Form No.-H+MEP(I)-2
THE NEW INDIA ASSURANCE COMPANY LIMITED
Registered & Head Office- 87, M.G. Road, Fort, Mumbai-400001.
HEALTH PLUS MEDICAL EXPENSES POLICY
PROSPECTUS
SALIENT FEATURES OF THE POLICY.
The policy covers reimbursement of hospitalization expenses only for
illness/diseases contracted or injury sustained by the Insured person.
In the event of any claim becoming admissible under the policy the Company will
pay to the Insured person the amount of such expenses as are reasonably and
necessarily incurred in respect thereof any where in India by or on behalf of such
insured person but not exceeding in any one period of Insurance the amounts
mentioned in the Table of Benefits.
SECTION I
Table of Benefits:
HOSPITALISATION BENEFITS
1. i. Room, Board & Nursing Expenses as provided
by the hospital/nursing home including
registration and service charges.
ii. If admitted into IC Unit
All admissible claims under (i) & (ii) during the
policy period
2. Surgeon, Anaesthetist, Medical Practitioner,
Consultants, Specialists Fees.
3. Emergency Ambulance charges upto 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.
LIMITS.
Up to 1% of SI per day.
Up to. 2% of SI per day.
Up to 30% of SI per illness/injury
Up to 30% of SI per illness/injury
Up to 40% of SI per illness/injury
Note:
1.The Hospitalization expenses incurred for treatment of any one illness under
agreed package charges will be restricted to 80% of the sum insured or
actuals whichever is less .
2.Hospitalization expenses of 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.
3.Hospitalization Treatment taken in Nepal & Bhutan will be considered under
the policy provided prior approval has been taken from the Company.
4.Ayurvedic Medical Treatment expenses per illness shall be restricted to 20% of
Sum Insured or Rs. 25000/- whichever is less.
SECTION II – (OPTIONAL - TO BE OPTED AT FIRST INCEPTION OF THE
POLICY)
EXTENSION OF THE GEOGRAPHICAL LIMIT OF THE POLICY TO COVER TREATMENT
ABROAD BY PAYMENT OF ADDITIONAL PREMIUM:
This policy can be extended provided the insured person claim has been admitted
under
section I of the Policy, to cover the expenses incurred for treatment of an insured
person for one additional sum insured (excluding cumulative bonus) abroad in case the
attending doctor or the hospital in India where the insured person is taking treatment
has recommended that such type of treatment is not available in India and the insured
person requires specialized treatment, surgery or post operative treatment abroad. The
Company on written certification by the attending doctor, will examine such request of
the insured person and after consulting its own penal doctor feels that such type of
treatment is not available in India, shall allow extension of the policy to cover the
medical expenses of the insured person incurred abroad. The reimbursement of such
medical expenses incurred abroad shall be paid in Indian Rupees only, limited to one
additional sum insured of the insured person mentioned in the policy schedule. This
extension of Medical benefit will be allowed to an insured person from the date of
admission in the hospital and discharge therefrom. No pre and post hospitalization
expenses will be covered under this extension. No Cumulative Bonus will accrue under
this extension
DEFINITIONS
1.0
PRE-EXISTING DISEASES/INJURIES: The pre-existing condition means a
medical condition which existed on the date of inception of the policy
for which :
i)
Insured received medical advice and or treatment; or
ii)
Symptoms are such for which an ordinary prudent person would seek
medical advice or treatment.
1.1
`HOSPITAL/NURSING HOME’ means that any institution in India established
for indoor care and treatment of sickness and injuries and which
Either
(a) 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
(b) should comply with minimum criteria as under :(i)It should have atleast 15 in patient beds.
(ii)Fully equipped operation theater of its own wherever surgical
operations are carried out
(iii ) Fully qualified Nursing Staff under its employment round the clock.
1.2
1.3
1.4
1.5
1.6
1.7
1.8
(iv) Fully qualified Doctor(s) should be in-charge round the clock.
Note: 1. In case of Ayurvedic Hospital (ii) is not applicable
2. In Class ‘C’ Town where population is less than 5 lakhs, condition
regarding number of beds is reduced to 10.
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 of
alcoholics, a hotel or a similar place.
“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.
Expenses incurred on hospitalization for minimum period of 24 hours are
admissible. However, this time limit is not applied to specific treatments i.e.
Dialysis, Chemotherapy, Radiotherapy, Eye surgery, Lithotripsy, (Kidney Stone
Removal) Tonsillectomy, D&C, Fracture due to accident which is proved by
X-ray, Anti Rabbies Vaccine taken in the Hospital/Nursing home and the
insured is discharged on the same day, the treatment will be considered to be
taken under hospitalization benefit. Further this condition will also not apply
in case of stay in hospital of less than 24hrs under any of the following
circumstances.
(a) The treatment is such that it necessitates hospitalization and the procedure
involves specialized infrastructural facilities available in hospitals.
(b) Due to technological advances hospitalization is required for less than
24 hours only.
(c) Surgical procedure is involved.
ANY ONE ILLNESS
Any one illness will be deemed to mean continuous period of the illness
for which treatment is undergone and it includes relapse within 45 days from
the date of last consultation with the Hospital/Nursing Home where treatment
may have been taken. Occurrence of same illness after a lapse of 45 days as
stated above will be considered as fresh illness for the purpose of this policy.
PRE-HOSPITALISATION : Relevant Medical Expenses incurred during
period upto 30 days prior to hospitalization on disease/illness/injury
sustained will be considered as a part of claim mentioned under table of benefits
under Section I, item 2 & 3 .
POST–HOSPITALISATION : Relevant Medical Expenses incurred during
period upto 60 days after hospitalization on disease/illness/injury sustained will
be considered as a part of claim mentioned under table of benefits under Section
item 2 & 3.
MEDICAL PRACTITIONER means a person who holds a degree/diploma of a
recognized institution and is registered by Medical Council of respective State
of India. The term Medical Practitioner would include Physician, Specialist and
Surgeon.
1.9
QUALIFIED NURSE means a person who holds a certificate of a recognized
nursing Council and who is employed on recommendations of the attending
Medical Practitioner.
2.0
EXCLUSIONS:
2.1
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.
2.1.1
All diseases/injuries which are pre-existing when the cover incepts for the first
time. This exclusion will be deleted after four consecutive continuous claims
free policy year provided, there was no hospitalization for pre-existing ailment
during the such four years of insurance.
Any disease other than those stated in clause 2.1.3 contracted by the insured
person during the first 30 days from the commencement date of the policy.
This condition 2.1.2. shall not however apply in case of the insured person
having been covered under this scheme or group insurance scheme with any of
the Indian Insurance Companies for a continuous period of proceeding 12 months
without any break.
Note : Theses exclusions 2.1.1 and 2.1.2 shall not however 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 AND
 Insured had not taken any consultation, treatment or medication in
respect of hospitalization for which claim has been lodged under the
policy prior to taking the insurance.
During the first two years of the operation of insurance cover, the expenses
Incurred on treatment of diseases such as Cataract, Benign Prostrate
Hypertropy, Hysterectomy for Menorrhagia, or Fibromyoma, Hernia,
Hydrocele, Congenital Internal disease/defect, Fistula in anus, piles, Arthrities,
Gout and Rheumatism, Joint Replacements, Sinusitis and related disorders
are not payable. These expenses can be considered after two years provided the
2.1.2
2.1.3
treatment is not for pre-existing disease.
2.1.4
2.1.5
Injury/disease 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).
Circumcision unless necessary for treatment of a disease not excluded hereunder
or as may be necessitated due to an accident, vaccination (other than anti rabbies
vaccination) or innoculation or change of life or cosmetic or aesthetic treatment
of any description, plastic surgery other than as may be necessitated due to an
accident or as part of any illness.
2.1.6
2.1.7
2.1.8
2.1.9
2.1.10
2.1.11
2.1.12
2.1.13
2.1.14
2.1.15
2.1.16
Cost of spectacles and contact lenses, hearing aids.
Any dental treatment or surgery which is a corrective, cosmectic or aesthetic
procedure, including wear and tear, unless arising from disease or injury
and which requires hospitalization for treatment.
Convalescence, general debility, ‘Run-down’ condition or rest cure, obesity,
Congenital external disease or anomalies, sterility, veneral disease, intentional
self injury and use of intoxication drugs/alcohol.
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 lymphotropathy 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.
Charges incurred at Hospital or Nursing Home primarily for diagnosis, X-Ray or
Laboratory examination not consistent with incidental to the diagnosis and
treatment of positive existence or presence of any ailment, sickness or injury,
for which confinement is required at a Hospital/Nursing Home.
Expenses on vitamins and tonics unless forming part of treatment for injury
or disease as certified by the attending physician.
Injury or Disease directly or indirectly caused by or contributed
to by nuclear weapons/materials.
Treatment arising from or traceable to pregnancy, childbirth, miscarriage,
abortion or complications of any of these including caesarean section.
However, this exclusion will not apply to abdominal operation for extra
uterine pregnancy (Ecotopic Pragnancy), which is proved by submission of
ultra Sonographic Report and Certification by Gynecologist that it is a
life threathening.
Naturopathy Treatment.
External Medical Equipment of any kind used at home as post hospitalization care
including cost of instrument used in treatment of sleep apnea syndrome (C.P.A.P.)
and continuous Peritoneal Ambulatory dialysis (C.P.A.D.) and Oxygen Concentrator for Bronchial Asthamatic condition.
Travel or transportation expenses other than Emergency Ambulance Services
in connection with any admissible claim limited to Rupees 1000/- or 1% of the
sum insured whichever is less.
AGE LIMIT : The cover is available between the age of 3 months to 70 yrs.
Children are covered only when one or both parents are covered simultaneously.
Persons above the age of 45 yrs have to undergo medical selection procedure as required
by the company at their own expenses.
PRE ACCEPTANCE MEDICAL CHECK UP: The Company may require submission
of Medical reports when the proposer is 45 years and above from a designated center,
cost of the same to be borne by the proposer. This requirement is for fresh proposal or
when the sum insured is enhanced at the time of renewal or when there is a break in
insurance for 15 days.
FAMILY DISCOUNT: A discount of 10% in the total premium will be considered only
when the insurance is taken by any one or more of the following from the proposers family
1. Spouse
2. Dependent children (i.e. legitimate or legally adopted children)
3. Dependent Parents.
N.B. 1. Family discount will not be applicable to dependent parents premium when
their age is above 60 years
2.This discount will be applicable only on Section I premium.
HOW TO APPLY FOR INSURANCE: The proposer has to complete the proposal form
and submit insured person’s details for each of the member to be enrolled under the
scheme.
NOTICE OF CLAIM
Preliminary notice of claim with particulars relating to Policy Numbers, Name
of insured person in respect of whom claim is made, Nature of disease/illness/
injury and Name and Address of the attending medical practitioner/Hospital/
Nursing Home should be given to the Insurance Company within seven days
from the date of Hospitalization.
Waiver: Waiver of period of intimation may be considered in extreme cases of
Hardships where it is proved to the satisfaction of the company that under the
Circumstances in which the insured was placed it was not possible for him or
Any other person to give such notice or file claim within the prescribed time limit .
Final claim along with hospital receipted original Bills/Cash memos, claim form
and list of documents as listed in the claim form etc. should be submitted to the
company after completion of treatment but not later than 30 days of discharge
from the Hospital. Also give the Company such additional information and
assistance as the Company may require in dealing with the claim.
PAYMENT OF CLAIM
All admissible claims shall be payable in Indian currency only.
SUM INSURED
The Companies liability in respect of all claims admitted during the period of
Insurance shall not exceed the sum insured opted by the insured person under
Section I or Section II as applicable.
(SECTION I)
PREMIUM SCHEDULE :
Sum insured
Hospitalization
Expenses
Rs. 50,000/-
_________ AGE UPTO___________________
25 yrs
35 yrs
45 yrs
46 to 55yrs
56 to 65yrs
66 to 70 yrs
600
650
900
1000
1200
1300
Rs. 1,00,000/- 1000
1200
1400
1900
2250
2700
Rs. 1,50,000/- 1550
1800
2100
2800
3300
3600
Rs. 2,00,000/- 2000
2300
2600
3650
4300
5000
Rs. 3,00,000/- 2900
3200
3500
5200
6100
6800
Rs. 4,00,000/- 3280
4000
4400
6600
7700
8750
Rs. 5,00,000/- 4000
4800
5600
8550
10200
10700
Rs.8,00,000/- 6500
8380
10450
13500
16500
17500
Rs.10,00,000/- 7500
10500
13000
17000
21000
22000
SECTION II – Extension of the geographical limit of the policy to cover treatment
abroad
Premium : 1% additional premium below the age of 45, 1.5% between 46 to 65, 2%
between the age of 66 and 70 years of the Applicable Sum Insured of the insured persons.
All the insured persons have to opt for this Section. No selection is allowed.
Cancellation Clause:
The Company may at any time cancel this Policy by sending the Insured 30 days notice by
registered letter at the Insured’s last known address and in such event the Company shall
refund to the Insured a pro-rata premium for un-expired Period of Insurance. The company
shall however, remain liable for any claim which arose prior to the date of cancellation.
The Insured may at any time cancel this Policy and in such event the Company
shall allow refund of premium at Company ‘s short period rate only (table given here
below) provided no claim has occurred up to the date of cancellation.
PERIOD ON RISK
RATE OF PREMIUM TO BE CHARGED
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
RENEWAL OF POLICY: The Company shall be under no obligation to renew the policy
on the expiring terms. The Company reserves the right to offer revised rates, terms and
conditions, at renewal. If the policy is to be renewed for enhanced sum insured then the
restriction as applicable to a fresh policy will apply to additional sum insured as if a
separate policy has been issued for the difference. In other words, the enhanced sum
insured will not be available for an illness, disease, injury already contracted
under the original policy.
MEDICAL EXPENSES INCURRED UNDER TWO POLICY PERIODS :
A policy shall reimburse only those expenses which are incurred during the policy year.
However, if a claim spreads over two policy periods the total benefit will not exceed the
sum insured of the policy during which the insured person was admitted to hospital.
CUMULATIVE BONUS
Sum Insured under the policy shall be increased by 5% at each renewal in respect of
each claim free year of insurance, subject to maximum of 50%.
In case of a claim under the policy in respect of insured person who has earned the
cumulative bonus the increased percentage will be reduced by 10% of sum insured
at the next renewal. However, basic sum insured will be maintained and will not
be reduced. Cumulative bonus will be lost if policy is not renewed on the date
of expiry unless the delay is condoned up to maximum of 15 days and waived by the
Company.
COST OF HEALTH CHECK UP
In addition to cumulative bonus the Insured shall be entitled for reimbursement of
cost of medical check up once at the end of a block of every four underwriting years
provided there are no claims reported during the block. The cost so reimbursable
shall not exceed the amount equal to 1% of the average Sum Insured excluding CB
during the block of four claim free underwriting years.
IMPORTANT
Both Health Check up and Cumulative Bonus provisions are applicable only in
respect of continuous insurance without break excepting however, in exceptional
circumstances the break should be condoned by the Company upto maximum of 15 days
subject to medical examination and exclusion of disease/ sickness/ injury
originating or suffered during the break period.
PERIOD OF POLICY : This insurance policy is issued for a period of one year and
subject to review continuation of insurance cover will be available if the renewal premium
is paid in time.
This prospectus shall form part of your proposal form hence please sign as you have noted
the contents of this prospectus.
Signature
Name of the Proposer
Address:
Tel. No./Mobile No.
Place & Date
THE NEW INDIA ASSURANCE CO. LTD.,
Regd. & Head Office: 87, M.G. Road, Fort, Mumbai- 400 001.
Health Plus MEP new 1
PROPOSAL FORM FOR HEALTH PLUS MEDICAL EXPENSES POLICY - INDIVIDUALS
(To be completed in Duplicate)
Please read the prospectus before filling up this form.
A) The Company shall not be on risk until the proposal has been accepted by the Company and
communications of acceptance has been given to the proposer in writing on full payment of premium.
B) For persons above 45 years of age, pre-acceptance health check up will be conducted at a
designated diagnostic center. A referral slip will be given by the Divisional Office/Branch Office in the
name of diagnostic center for conducting the pre-acceptance health check up. The details of the check
up is available with the Divisional Office/Branch Office.
C) Separate detail information should be given for all the persons proposed to be covered under the
policy.
D) Fresh proposal form is required along with pre acceptance medical check up as mentioned in item
(B) above, irrespective of age, when there is break of more than 15 days in insurance cover or when
there is request for enhancement in the sum insured.
E) Non-disclosure of facts material to the assessment of the risk, providing misleading
information, fraud or non-co-operation by the insured will nullify the cover under the policy
issued.
1. NAME OF PROPOSER : Mr./Ms.____________________________________
2. RESIDENTIAL
ADDRESS:_______________________________________________________
Tel. No.
Fax No.
E-Mail:
3. Occupation:_____________________
4. Average Monthly Income Rs._______________ Income Tax Pan No:__________
5. NAME, ADDRESS & TE.NO: OF FAMILY PHYSICIAN_____________________________
_______________________________________________________________________
QUALIFICATION:____________________ REG .NO: _________________
6. Are you at present or have you been at any other time in the past covered under any other Insurance
(PA, Cancer Insurance, Hospitalization Insurance or other Medical Insurance). If so, give particulars of:
1. Name of Insurer,
2. Policy No.
3. Period of cover
4. Claim Amt. Recd./receivable
7.Any proposal for this Insurance or any other similar insurance refused or cancelled or higher premium
charged. If so, give details:
8.DETAILS OF PERSONS TO BE INSURED:
Sr. Name of all the person
Date
Age
No
of
:
Birth
1
2
3
4
5
6.
Sex
M/F
Relation Sum
with the
Insured
Proposer selected
Signature:
9.Do you wish to opt insurance under Section II____________________
MEDICAL HISTORY: Please answer the following questions with Yes or No (A dash is not sufficient
and give full details in respect of all the persons to be insured)
1
2
3
4
5
6
7
1) Are you in good health and free from physical and
Mental disease or infirmity.
2) Have you ever suffered from any illness or disease
upto the date of making this proposal.
3) Do you have any physical defect or deformity
4) Have you ever been admitted to any hospital/
nursing home/clinic for treatment or observation
5) Has any of the persons proposed for insurance
has suffered from any illness/disease or had an
accident in the past. If so, give details as under:
Sr.No:of Nature of
Date on which first
Persons illness/disease/injury & treatment taken
treatment received
First treatment
completed/is
continuing
Name of
attending medical
practitioner/surge
on with his
address & tel.
Nos.
1.
2.
3.
4.
5.
6.
7.
Note: This information should be given for any of the persons proposed for insurance, if he/she had
suffered from any illness/disease injury, please give details separately.
6) Are there any additional facts affecting the proposed
Insurance which should be disclosed to insurers? If yes,
then give details below:
7) Please give details of any knowledge of any positive
existence or presence of any ailment, sickness or
injury which may require medical attention? If yes,
then give details :
8) Name of the Assignee-
Relationship
9) Period of Insurance: From____________ To _______________
10) Declaration: I declare that the persons proposed for insurance are my family members and
they are not engaged in high risk occupation. I also declare that none of them suffer from
any pre-existing conditions and that I have given explicit information of such
sickness/disease/injury sustained in the above columns where the information has been
sought. I further declare that the above statements in respect of myself and my family
members, are true and complete. I consent and authorize the insurers to seek medical
information from any Hospital/Medical Practitioner who has at any time attended me or my
family members or may attend concerning any disease or illness which affects my or my family
members, physical or mental health. I agree that this proposal shall form the basis of the
contract should the insurance be affected. If after the insurance is affected, it is found that the
statements, answers or particulars stated in the Proposal form and its Questionnaires are
incorrect or untrue in any respect, the Insurance Company shall incur no liability under this
insurance.
I have read the prospectus and am willing to accept the coverage subject to the terms,
conditions and exceptions prescribed by the Insurance Company therein.
Signature of the Proposer : __________________Date:
__________/_________/_________Place:______________
N.B. Premium will be quoted on application.
Insurance is the subject matter of solicitation.
Section 41 of Insurance Act, 1938
Prohibition of Rebates
1) No person shall allow or offer to allow either directly or indirectly as an inducement of any person to
take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in
India any rebate of the whole or part of the commission payable or any rebate of the premium shown on
the policy nor shall any person taking out or renewing or continuing a policy except any rebate except
such rebate as may be allowed in accordance with the prospectus or tables of the insurer.
2) Any person making default in complying with the provisions of this Section shall be punishable with
fine which may extend to five hundred rupees.
For Office Use:
Basic premium under Section I for each of the insured person covered Rs.
Less: Family Discount
Rs.
Premium under Section II
(If opted)
Rs.
Plus: Service Tax
Rs.
(Family discount is not available to dependent parents premium when they are above 60 years of age under Section I)