THE NEW INDIA ASSURANCE
COMPANY LIMITED
Mount Casa Blanca Building, 2nd Floor, 260 Anna Salai, CHENNAI-600
006
Phone 044-23456824, 23456826, 23456827 Fax :
044-23456825 Email : nia25@vsnl.com
Registered & Head Office : New India Assurance
Building, 87 Mahatma Gandhi Road, Fort, Mumbai.- 400 001.
GOOD HEALTH MEDICLAIM POLICY
Policy Benefits
| Hospitalisation | Domiciliary
Hospitalisation | Pre-Hospitalisation |
Post-Hospitalisation | Insured/Insured Person |
Age Limit | Medical Examination |
Claims Procedure | Premium Rates
|
IT
Benefit | I
want to buy this policy | Renewal of
Policy |
Cancellation of
policy | Cashless Access,
Hospital Cash benefits
The policy covers reimbursement of
hospitalisation/domiciliary hospitalisation expenses for illness / disease or injury
sustained subject to
the following limits of sum insured, policy terms, conditions and exclusions as specified in the
policy
certificate.
|
Sl. No. |
Hospitalisation Expenses |
Limits |
|
|
1. |
(i) |
Room, Board & Nursing Expenses as provided by the hospital/nursing home including registration and service charges |
Up to 1% of Sum Insured per day |
|
|
(ii) |
If admitted into IC Unit |
Up to 2% of Sum Insured per day |
|
|
(iii) |
All admissible claims under (i) and (ii) during the policy period |
Up to 30% of Sum Insured per illness/injury |
|
2 |
|
Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees |
Up to 30% of Sum Insured per illness/injury |
|
3 |
|
Emergency Ambulance charges upto Rs.1000/-, Aneaesthesia, 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/treatment |
Up to 40% of Sum Insured per illness/injury |
NON-ALLOPATHIC TREATMENT
The claims which are otherwise
admissible under this policy, will be restricted to 20%
of the sum insured subject to
a maximum limit of Rs.25,000/- per claim.
NOTE :
a) Hospitalisation expenses incurred for treatment of any one illness under
agreed package charges will be restricted to 80% of the actual package charges
or the sum insured whichever is less.
b) Hospitalisation expenses of a 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.
c) The limit per claim would apply to the overall total claim amount including
pre and post-hospitalization claims and shall be subject to clause 2.5
pertaining to Any one Illness.
d) Company's liability in respect of all claims admitted during the period of
Insurance shall not exceed the Sum Insured for the insured person as mentioned
in the Policy Certificate.
Liability of the Company under policy clause is restricted as below.
| Plan Option | Total Sum Insured (Rs.) | Domiciliary
Hospitalisation Limit (Rs.) |
Maximum days for Hospital Cash |
Hospital Cash Benefits per day (Rs.) |
| 5,15,23 | 50,000 | 5,000 | 0,15,30 | 0,100/- |
| 6,16,24 | 1,00,000 | 10,000 | 0,15,30 | 0,200/- |
| 7,17,25 | 1,50,000 | 15,000 | 0,15,30 | 0,300/- |
| 8,18,26 | 2,00,000 | 20,000 | 0,15,30 | 0,400/- |
| 9,19,27 | 2,50,000 | 25,000 | 0,15,30 | 0,500/- |
| 10,20,28 | 3,00,000 | 30,000 | 0,15,30 | 0,600/- |
| 11,21,29 | 4,00,000 | 40,000 | 0,15,30 | 0,800/- |
| 12,22,30 | 5,00,000 | 50,000 | 0,15,30 | 0,1000/- |
Note : Plan options 5 to 12 do not have hospital cash
benefits.
In respect of following
specified ailments, Company’s liability in respect of each and every claim,
admitted during the period of
insurance, subject to the policy terms, conditions
and exclusions, shall not exceed the limits mentioned against the respective
ailment or the sum insured available for the insured person, whichever is less:
The expenses incurred on treatment of the
following specified diseases are payable only after completion of continuous,
period of insurance as specified against each
disease.
|
* Diseases /
Ailments / Treatment |
Period for which claims not admissible |
Limit per claim (after the exclusion period) |
|
Knee Replacement (due to arthritis, rheumatism and other degenerative disorders) |
3 years |
** 50% of sum insured |
|
Hip Replacement(due to arthritis, rheumatism and other degenerative disorders) |
3 years |
** 50% of sum insured |
Cataract Surgery |
3 years |
20% of sum insured |
|
Benign Prostatic Hypertrophy |
2 years |
20% of sum insured |
|
Hysterectomy (Due to fibroids or Menorrhagia) |
2 years |
20% of sum insured |
|
Hernia |
2 years |
20% of sum insured |
|
Hydrocele |
2 years |
20% of sum insured |
|
Congenital Internal Disease/Defect |
2 years |
20% of sum insured |
|
Fistula in Anus and Piles |
2 years |
20% of sum insured |
|
Sinusitis & Related Disorders |
2 years |
20% of sum insured |
* All pre-existing diseases/defects are excluded permanently from the scope of the policy.
** In case of Cataract/Total Knee/Hip replacements, where two eyes or
two knees or two hips are replaced/operated
in a single procedure, the limit per claim indicated as
above will be reckoned at twice these limits.
The limit per claim would apply to the overall total claim amount including
pre and post hospitalization claims and shall
be subject to our policy terms and conditions pertaining to Any
one illness mentioned.
If these diseases (other than congenital internal diseases/defects) are pre-existing at the time of proposal they will not be covered even during subsequent period of renewal.
If insured is aware of the existence of congenital internal disease/defect before inception of policy, it will be treated as pre-existing.,and hence will be excluded from the scope of cover.
This is a cash benefit offered other than medical claim and sum insured..
Plan options 15 to 30 cover this benefits.
Plan options 15 to 22 cover 15 days benefits and plan options 23 to30 cover 30 days benefits.
Plan options 5 to 12 do not cover this benefits.
Per day eligible amount for disbursement is based on plan options as stated above.
Eligibility to claim this benefits:
1) Plan options between 15 and 30 should be opted.
2) Hospitalisation is required
3) Medical claim under the policy should be valid.
If the sum insured under the policy is exhausted and
maximum no. of days for hospital cash benefits are not exhausted,
then hospital cash benefits is still payable for eligible hospital cash benefits
days.
If there is no balance days for hospitalisation cash benefits is available, then
hospitalistion cash benefits will not be paid.
The payment in respect of this benefit will be made
directly to the insured afater discharge from the hospital upon submission
of proof of hospitalization and the relevant claim form to the claim
processing third party administrators.
As in the case of Good Health Mediclaim Section, all the claims under this
benefit also, are to submitted to the Third Party Administrators, viz. TTK
HealthCare TPA Private Ltd.
CUMULATIVE BONUS
Cumulative Bonus will be
available under this policy subject to the following conditions:
Ø Sum
Insured under the Policy shall be progressively increased by 5%, by way of
cumulative bonus, in respect of each claim free year of insurance, subject to a
maximum accumulation of 10 claim free years.
Ø This
cumulative bonus is applicable to the sum insured, which is renewed continuously
for a period of 3 years including the current year. In other words, the
cumulative bonus will be applicable on the least of the sum insured during this
3 year period.
Ø For fresh customers who are already covered under any other mediclaim policy, the cumulative bonus, if any, earned by them earlier, shall be allowed upon continuous renewal under this policy subject to a maximum of 5% only.
Ø For renewal customers of Good Health Mediclaim policy, this cumulative bonus would apply effective from Oct 2004 GH scheme only subject to a maximum of 5% in the first year provided there being no claim during 2003-04 policy.
Ø In case of any claim under this policy in respect of the insured person who has earned the cumulative bonus, the increased percentage will be reduced by 10 % at the next renewal. However basic sum insured will be maintained and will not be reduced.
Ø Cumulative bonus will be lost if policy is not renewed on the date of expiry.
Ø
The
Cumulative bonus shown in the policy certificate is provisional and it is
subjedt to revision in the event of any claim
under the earlier policy being reported after
issuance of this policy.
Expenses
on HOSPITALISATION
for a minimum period of 24 hours are admissible.
However, this time limit will not
apply for specific treatments i.e., Dialysis, Chemotherapy, Radiotherapy, Eye
Surgery,
Dental Surgery, Lithotripsy, (Kidney stone removal), D & C, Tonsillectomy
taken in the
Hospital/Nursing Home and the Insured is discharged on the same day ; the
treatment will be considered
to be
taken under
Hospitalisation Benefit.
for such treatments.
Relevant medical expenses incurred, during the period
up to 30 days prior
to hospitalistion,
on disease/illness
sustained, other than those for which the time limit of 24 hours hospitalisation
does not apply as mentioned under the head "HOSPITALISATION"
this does not include the expenses on doctor's house visits and on engaging
nurses or maids to take care insured person(s)
convalescing at home.
5
POST-HOSPITALISATION
Relevant medical expenses incurred, during the period
up to 60 days after hospitalisation, on disease/illness sustained
INSURED
means Citibank Credit Card
members who have proposed for this insurance.
INSURED PERSON
means Citibank Credit Card members and/or their family members
covered by this policy.
7.1
This
insurance is available to persons between ages of 5 yrs and 70 yrs.
7.2
Children
between 3 months and 5 years of age can be covered provided one or both parents
are covered
simultaneously.
7.3 The upper age limit for coverage has been extended to 100 years for the existing policy holders who have been covered our good health policy continuously without any break for 5 years.
7.4
The right
to accept or reject for coverage any person proposed for this mediclaim
insurance, whether for fresh or
renewal, shall rest solely with the Company.
8.
MEDICAL
EXAMINATION FOR FRESH ENTRANTS AGED 61 YEARS AND ABOVE [Go
top]
Persons
between the ages of 61 and 70 years (No fresh policy will be issued for above
70 years) , who are proposed for this mediclaim
insurance for the first time, can be covered subject to a) their medical
examination by a Medical Practitioner registered with the Indian Medical
Association and b) the reports of specified diagnostic tests, such as ECG, Blood
Sugar (Fasting and Post Prandial) and/or Urine Strip Test, etc., on them duly
evaluated by such Medical Practitioner.
The findings of such Medical examination and evaluation of diagnostic test reports duly recorded in the prescribed format of Medical Practitioner’s Report and signed by such Medical Practitioner and also the insured person should be submitted to the Citibank along with the copies of diagnostic test reports at the time of submission of the Proposal form in respect of such persons.
Such medical
examination and diagnostic tests should have been done within a period of 60
days prior to the commencement of this mediclaim policy. The coverage of such
persons for mediclaim insurance under this policy shall be solely at the
discretion of the Company. Proposals
accepted based on such Medical Practioner's Report does not prejudice the right
of the Company to reject claims arising out of any pre-existing disease which
has not been disclosed at the time of the proposal.
9. CLAIMS
PROCEDURE
[Go top]
Card members who are all covered under the Feb 2003 scheme onwards, should
contact our Third Party
administrator, TTK Health Care TPA Pvt.Ltd.,
for claim purpose. For others, the procedure is given below:
9.1 Preliminary notice of claim with
particulars relating to policy number, name of insured person in respect of whom
claim is made, nature of illness/injury and name and address of attending
medical practitioner/hospital/nursing home should be given by the Card Member to
the Company within 7 days from the date of
hospitalisation/domiciliary hospitalisation.
9.2 Final claim along with completed
claim form,(claim form can be downloaded from
www.ttkhealthcareservices.com) Originals of all receipts, bills and
cash memos, and documents (as listed in the claim form) such as
Admission-cum-Discharge Summary from the Hospital, Attending Doctor’s
Certificate (in the prescribed format), copies of diagnostic test reports,
prescriptions for medicines purchased, police report/FIR (only in case of
accidents) wherever applicable, etc., and the copies
of policy copies of earlier years, should be submitted to the Company
within 30 days from date of completion of treatment.
Hospital/Diagnostic center bills should be supported
by proper printed and revenue-stamped receipts and the receipts for Doctor's
fees should have the name, address and registration number of the Doctor
printed therein. (Receipts for Doctor's fees on plain paper with the rubber
stamp of the Doctor affixed therein or on the letter head of the hospital will
not be accepted).
9.3 Any medical practitioner or other
representative authorised by the Company shall be allowed to
examine
the insured person,
in the event of any claim
for Hospitalisation or Domiciliary
Hospitalisation being made on
the Company, when
and so often as the same may reasonably be required by or on behalf of the
Company.
9.4 The Company shall not be liable to make any payment
under this policy in respect of any
claim if such claim be
in any manner fraudulent
or supported by any fraudulent
means or device whether by the Insured
Person or by
any other person acting
on his behalf. The insured shall forfeit all benefits under this policy and the
policy shall
become void.
9.5 All medical/surgical treatment under this policy shall
have to be taken in India and admissible claims thereof shall be
payable in Indian currency.
9.6 If the policy is to be renewed for enhanced sum insured,
then the restriction as applicable to a fresh policy will apply
to the additional sum insured,
as if a separate policy has been issued for the same. Hence, claims for
illnesses
contracted during
the previous policy period(s) shall be restricted to the old sum insured
under the relevant
previous policy period.
10. Good Health Mediclaim Insurance Premium Rates [Go top]
Click here to view premium rates
Citibank customers need pay only the premium amount indicated above plus the transaction fee charged by Citibank, according to the plan option selected by them. The limits indicated for the Domiciliary Hospitalisation Benefit under the various plan options is forming part of the Maximum sum insured for such plan options. The Sum Insured and Premium indicated above are per person. Premium includes 12.24% service tax but does not include the Transaction fee charged by Citibank.
11. INCOME TAX BENEFIT [Go top]
Premium paid for availing this Mediclaim Insurance cover for self, spouse, dependant children, and dependant parents only, (kindly consult the relevant Income Tax Act provision for a definition of the term "dependant") is eligible for 100% deduction under Section 80-D of the Income Tax Act, 1961, at the hands of the Citibank Card Member,
12. What is the procedure for availing this Policy ?
The Proposer shall make an application either:
(a) in writing, in the prescribed application / proposal form, duly completed and signed, alongwith the prescribed Medical Practitioner’s Report and diagnostic test reports, wherever applicable, in respect of all the persons proposed for this mediclaim insurance, to Citibank Card Center (Attn. Good Health Policy), 2 Club House Road, Chennai-600 002 , so that the said forms are received at Citibank prior to the last date specified for this purpose, to be eligible for consideration of his/her request for Good Health Mediclaim Policy cover, or
(b) over phone, (local citiphone numbers) where the persons proposed for insurance are not over 45 years of age, by providing the required details to Citibank authorized telecalling company and for which Citibank would submit the prescribed Authorisation–cum- Advice for policy issuance (MOTO) to the Company, or
The Company shall not be liable for any dispute arising out of the transaction between the proposer and Citibank in respect of this insurance. The Company shall not be liable for omission or rejection of any such application either wholly or in part, due to any decision, action or omission of Citibank or due to non-receipt or delayed receipt (i.e., after the due date) of the application form or of the medical practitioner’s report, wherever required, or due to the application received being incomplete in any respect or due to any other reason whatsoever.
13. How to renew this Policy ?
Kindly look
in at Renewal of Policy
for details. Card Members should ensure renewal of their Good health
policy without any break. If you opt
for non-renewal of this policy or changes in members for subsequent
policies, kindly inform the Citibank by filling in the application form indicating your preference and ensuring that
it reaches at least 10 days prior to the date of commencement of the policy. Once the policy is renewed no
request for
alteration of policy choice will be entertained. If the policy is to
be renewed for enhanced sum insured,
as a continuation of the earlier policy
either with this company, or with any other insurance company in India, then the
restriction as applicable to a fresh policy
will apply to the additional sum insured, as if a separate policy has been
issued for the same.
14. How to
cancel this
Policy ?
In case
renewal of policy was effected against the insured's option for non-renewal, the said policy may be
cancelled from its inception, at the
request of the insured to either Citibank/the Company,
within the
prescribed time limit, and full refund of
premium shall be made over to Citibank on behalf of
the insured by the
Insurance Company provided no claim has
occurred up to the date of cancellation. Citibank's confirmation of
receipt of request for such cancellation
will be binding upon the insured.
In all other cases 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 rates only as indicated below, provided no claim has
occurred up to the date of cancellation.
Period on Risk
Rate of premium to be retained
Up to 1 month
1/4 th of the Annual Rate
Up to 3
months
1/2 th of the Annual Rate
Up to 6 months
3/4 th of the Annual Rate
Exceeding
6 months
Full Annual Rate
In the event of the insured
requesting for cancellation of this policy and seeks refund of premium,
any certificate issued to the insured for the purpose of claiming deduction
under Section 80-D of the Income-Tax Act, 1961, shall also be deemed to be
cancelled and the insured cannot claim any deduction for Income-Tax purposes,
against the such policy or certificate.
Policy Benefits
| Hospitalisation | Domiciliary
Hospitalisation | Pre-Hospitalisation |
Post-Hospitalisation | Insured/Insured Person |
Age Limit | Medical Examination |
Claims Procedure | Premium Rates
|
IT
Benefit | I
want to buy this policy | Renewal of
Policy |
Cancellation of
policy |.Cashless Access,Hospital
Cash benefits