HOSPITALISATION AND DOMICILIARY

HOSPITALISATION BENEFIT POLICY

Salient features of the policy

1. 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. 

Definitions

2. 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 or joints or 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-enteritis

5.  Diabetes Mellitus and Insipidus

6.  Epilepsy

7.  Hypertension

8.  Infleunza, 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. 

Exclusions

3. (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 self-injury, 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 sub-clauses 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. 

Age limit

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

Family discount

5. 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 dependent children

(iii) Dependent parents. 

Notice of claim

6. 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. 

Payment of claim

7. 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. 

Cumulative bonus

8. (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. 

Table of benefits

9. 1. Hospitalisation and Domiciliary Hospitalisation Policy (all Limits are for the policy period) :

5. Permanent Partial Disablement :

Compensation in percentage of death

benefits under Category I, II or III

(a)  Loss of toesAll              20

      Great-both phalanges 5

      GreatOne Phalanx    2

      Other than Great, if more than one toe lost-each  1

(b)  Loss of hearingboth ears 50

(c)  Loss of hearingOne ear  15

(d)  Loss of 4 fingers and thumb of one hand 40

(e)  Loss of 4 fingers    35

(f)  Loss of thumbboth Phalanges              25

      One Phalanx  10

(g)  Loss of index fingerThree Phalanges              10

      Two Phalanges 8

      One Phalanx    4

(h)  Loss of middle fingerThree Phalanges 6

      Two Phalanges 4

      One Phalanx    2

(i)  Loss of ring fingerThree Phalanges 5

      Two Phalanges 4

      One Phalanx    2

(j)  Loss of little fingerThree Phalanges 4

      Two Phalanges 3

      One Phalanx    2

(k)  Loss of Metacarpus-1st or 2nd (additional)                3

      3rd, 4th or 5th (additional)                2

(l)  Any other permanent partial disablement :

% as assessed by the Doctor

(Annual Premium Rates per Person per annum)

Important :

Premium paid under the Schemes A and B is eligible for deduction as per provisions under section 80D of the Income-tax (Amendment) Act, 1986. As required by the Act, the premium is to be paid by cheque only.