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.

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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


POLICY 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
   (Refer to 4.3 clause of our policy
    condition)         

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.

HOSPITAL CASH BENEFITS

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.                    [Go top]

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.  However, pre-hospitalisation and post-hospitalisation expenses are not admissible
for such treatments.

4.       PRE-HOSPITALISATION                                                                                                  [Go top]

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"
above  will be considered as part of claim mentioned under item 1.1 above.  However,
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                                                                                               [Go top]

Relevant medical expenses incurred, during the period up to 60 days after hospitalisation, 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" above will be considered as part of claim as mentioned under item 1.1 above. However, this does not  include the expenses on doctors' house visits and on engaging nurses to take care of  patients convalescing at home.

6.      INSURED/INSURED PERSON

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.             AGE LIMIT                                                                                                                        [Go top]

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

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