of any kind caused directly or indirectly by:
16.1. Ionising radiation or contamination by any nuclear fuel or from any nuclear waste from burning, nuclear fuel
Or
16.2. Radioactive, toxic, explosive or other dangerous properties of any explosive nuclear machinery or part of it.
17. Any routine or preventative examinations, vaccinations, inoculation or screening.
18. Outpatient treatment charges, unless allowed.
19. Sex change or treatment which results from, or is in any way related to, sex change.
20. Hormone replacement therapy.
21. Renal dialysis, Chemotherapy, Radiotherapy except where this is in connection with acute secondary failure and is part of the intensive treatment.
22. The treatment of psychiatric, mental or nervous conditions, insanity
23. Any cosmetic, plastic surgery, aesthetic or related treatment of any description, whether or not for psychological reasons, unless medically necessary as a result of an accident.
24. Use of intoxicating drugs / alcohol and the treatment of alcoholism, solvent abuse, drug abuse or any addiction and medical conditions resulting from, or related to, such abuse or addiction.
25. Any treatment received in convalescent homes, convalescent hospitals, health hydros, nature cure clinics or similar establishments.
26. Any stay in hospital for any domestic reason or where there is no active regular treatment by a specialist.
27. Any treatment received outside India.
28. Industrial disaster.
29. Any Ayurvedic, homeopathic, Naturopathy or any other forms of local medication.
30. Complication of any surgery, therapy or treatment administered on the Insured Person which is not prescribed or required by a Registered Medical Practitioner/Registered Medical Institution in their Professional capacity.