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| 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  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 per Claim

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 Claim

2

 

Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees

Up to 30% of Sum Insured per Claim

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 claim

 

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 to sum insured applicable for the plan number opted.

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 claim 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)

3years

 ** 50% of sum insured

Cataract Surgery

3 years

 20% of sum insured subject to a maximum of Rs.40,000/- per eye.

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 (PED) will be covered under the scope of the policy AFTER FOUR CONTINUOUS POLICY PERIOD..

** 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.

 

This is a cash benefit extended to cover incidental expenses during hospitalisation.  The amount of cash benefit and the maximum number of days allowable during a policy period depends upon the Table and plan number chosen :

Table wise Hospital Cash Benefit
Table  Table -2  Table -3  Table - 5
Plan Nos. 15 to 22 & 93 to 94 23 to 30 & 95 to 96 31 to 35
No. of Days 15 30 200
Age Up to 100 yrs Up to 100 yrs Up to 70 yrs Age more than 70 yrs
Cash Benefit payable  0.2% of Basic Sum Insured per day for Plan Nos.15-22.  0.2% of Basic Sum Insured per day for Plan Nos.23-30. 1. @ Rs.1,000/- per day for Non-Accident Hospitalisation. Rs.500/- per day for a maximum of 30 days during the period of insurance irrespective of nature of Hospitalisation.
Rs.1,250/- for Plan no.93 Rs.1,250/- for Plan no.95 2. However if the insured person is in ICU, during such period benefit shall be paid @ Rs.2,000/- per day for a maximum of 15 days during the policy year.
Rs.1,500/- for Plan no.94 Rs.1,500/- for Plan no.96 3. @ 2000/- per day for a maximum of 15 days during the policy year for Hospitalisation due to Accident.
    4. Convalescence Benefit - Rs.15,000/- if confinement in hospital exceeds 21 consecutive days payable once during the policy year.

This benefit shall be payable

1) In addition to the Hospitalisation expenses covered by the Policy..
2) Only in the event of claim for Hospitalisation being admissible.
3) In all, only for maximum number of days opted, in respect of any number of Hospitalisation / claims that may occur
    during the Period of insurance.
4) Under 200 days for age upto 70 yrs the benefits 2 & 3 starts on completion of first 24 hrs and only one benefit either 1,
     2 or 3 shall be payable at a time and not collectively.

<< If the sum insured under the policy is exhausted and maximum no. of days for hospital cash benefits are not exhausted, then hospital cash benefit is still payable for eligible number of days.

<< The payment in respect of this benefit will be made directly to the insured after discharge from the hospital upon submission of proof of hospitalization along with the relevant claim form to Third Party Administrator.

Cumulative Bonus will be available under this policy subject to the following conditions:

  1. 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.

  2. Cumulative Bonus accrual will start from zero for the increased sum insured.

  3. 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.

  4. 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.

  5.  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.

  6. Cumulative bonus will be lost if policy is not renewed on the date of expiry.

  7. The Cumulative bonus shown in the policy certificate is provisional and it is subject 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 referred to as Day Care Procedure.

In addition to the above, the following Day Care procedures are covered with a sub limit of 20% of the Sum Insured :

 

Relevant medical expenses incurred, during the period up to 30 days prior to 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 mentioned 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.

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.

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

  1. This insurance is available to persons between ages of 5 yrs and 65 yrs.

  2. Children between 3 months and 5 years of age can be covered provided one or both parents are covered simultaneously.

  3. 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.

 

Persons between the ages of 61 and 65 years (No fresh policy will be issued for persons aged above 65 years) , who are proposed for this mediclaim insurance for the first time, can be covered subject to

  1. their medical examination by a Medical Practitioner registered with the Indian Medical Association

  2. 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.

Card members  should contact our Third Party administrator for all claim related queries. 

The policy provides for cashless access to network hospitals i.e. those hospitals empanelled by the TPA.  If cashless access facility is availed, the TPA will directly settle the Hospital bills, subject to fulfillment of specified formalities by the insured and policy terms and conditions. 

Where cashless access facility is not availed, the procedure for making a claim under Good Health Policy is given below:

  1. Preliminary notice of claim with particulars relating to Good Health Certificate 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.

  2. Final claim along with completed claim form (claim form can be downloaded under Downloads option), 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.  

  3. Hospital/Diagnostic center bills should be supported by proper printed and revenue-stamped receipts.  No payments shall be made for any Hospitalisation expenses incurred, unless they form part of the Hospital Bill.  However the bills raised by Surgeon, Anaesthetist directly and not included in the Hospital Bill shall be paid provided a numbered Bill giving details of cheque / cash payment is produced in support thereof.  If payment is made in cash, the maximum amount payable will be restricted to Rs.10,000/-. 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).

  4. 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.

  5. 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.

  6. All medical/surgical treatment under this policy shall have to be taken in India and admissible claims thereof shall be payable in Indian currency.

  7. 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.

             Click here to view premium rates

Citibank customers need to pay only the premium amount indicated in the premium chart  based on  the plan option selected by them. The Sum Insured and Premium indicated above are per person. Premium includes service tax.

Premium paid under Good Health Insurance covering self, spouse, dependent children, and dependent parents only, (kindly consult the relevant Income Tax Act provision for a definition of the term "dependent") is eligible for 100% deduction under Section 80-D of the Income Tax Act, 1961.

            To avail a Good Health Policy, the card member has to send SMS "GHP" to 52484 from his registered mobile with

            Citibank.

            <<Payment of Premium

The premium for Good Health Policy in respect of eligible persons will be debited to the Card/Account of the customers by Citibank. Premium rates for Good Health Mediclaim Policy and Good Health Personal Accident Policy are given separately.

            <<Issuance of Goodhealth Policy Certificate

Good Health Policy certificates will normally be dispatched  within 45 days from the date of commencement of the 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 for any changes in the renewal policy, kindly inform Citibank by filling in the application form indicating your preference and ensuring that it reaches at least 30 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.

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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