Scheme Of Hospitalisation And Domiciliary Benefit Policy

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Scheme Of Hospitalisation And Domiciliary Benefit Policy
Total Sections 9
Enforcement Year
State or Central Central
Editor Template:USERNAME
ASSN: 125396


1. Salient features of the policy :- In the event of any claim becoming admissible under Hospitalisation and Domiciliary Hospitalisation Insurance, the company will pay to the insured person 80 per cent of the amount of such expenses as are actually and necessarily incurred in respect thereof anywhere in India by or on behalf of such insured person but not exceeding in any one period of insurance the amounts under the category in the Table of Benefits.

2. Definitions :- I. Hospital/nursing home/clinic shall be deemed to mean any institution in India operated for the care and treatment of sickness and injuries and which has been registered either as a Hospital or Nursing Home or Clinic with the local authorities and is under the supervision of a registered and qualified doctor. The term, "Hospital" shall not include an establishment which is a place of rest, a place for the aged, a place for drug addicts, a place of alcoholics or a hotel. II. Surgical operation means: (i) cutting operation (not including any lancing operations or injections); (ii) any operation involving the reducing of fractures; (iii) any treatment or adjustment in respect of or any dislocation of joints of bones, orthopaedic or neuro surgery or plastic surgery by qualified surgeon; (iv) stitching of wounds. III. Domiciliary hospitalisation benefit means.-Medical treatment for a period exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at a hospital/nursing home/clinic but actually taken whilst confined at home in India under any of the following circumstances, namely:- (i) The condition of the patient is such that he/she cannot be removed to the hospital/nursing home/clinic; or (ii) The patient cannot be removed to hospital/nursing home/clinic for lack of accommodation therein; or (iii) The patient prefers to be confined at home for treatment with the approval of the attending medical practitioner subject however that domiciliary hospitalisation benefits shall not cover: (i) expenses incurred for pre-and post-hospital treatment, and (ii) expenses incurred for treatment for any of the following diseases: 1. Asthma 2. Bronchitis 3. Chronic nephritis and nephritic syndrome 4. Diarrhoea and all types of dysenteries including gastro enterities 5. Diabetes millitus and insipidus 6. Epilepsy 7. Hypertension 8. Influenza, cough and cold 9. All Psychiatric or psychosomatic disorders 10. Viral fever of duration for less than 10 days 11. Tonsilitis and upper respiratory tract infection including laryngitis and phyringitis 12. Pyrexia of unknown origin. IV. Major surgical and/or major disease means treatment taken in the hospital for the following diseases. Benefits under this extension are payable in addition to the benefits payable under Benefit 1 (B) of Table of Benefits. (i) Renal diseases (ii) Cerebral or vascular strokes (iii) Open and closed heart surgery (iv) Kidney transplantation and dialysis (v) Malignancy (vi) T.B. which includes Pulmonary T.B. (vii) Encephalitis (Viral) (viii) Neuro-surgery (ix) Total replacement of joints. V. Qualified nurse means a person who holds a. certificate/diploma of a recognised hospital/institution and who is employed on recommendations of the attending medical practitioner.

3. Exclusions :- (A) Under Hospitalisation and Domiciliary Hospitalisation Insurance 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: 1. Any disease suffered by the insured person during the first 30 days from the commencement date of the policy. This exclusion shall not, however, apply if in the opinion of the panel of medical practitioners constituted by the company for the purpose, the insured person could not have known the existence of the disease or any symptoms thereof at the time of making the proposal for insurance to the company. This shall not, however, apply in case of the insured person having been covered under this scheme with any of the Indian insurance companies for a continuous period of 12 months preceding, without any break. 2. Injury or disease directly or indirectly caused by or arising from or attributable to war, invasion, act of foreign enemy, hostilities or warlike operations (whether war be declared or not) and breach of criminal law by the insured person. 3. Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident, 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. 4. Routine eye examinations and cost of glasses and contact lenses. 5. Dental treatment or surgery of any kind unless necessitated by an accident or due to a constitutional disease. 6. Convalescence, nervous breakdown (which expression shall cover also general debility "Run-down" condition) or rest cure, congenital defects or anomalies, venereal disease, insanity, intentional selfinjury, any disease or injury directly or indirectly attributed to intemperance or the use of intoxicating drugs or liquors. 7. Charges incurred at hospital or nursing home or clinic primarily for diagnostic, X-Ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a hospital, nursing home or clinic or at home under domiciliary hospitalisation as defined. 8. Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician. 9. Injury or disease directly caused by or arising from tonising radiations or contamination by radioactivity from any source whatsoever. 10. Injury or disease directly or indirectly caused by or contributed to nuclear weapons/materials. 11. A (a) Treatment arising from or traceable to pregnancy, child birth including normal ceasarean section; (b) Abortion or miscarriage or any complications and/or sequel therefrom unless arising out of accident. B. Under Personal Accident Insurance The company shall not be liable under this insurance for- (a) Insured persons working in underground mines, explosives, magazines, workers involved in electrical installation with high tension supply jockeys, circus personnel, persons engaged in activities like racing on wheels or horse back, big game hunting, mountaineering, winter sports, skiing, ice hockey, ballooning, polo and persons engaged in occupations of similar hazards, unless additional premium required is paid. (b) Payment of compensation in respect of death, injury or disablement of the insured person whilst engaged in aviation or whilst mounting into or dismounting from or travelling in any aircraft other than as a passenger (fare-paying or otherwise) in any duly licensed standard type of aircraft. (c) Compensation under more than one of the foregoing subclauses in respect of the same period of disablement. (d) Any payment in excess of the capital sum insured in case of more than one claim under this insurance during any one period of insurance.

4. Age limit :- This insurance is available to persons between the ages of 12 and 70 years (male and female).

5. Family discount :- A discount of 10% in the total premium under Scheme 'A' or 'B' will be allowed for insurance of a family comprising the insured and any one or more of the following: (i) Spouse . (ii) Two dependant children (iii) Dependant parents.

6. Notice of claim :- 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. Name and Address of the attending Medical Practitioner/Hospital/Nursing Home/Clinic should be given to the Insurance Company within seven days from the date of death/injury/ hospitalisation/domiciliary hospitalisation. Final claim along with hospital receipted bills/cash memos, etc., should be submitted to the company within 15 days of the date of completion of the treatment. Failure to give notice or to file such claim in time as stated above may not, however, invalidate or reduce any claim if it is substantiated that it was not reasonably possible for the claimant to give notice or to file claim within the prescribed time.

7. Payment of claim :- All claims under this policy shall be payable in Indian currency. All medical treatments for the purpose of this insurance will have to be taken in India only.

8. Cumulative bonus :- (A) Applicable to Hospitalisation and Domiciliary Hospitalisation Insurance.-The limits of benefits under the policy shall be progressively increased by 5% in respect of each claim, free year of insurance, but the overall amount of such increase shall not exceed 50% of the limits stated in the Table of Benefits. In case of a claim under the policy in respect of an insured person who has earned the Cumulative Bonus, the increased percentage will be reduced by 10% of the Table of Benefits at the next renewal. However, the benefit shall not be less than the benefits indicated in the Table of Benefits. The cumulative bonus shall operate separately per insured person in the case of a family. (B) Applicable to Personal Accident Insurance.-Compensation payable under clauses (a), (b), (c) and (d) of this endorsement, viz., death, loss of limb(s) or sight and permanent total disablement arising out of accidental injuries shall be increased by 5% thereof in respect of each completed year prior to the occurrence of an accident for which claim becomes payable under clauses (a), (b), (c) and (d) of this endorsement. The amount of such increase, however, shall not exceed 50% of the capital sum insured stated in the endorsement.

9. Table of benefits :- 1. Hospitalisation and domiciliary hospitalisation policy (all limits are for the policy period)