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1. WHEREAS the Insured designated in the Schedule hereto has by a proposal and declaration which shall be the basis of this Contract and is deemed to be incorporated herein, has applied to NATIONAL INSURANCE COMPANY LTD (hereinafter called the COMPANY), for the insurance hereinafter set forth in respect of Account holders of BANK OF INDIA (including their eligible family members) named in the Schedule hereto (hereinafter called the INSURED PERSON) and has paid premium as consideration for such Insurance.
COVERAGE:
1.1 NOW THIS POLICY WITNESSES that subject to the terms, conditions, exclusions and definitions contained herein or endorsed, or otherwise expressed hereon the Company undertakes that if during the period stated in the schedule or during the continuance of this policy by renewal any insured person shall contract any disease or suffer from any illness (hereinafter called DISEASE) or sustain any bodily injury, through accident (hereinafter called INJURY) and if such disease or injury shall require any such insured person, upon the advice of a duly qualified physician/Medical Specialist/Medical Practitioner(hereinafter called MEDICAL PRACTITIONER) or of a duly qualified Surgeon(hereinafter called SURGEON) to incur hospitalization expenses for medical/surgical treatment at any Nursing Home/Hospital in India as herein defined (hereinafter called HOSPITAL) as an inpatient, the company will pay through the TPA to the Hospital/Nursing Home or Insured person the amount of such expenses as are reasonably and necessarily incurred in respect thereof by or on behalf of such Insured Person but not exceeding the Floater Sum Insured in aggregate in anyone period of insurance stated in the schedule hereto.
1.2 In the event of any claim becoming admissible under the policy, the company will pay through TPA to the Hospital/Nursing Home or insured person the amount of such expenses as would fall under different heads mentioned below and as are reasonably and necessarily incurred thereof by or on behalf of such insured person.
a) Room, Boarding expenses as provided by the Hospital/Nursing Home.
b) Nursing expenses. ¬
c) Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees.
d) Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical appliances, Medicines & Drugs, Diagnostic Materials and X-Ray, Dialysis, Chemotherapy, Radiotherapy cost of pacemaker, Artificial Limbs and cost of organs and similar expenses.
1.3:Additional covers:
1) Ambulance charges not exceeding Rs.1000/- (Rupees one thousand only) per Policy period.
2) In case of Hospitalization of children below 12 years, a lump sum amount of Rs.1000/- (Rupees one thousand only) per policy period towards the out-of-pocket expenses. The payment will be made on the basis of a declaration from the parent without insisting on any supporting bill/cash memo.
3) Cost of health check-up: It is allowed at the rate of 1% of the sum insured after completion of three continuous claim free years of policy/policies issued by National Insurance Company Ltd. only.
4) Pre & Post Hospitalization Expenses for first 30 days and 60 days respectively.
5) Pre-existing Diseases Cover:
Benefits for pre existing diseases will be available only after the completion of 36 months of continuous coverage since inception of the first policy with us.
Pre-existing disease shall mean any condition, ailment or injury or related condition(s) for which you had signs or symptoms and/or were diagnosed and/or received medical advice/treatment within 48 months prior to your first policy with us.
6) Maternity Benefit and Baby Care Expenses are also reimbursed up to 5% of the sum insured.
7) In case of death in hospital, funeral expenses are reimbursed up to Rs.1000/- over and above the sum insured subject to original illness/accident claim admitted under the policy.
8)Treatment of NRIs in Indian hospitals allowed.
9) Treatment in hospitals in Nepal and Bhutan are also covered in Indian currency.
(N.B. Company's Liability in respect of all claims admitted during the period of Insurance shall not exceed the Floater Sum Insured per family as mentioned in the schedule).
2. DEFINITIONS:
2.1 HOSPITAL / NURSING HOME means 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:
(1) It should have at least 15* inpatient beds
(2) Fully equipped operation theatre of its own wherever surgical
Operations are carried out. ¬
(3) Fully qualified Nursing Staff under its employment round the clock.
(4) Fully qualified Doctor(s) should be in-charge round the clock.
*N.B. In class 'C' towns’ proviso of number of beds is reduced to 10.
2.1.1 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, hotel or a similar place.
2.1.2 '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.
2.1.3 Expenses on Hospitalization for 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 and such treatment will be considered to be taken under Hospitalization Benefit. This condition will also not apply in case of stay in Hospital of less than 24 hours provided.
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
2.1.4 Family: The size of the family shall consist of the Bank of India Account holder, his/her spouse and their two dependent children (i.e. maximum 1 + 3 only)
3. ANY ONE ILLNESS:
Anyone illness will be deemed to mean continuous period of illness and it includes relapse within 45 days from the date of discharge from the Hospital/Nursing Home from where treatment was 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.
3.1 PRE HOSPITALISATION: Relevant medical expenses incurred during period up to 30 days prior to Hospitalization on disease/illness/injury sustained will be considered as part of claim as mentioned under item 1.2 above.
3.2. POST HOSPITALlSATlON : Relevant medical expenses incurred during the period up to 60 days after Hospitalization on disease/illness/injury sustained will be considered as part of claim as mentioned under item 1.2 above.
3.3 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.
3.4 QUALIFIED NURSE means a person who holds a certificate of recognized Nursing Council and who is employed on recommendation of the attending Medical Practitioner.
3.5 TPA means a Third Party Administrator, who, for the time being, is licensed by the Insurance Regulatory and Development Authority, and is engaged, for a fee or remuneration, by whatever name called as may be specified in the agreement with the Company, for the provision of health services.
3.6: Pre-existing disease shall mean any condition, ailment or injury or related condition(s) for which you had signs or symptoms and/or were diagnosed and/or received medical advice/treatment within 48 months prior to your first policy.
4. 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:
4.1 Benefits for pre existing diseases will not be available for any condition(s) as defined in the policy until 36 months of continuous Coverage has elapsed since inception of the first policy with us.
4.2 Any hospitalization expenses incurred in the first 30 days from the commencement date of Insurance cover except in case of Injury arising out of accident.
4.3 During the period of twelve months from the date of inception of the policy, the expenses on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, and Hysterectomy for Hemorrhagic, or Fibromyoma, Hernia, Hydrocele, congenital internal disease, Fistula in anus, Piles, Sinusitis and related disorders are not payable. These diseases, if pre-existing, will be covered only as per provisions of4. 1 above.
4.4 Injury/disease directly or indirectly caused by or arising from or attributed to War, Invasion, Act of Foreign enemy, War like operations (whether war be declared or not).
4.5 Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident, vaccination or inoculation 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 a part of any illness.
4.6 Cost of spectacles and contact lenses, hearing aids.
4.7 Dental treatment or surgery of any kind unless requiring hospitalization.
4.8 Convalescence, general debility, run-down condition or rest cure, congenital external disease or defects or anomalies, Sterility, Infertility, Venereal disease, intentional self injury and illness, disease or accident for use of or contributed by use of intoxication drugs/alcohol.
4.9 All expenses arising out of any condition directly or indirectly caused to or associated with Human T-Cell Lymph tropic Virus Type-III (HTLB-III) or Iymphadinopathy Associated Virus (LAV) OR The Mutants Derivative or Variation Deficiency Syndrome or any syndrome or condition of similar kind commonly referred to as AIDS.
4.10 Charges incurred at Hospital or Nursing Home primarily for diagnosis X-ray or Laboratory examinations or other diagnostic studies not consistent with or 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.
4.11 Expenses on vitamins and tonics unless forming part of treatment for injury or diseases as certified by the attending physician.
4.12 Injury or Disease directly or indirectly caused by or contributed to by nuclear weapon/materials.
4.13 Expenses in excess of 5% of the Sum Insured as mentioned in the schedule due to treatment arising from or traceable to pregnancy (including voluntary termination of pregnancy) and child birth (including Caesarean Section) and allied maternity benefits. No expenses will be payable for any treatment arising from or traceable to Voluntary Termination of Pregnancy.
4.14 Naturopathy Treatment.
4.15 Domiciliary Hospitalization expenses
4.16 The benefits like Cumulative Bonus, health check up including continuity accrued under the previous Policy/Policies, issued by any other Insurance Company shall not be available under this Policy.
5. Conditions applicable to Hospitalization Expenses Cover:
5.1 Every notice or communication to be given or made under this Policy shall be delivered in writing at the address of the TPA office as shown in the Schedule.
5.2 Upon the happening of any event, which may give rise to a claim under this policy notice with full particulars shall be sent to the TPA named immediately and in case of emergency within 24 hours of Hospitalization.
5.3 All supporting documents relating to the claim must be filed with TPA within 30 (thirty) days from the date of discharge from the hospital. In case of Post-hospitalization, treatment (Limited to 60 days), all claim documents should be submitted within 30 (thirty) days after completion of such treatment.
Note: Waiver of this Condition may be considered in extreme cases of hardship where it is proved to the satisfaction of the Company that under the physical 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.
5.4 The Insured Person shall obtain and furnish the TPA with all original bills, receipts and other documents upon which a claim is based and shall also give the TPA such additional information and assistance as the TPA may require in dealing with the claim.
5.5 Any medical practitioner authorized by the TPA shall be allowed to examine the Insured person in case of any alleged injury or disease requiring Hospitalization when and so often as the same may reasonably be required on behalf of the Company at the cost of the Company.
5.6 If at the time when any claim arises under this Policy, there is in existence any Mediclaim/Health Insurance Policy issued by any other Insurer (other than Cancer Insurance Policy in collaboration with Indian Cancer Society), whether it be effected by or on behalf of any Insured Person in respect of whom the claim may have arisen covering the same loss, liability, compensation, costs or expenses, the Company shall not be liable to pay or contribute more than its rateable proportion of any loss, liability, Compensation, cost or expenses. The benefits under this Policy shall be in excess of the benefits available under the Cancer Insurance Policy subject to the Floater Sum Insured of this policy set in the schedule and also subject to admissibility of the claim under this policy.
5.7 All Medical/Surgical treatments under this policy shall have to be taken in India or as provided in 1.3.9 above and admissible claims thereof shall be payable in Indian Currency. Payment of claim shall be made through TPA to the Hospital Nursing Home or the Insured Person as the case may be.
Additional Conditions:
1. The Policy shall commence either from (a) the date of Debit of Premium from the Insured’s Bank account if the instrument with the proposal/renewal advice is dispatched to the Company on the same date or (b) the actual date of dispatch of the instrument with proposal/renewal advice or (c) the date of deposit of premium to the Company to comply to provisions of Section 64 VB of Insurance Act.
The due payment of premium and the observance and fulfillment of the terms, provisions, conditions and endorsements of this Policy by the Insured Persons in so far as they relate to anything to be done or complied with by the Insured Person shall be a condition precedent to any liability of the Company to make any payment under this policy. No waiver of any terms, provisions, conditions and endorsements of this policy shall be valid unless made in writing and signed by an authorized official of the Company.
2. 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.
3. The Policy may be renewed by mutual consent. The Company shall not however be bound to give notice that it is due for renewal. In case the policy is not renewed in time due to any exceptional circumstances beyond the physical control of the insured and is to the satisfaction of the Company, a grace period up to 15 days may be allowed for renewal of the policy without withdrawal of any accrued benefit under the policy.
The Company may at any time cancel this policy on grounds of misrepresentation, fraud, moral hazard, non-disclosure of material facts or non co operation of the insured by sending 30 days notice by registered letter at insured’s last known address. In the event of the Company canceling the policy for mis-representation, fraud, moral hazard, non-disclosure of material facts or non-co operation, no refund of premium shall be made. The Company shall, however, remain liable for any claim, which arose prior to the date of cancellation.
It is further understood and agreed that the premium has been remitted by the bank on collection of the same or by duly debiting the account of account holders with prior consent. On such policy of insurance being issued, the company shall not entertain any request for cancellation and consequent refund of premium therefore on any grounds whatsoever shall not arise.
4. The Company shall not be bound to take notice or be affected by any notice of any trust, charge, lien, assignment or other dealings with or relating to this policy but the receipt of the insured or his legal personal representative(s) shall in all cases be an effective discharge to the Company.
5. If any dispute or difference shall arise as to the quantum to be paid under the policy (Liability being otherwise admitted) such difference shall independently of all other questions be referred to the decision of a sole arbitrator to be appointed in writing by the parties or if they cannot agree upon a single arbitrator within 30 days of any party invoking arbitration, the same shall be referred to a panel of three arbitrators, comprising of two arbitrators, one to be appointed by each of the parties to the dispute / difference and the third arbitrator to be appointed by such two arbitrators and arbitration shall be conducted under/in accordance with the provisions of the Arbitration and Conciliation Act 1996.
It is clearly agreed and understood that no difference or dispute shall be referable to arbitration as herein before provided if the Company has disputed or not accepted liability under or in respect of this Policy.
It is hereby expressly stipulated and declared that it shall be condition precedent to any right of action or suit upon this Policy that award by such arbitrator/arbitrators of the amount of the loss or damage shall be first obtained.
6. It is also hereby further expressly agreed and declared that if the Company/TPA shall disclaim liability to the insured for any claim hereunder and such claims shall not within 12 calendar months from the date of such disclaimer have been made the subject matter of a suit in court of law, then the claim shall for all purposes be deemed to have been abandoned and shall not thereafter be recoverable hereunder.
7. No sum payable under this Policy shall carry interest except in accordance with IRDA regulations.
8. Special conditions applicable to Maternity & Baby care Expenses Benefit:
• Those Benefits are admissible only if the expenses are incurred in hospital/ nursing home as
inpatient in India up to 5% of sum insured.
• A waiting period of 9 months is applicable for payment of any claim relating to normal delivery or caesarean section or abdominal operation for extra uterine pregnancy. The waiting period may be relaxed only in case of delivery, miscarriage or abortion induced by accident or other medical emergency.
• Claim in respect of delivery for only first two children and/or operations associated therewith will be considered under the Policy or any renewal thereof. Those Insured persons who are already having two or more living children will not be eligible for this benefit.
• Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 weeks from the date of conception are not covered.
• Pre-natal and post-natal expenses are not covered unless admitted in Hospital/ Nursing home and treatment is taken there.
6. COST OF HEALTH CHECK UP
The insured shall be entitled for reimbursement of the cost of medical check up once at the end of block of every three underwriting years/policy periods provided there are no claims reported during the block. The cost so reimbursable shall not exceed the amount equal to 1% of the amount of average sum insured during the block of three underwriting years/policy periods.
IMPORTANT
Health Check-up provision as aforesaid is applicable only in respect of continuous insurance without break under this scheme. Health Check-up benefit will be accrued after completion of Three years continuous claim free insurance.
Procedure for availing Cashless Access Services in Network Hospital/Nursing Home.
Claims in respect of Cashless Access Services will be through the list of the network of Hospitals/Nursing Homes and is subject to pre admission authorization. The TPA shall, upon getting the related medical information from the insured persons/ network provider, verify that the person is eligible to claim under the policy and after satisfying itself will issue a pre-authorisation letter/ guarantee of payment letter to the Hospital/Nursing Home mentioning the sum guaranteed as payable, also the ailment for which the person is seeking to be admitted as a patient.
The TPA reserves the right to deny pre-authorization in case the insured person is unable to provide the relevant medical details as required by the TPA. The TPA will make it clear to the insured person that denial of Cashless Access is in no way construed to be denial of treatment. The insured person may obtain the treatment as per his/her treating doctors advice and later on submit the full claim papers to the TPA for reimbursement.
The TPA may repudiate the claim, giving reasons, if not covered under the terms of the policy. The insured person shall have right of appeal to the insurance company if he/she feels that the claim is payable. The insurance company’s decision in this regard will be final and binding on TPA.
GRIEVANCE REDRESSAL:
In compliance to IRDA (Protection of Policy Holders’ Interest) Regulations, 2002, the Company has opened grievance cell at Divisional, Regional as well as Head Office. The policyholder may submit his complaint / grievance to the said grievance cell of the Company for remedial action.
The policy holder has also the option to approach the office of Insurance Ombudsman with complaints in respect of (a) any dispute on partial or total repudiation of claim (b) any dispute in regard to premium paid or payable in terms of policy (c) any dispute on the legal construction of the policy in so far as such disputes relate to claims (d) delay in settlement of claims and(e) non-issue of insurance document after receipt of premium.
Nb/08
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