UNITED INDIA INSURANCE COMPANY LTD.

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Note : A brief snapshot about the policy is given.For complete information refer to policy wordings or visit our nearest branch office.

The Policy covers aggregate hospitalization expenses reasonably and necessarily incurred in India in respect of all covered hospitalization during the policy period exceeding the Threshold Level or any amount reimbursed or reimbursable under any Health Insurance Policies/Reimbursement Scheme whichever is higher, upto the Sum Insured stated in the policy. 

2.   DEFINITIONS:

2.1 ACCIDENT:

An accident is a sudden, unforeseen and involuntary event caused by external, visible and violent means.

2.2(a) ACUTE CONDITION:

Acute condition is a disease, illness/injury that is likely to respond quickly to treatment which aims to return the person to his/her state of health immediately before suffering the disease/illness/injury which leads to full recovery.

(b) CHRONIC CONDITION:

A chronic condition is defined as a disease, illness, or injury that has one or m ore of the following characteristic; - it needs ongoing or long term monitoring through consultations, examinations, check-ups, and/or tests – it needs ongoing or long term control or relief of symptoms – it requires your rehabilitation or for you to be specifically trained to cope with it – it continues indefinitely – it comes back or is likely to come back.

2.3 ALTERNATIVE TREATMENTS:

Alternative Treatments are forms of treatment other than treatment “Allopathy” or “modern medicine and includes Ayurveda, unani,siddha and homeopathy in the Indian Context.

2.4 ANY ONE ILLNESS: 

Any one illness means continuous period of illness and it includes relapse within 45 days from the date of last consultation with the Hospital / Nursing Home where treatment has been taken. Occurrence of the same illness after a lapse of 45 days as stated above will be considered as fresh illness for the purpose of this policy.

2.5 CASHLESS FACILITY: 

Cashless facility “means a facility extended by the insurer/TPA to the insured where the payments, of the cost of treatment undergone by the insured in accordance with the policy terms and conditions, or directly made to the network provider by the insurer/TPA to the extent preauthorisation approved.

2.6 CONGENITAL ANOMALY: 

Congenital Anomaly refers to a condition(s) which is present since birth, and which is abnormal with reference to form, structure or position.

a.Internal Congenital Anomaly which is not in the visible and accessible parts of the body.

b.External Congenital Anomaly which is in the visible and accessible parts of the body.

2.7 CONDITION PRECEDENT:

Condition Precedent shall mean a policy term or condition upon which the Insurer’s liability under the policy is conditional upon.

2.8 CONTRIBUTION:

Contribution is essentially the right of an insurer to call upon other insurers liable to the same insured, to share the cost of an indemnity claim on a rateable proportion.

2.9 DAYCARE CENTRE:

 A day care centre means any institution established for day care treatment of illness and/ or injuries or a medical setup within a hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified medical practitioner AND must comply with all minimum criteria as under;-

 -  has qualified nursing staff under its employment

 -  has qualified medical practitioner(s) in charge 

 -  has a fully equipped operation theatre of its own where surgical procedures are carried out.

 - maintains daily records of patients and will make these accessible to the insurance companies authorised personnel.

2.10 DAY CARE TREATMENT:

 Day care Treatment refers to medical treatment and or surgical procedure which is 

i.undertaken under general or local anaesthesia in a hospital/day care centre in less than 24 hours because of technological advancement, and 

ii.Which would have otherwise required a hospitalisation of more than 24 hours.

Treatment normally taken on an outpatient basis is not included in the scope of this definition.

2.12 GRACE PERIOD: 

Grace Period means the specified period of time immediately following the premium due date during which a payment can be made to renew or continue a policy in force without loss of continuity benefits such as waiting periods and coverage of pre-existing diseases. Coverage is not available for the period for which no premium is received.

2.13 HOSPITAL / NURSING HOME 

Hospital/Nursing Home means any institution established for in patient care and day care treatment of illness and/or injuries and which has been registered as a Hospital or Nursing Home with the local authorities under the Clinical Establishments, (Registration and Regulation) Act, 2010 or under the enactments specified under the schedule of Section 56(1) of the said Act 

OR

complies with all minimum criteria as under

i.has at least 10 in-patient beds in towns having a population of less than 10 lacs, and 15 in-patient beds in all other places  

ii.Fully equipped operation theatre of its own wherever surgical procedures are carried out.

iii.Fully qualified Nursing Staff under its employment round the clock.

iv.Fully qualified Medical Practitioner(s) in-charge round the clock.

v.Maintains daily records of patients and will make these accessible to the Insurance Company’s authorized personnel.

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 for alcoholics, a hotel or a similar place.

2.14 HOSPITALISATION means admission in a Hospital/Nursing Home for a minimum period of 24 consecutive hours of inpatient care except for specified procedures/treatments, where such admission could be for a period of less than 24 consecutive hours

2.15 ID CARD: means the identity card issued to the insured person by the TPA to avail cashless facility in network hospitals.

2.16 ILLNESS: 

Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function which manifests itself during the policy period and requires medical treatment.

2.17 INJURY:

Injury means accidental physical bodily harm excluding illness or disease solely and directly caused by external, violent and visible and evident means which is verified and certified by a medical practitioner.

2.18 In-Patient Care:

In-Patient Care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.

2.19 INTENSIVE CARE UNIT:

Intensive Care Unit means an identifies section, ward or wing of a Hospital which is under the constant supervision of a dedicated medical practitioner(s) and which is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards.

2.20 MEDICAL ADVICE:

Any consultation or advice from a medical practitioner/doctor including the issue of any prescription or repeat prescription.

2.21 MEDICAL EXPENSES:

Medical Expenses means those expenses that an insured person has necessarily and actually incurred for medical treatment on account of illness or accident on the advice of a medical practitioner, as long as these are no more than would have been payable if the insured person had not been insured and no more than other hospitals or doctors in the same locality would have charged for the same medical treatment.

2.22 MEDICALLY NECESSARY: 

Medically necessary treatment is defined as any treatment, test, medication or stay in hospital or part of a stay in a hospital which 

-is required for the medical management of the illness or injury suffered b y the insured;

-must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration or intensity;

-must have been prescribed by a medical practitioner;

-must confirm to the  professional standards widely accepted in  international medical practice or by the medical community in India.

2.23 MEDICAL PRACTITIONER:

Medical Practitioner is a person who holds a valid registration from the Medical Council of any State or Medical Council of India or Council for Indian Medicine or the homeopathy set up by the Government of India or a State Government and is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of his license. The term medical practitioner would include physician, specialist and surgeon.

 (The Registered practitioner should not be the insured or close family members such as parents, in-laws, spouse and children.)

2.24 NETWORK PROVIDER: 

Network Provider means hospital/nursing home or health care providers enlisted by an insurer or by a TPA and insurer together to provide medical services to an insured on payment by a cashless facility. 

The list of network hospitals is maintained by and available with the TPA and the same is subject to amendment from time to time.

Preferred Provider Network means a network of hospitals which have agreed to a cashless packaged pricing for certain procedures for the insured person.  The list is available with the company/TPA and subject to amendment from time to time.  Reimbursement of expenses incurred in PPN for the procedures (as listed under PPN package) shall be subject to the rates applicable to PPN package pricing.

2.25 NON NETWORK:

Any hospital, day care centre or other provider that is not part of the network.

2.26 NOTIFICATION OF CLAIM:

Notification of claim is the process of notifying a claim to the insurer or TPA by specifying the timelines as well as the address/telephone number to which it should be notified.

2.27 PRE-EXISTING DISEASE: 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 the first policy issued by the insurer.

2.28 PORTABILITY:

Portability means transfer by an individual health insurance policyholder (including family cover) of the credit gained for pre-existing conditions and time-bound exclusions if he/she chooses to switch from one insurer to another.

2.29 PRE – HOSPITALISATION MEDICAL EXPENSES:

Relevant medical expenses incurred immediately 30 days before the insured person is hospitalised will be considered as part of a claim as mentioned under Item 1.2 above provided that;

i. such medical expenses are incurred for the same condition for which the insured person’s hospitalisation was required and 

ii. the inpatient hospitalisation claim for such hospitalisation is admissible by the insurance company.

2.30 POST HOSPITALISATION MEDICAL EXPENSES:

Relevant medical expenses incurred immediately 60 days after the Insured person is discharged from the hospital provided that ;

a.Such Medical expenses are incurred for the same condition for which the Insured Person’s Hospitalisation was required; and

b.The In-patient Hospitalisation claim for such Hospitalisation is admissible by the Insurance Company.

2.31 QUALIFIED NURSE:

Qualified nurse is a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India and/or who is employed on recommendation of the attending medical practitioner.

2.32 REASONABLE AND CUSTOMARY CHARGES:

Reasonable and Customary Charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness/injury involved.

2.33 RENEWAL:

Renewal defines the terms on which the contract of insurance can be renewed on mutual consent with a provision of grace period for treating the renewal continuous for the purpose of all waiting periods.

2.34 ROOM RENT:

Means the amount charged by the hospital for the occupancy of a bed on per day (24 hours) basis and shall include associated medical expenses.

2.35 SUBROGATION: Subrogation shall mean the right of the insurer to assume the rights of the insured person to recover expenses paid out under the policy that may be recovered from any other source.

2.36 SURGERY: 

Surgery or surgical procedure means manual and/or operative procedure(s) required for treatment of an illness or injury, correction of deformities and defects, diagnosis and cure of diseases, relief of suffering or prolongation of life, performed in a hospital or day care centre by a medical practitioner.

2.37 TPA: means a Third Party Administrator who holds a valid Licence from Insurance Regulatory and Development Authority to act as a THIRD PARTY ADMINISTRATOR and is engaged by the Company for the provision of health services as specified in the agreement between the Company and TPA.

2.38 UNPROVEN/EXPERIMENTAL TREATMENT:

Unproven/Experimental treatment is treatment, including drug Experimental therapy, which is not based on established medical practice in India.

 

The Policy is available both on Individual and Floater basis.

Individual basis – All family members including the parents can be covered under single policy with difference sum insureds and threshold level.

Group basis – Single Sum Insured/Thereshold level for all family members covered under the policy.  Parents can take a separate policy.

The age of the proposer shall be between 18 and 80 years. Children between the age of 3 months and 18 years are covered provided either or both parents are covered concurrently. Children above 18 years will cease to be covered if they are employed/self-employed or married.

Various Options with different Sum Insureds and Threshold Level are available.

Basis of Payment –
Any claim under this policy shall be payable only if the aggregate of covered hospitalization expenses exceeds the Threshold level or any amount received/receivable under any Health Insurance policy/ Reimbursement scheme whichever is higher.

The Policy provides the following benefits subject to the Basis of Payment clause mentioned above.

I      Hospitalisation expenses
       1 Room, Boarding and Nursing expenses.
       2 Expenses incurred for Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees.
       3 Expenses incurred on Anesthetic, blood, oxygen, Operation theatre charges, surgical appliances, Medicines & drugs, dialysis, chemotheraphy, radiotheraphy, cost of artificial limbs, cost of prosthetic devices implanted during surgical procedure like Pacemaker, orthopaedic implants, infra cardiac valve replacements, vascular stents, relevant laboratory/diagnostic tests, x-ray and similar expenses that are medically necessary and hospitalization expenses (excluding cost of organ) incurred for donor in respect of organ transplant to the insured.

       Expenses incurred for covered hospitalization exceeding the Threshold level or any amount received/receivable under any Health Insurance policies/Reimbursement scheme whichever is higher.

II    Cashless facility in more than 7000 hospitals across Pan India.

III    Free Look period of 15 days shall be applicable at the inception of the first policy.

IV    Premium paid for self, spouse, dependent children and dependent parents are exempt from Income Tax under Section 80-D of the IT act.
For detailed terms and conditions, please see our Prospectus and Policy in our website.

1    All Pre-existing diseases upto 48 months of continuous coverage.
2    Vaccination and Inoculation of any kind unless it is post-animal bite
3    General debility and Run down conditions
4    Circumcision, Cosmetic surgery, Plastic surgery.
5    HIV/AIDS
6    Pregnancy, ailments related thereto and child birth
7    War, act of foreign enemy, ionizing radiation and nuclear weapon.
8    Naturopathy
9    Experimental or unproven treatment
10    All external equipments

For detailed exclusions, please see the policy in our website.

All claims shall be paid in Indian Rupees only.

Upon happening of any event, notice of Intimation about the hospitalization or claim should be sent to the address of Insurer/TPA stated in the Policy.  In case of emergency hospitalization, notice of intimation to be sent within 24 hours from the time of hospitalization.  

Claim form should be collected on intimation of claim. The completed claim form along with all required/relevant hospitalization documents should be submitted to servicing TPA within 15 days from the date of discharge from the hospital.

For Cashless treatment, the Insured or the representative has to submit the Pre-authorisation Cashless form to TPA through the hospital where the treatment is taken.  No separate intimation is required if the pre-authorisation form is submitted immediately on admission.

In case of Reimbursement claims, the insured should submit documents in respect of the hospitalization expenses incurred within 15 days from the date of discharge from hospital.