Kidney failure
Organ transplant
Multiple sclerosis
and
Coronary artery
surgery (20 percent of Sum Insured)
Top
What is the amount
of Insurance offered by a Critical Illness policy?
Under a Critical Illness
policy, the amount of insurance has to be selected by the client. It is
at 4 levels %u2013 Rs.5 lakhs, Rs.10 lakhs, Rs.20 lakhs and Rs.25 lakhs.
Top
Under Critical
Illness insurance while selecting the level of benefit, does the client
exercise his choice or does the insurance company make a decision ?
Under Critical Illness
insurance if the client is financially well off then he can go for a higher
level of insurance. If his annual earnings are less then he cannot opt
for a higher level of benefits. Basically, the level of benefits depends
upon the earning capacity of the person.
Top
Is there a minimum
annual income requirement under Critical Illness insurance ?
If the client is
an income tax payer and his annual income is worth a minimum of Rs.2 lakhs,
he can opt for Critical Illness insurance.
Top
When does the Critical
Illness policy cover all the five illnesses ?
As long as the policyholder
was not suffering from any of the illnesses, the pre-existing illness
exclusion applies to the Critical Illness policy also.
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What is the rate
of premium calculated under the Critical Illness policy ?
Under Critical Illness insurance, the premium depends upon the age and
the sex of the person. For every age, there is a different premium charged.
For instance, a 35-year old male will be charged a premium of Rs.1.53
per thousand whereas for a female of the same age, it is Rs.2.28 per thousand.
For a 65-year male it is Rs.21.86. per thousand while a female of the
same age will be charged Rs.15.25 per thousand.
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For how long can
a Critical Illness policy be issued ?
Under Critical Illness insurance, a policy can be issued only for one
year and has to be renewed every year. And it is on the insurance company's
discretion if they wish to renew the policy or not.
Mediclaim FAQs
In case an individual
is already suffering from a disease, will Mediclaim still reimburse his
or her expenses related to the disease?
The insurance company
will not reimburse any expenses related to any disease or injury which
already existed at the time of first obtaining the insurance cover.
Top
Are all diseases
and injuries covered by Mediclaim ?
There are certain
diseases and injuries that are not covered by this policy. These fall
under basically 3 categories The injuries or diseases not covered in the
first year of operation of the policy are:
- Cataract
- Benign prostatic
hypertrophy
- Hysterectomy for
menorrhagia or fibromyoma
- Hernia, hydrocele
- Congenital internal
diseases
- Fistula in anus
- Piles
- Sinusitis and related
disorders
Note: The diseases
listed above are only excluded from cover only for the first year of the
policy and not afterwards.
The injuries and diseases
or medical conditions not covered at all under Mediclaim are:
- Cost of spectacles,
contact lenses,hearing aids
- Dental treatment,
surgery unless it requires hospitalisation
- Convalescence
or rest cure
- Congenital external
diseases
- Sterility
- Venereal diseases
- Condition directly
or indirectly related to AIDS
- Pregnancy
- Circumcision, unless
it is necessary under certain circumstances alone
The injuries and diseases
not covered under certain circumstances are:
- Intentional self-injury
- Use of intoxicating
alcohol and / or drugs
- Diseases or injuries
arising in the first 30 days from the commencement of policy (this does
not include the diseases excluded in the first year of operation of
the insurance policy), however if a medical practitioner named by the
insurance company states that the policyholder had no knowledge of the
existence of the disease, then it will be covered (this also does not
apply if the insured had been covered under this policy or group insurance
scheme with any Indian Insurance Company, in the immediately preceding
12 months)
Top
Are the tests prescribed
by the doctor be reimbursed under Mediclaim ?
All charges incurred
at the hospital or nursing home primarily for diagnostic purposes such
as X-rays, blood analysis, ECG, etc will be reimbursed only if they are
consistent with or incidental to the diagnosis and treatment of the ailment
for which the policyholder has been hospitalised and not otherwise.
Top
Can the Mediclaim
the insurance contract be cancelled midway?
The policy can be
cancelled at any time during the course of its operation. In such cases,
the insurance company will refund the premium paid (on the basis of the
table provided below) only if no claim has been up to the date of cancellation.
| Date
of cancellation |
Amount
to be refunded |
| within
1 month |
quater
of the annual rate |
| Within
3 months |
half
of the annual rate |
| After
6 months |
No
refund |
|
Note: The policy
may also be cancelled at any time by the insurance company by giving the
insured person 30 days notice through a registered letter sent to the
last known address of such person.
such circumstances,
the insurance company has to refund the premium pro-rata for the un-expired
period of insurance. The insurance company is however liable for any claim
made prior to the date of cancellation.
Top
What is the coverage
offered by the Mediclaim policy ?
A Mediclaim policy
reimburses hospitalisation expenses for the treatment of sickness or accident
occurring during the period of insurance.
Top
What type of hospitalisation
expenses are covered by Mediclaim ?
Mediclaim covers
room, boarding charges, nursing expenses, surgeon, anaesthetist / doctor's
fees, blood, oxygen, operation theatre charges, x-ray, other tests pertaining
to sickness, etc.
Top
What kinds of
medical tests are covered by Mediclaim ?
Mediclaim covers
medical tests connected with the sickness. Hospitalisation expenses for
medical check up only are not covered. There has to be positive existence
of diseases to claim under Mediclaim.
Top
Can treatment can
be taken at any hospital or at a particular hospital under Mediclaim ?
Under Mediclaim, treatment
at all the hospitals / nursing homes registered with local authorities
is allowed. In case there is no registration with the local authority
the hospital should have at least 15 in-patient beds, a fully operational
operation theatre, qualified nursing staff and doctor in charge. Only
if these conditions are satisfied can the person go to his or her hospital
of choice.
Top
Is there a minimum
time limit for stay within the hospital under Mediclaim ?
Under Mediclaim, the
minimum stay within the hospital must be for a minimum of 24 hours. However
for dialysis, chemotherapy, eye surgery, etc - the stay can be for less
than 24 hours.
Top
What is considered
as "domiciliary hospitalisation" under Mediclaim ?
When the condition
of the patient is such that he cannot be moved to the hospital or when
there is no bed available in any of the hospitals, then the treatment
taken at home only if it is like the treatment given at the hospital /
nursing home is reimbursable under the Mediclaim policy.
Top
Are there any other
restrictions on domiciliary hospitalisation benefits under Mediclaim ?
Under Mediclaim, the
limit of compensation is low and for certain diseases like asthma, bronchitis,
diabetes, epilepsy, etc it is not available.
Top
Does Mediclaim
cover any expenses besides hospitalisation costs ?
Mediclaim covers pre-hospitalisation
(limited up to 30 days) and post-hospitalisation (limited to 60 days from
discharge) expenses also if they are connected with the sickness / accident
for which the hospitalisation takes place.
Top
Under Mediclaim,
is the limit of insurance per sickness or annual ?
Under Mediclaim,
the amount of insurance is the limit until which the insurance company
will pay during any policy period. They are annual limits for all sicknesses
/ accident during a year.
Top
What happens when
the limit of insurance is exhausted under Mediclaim ?
Under Mediclaim, future
expenses are not covered during the same policy period however when the
policy is renewed, the limit of insurance starts afresh.
Top
Under Mediclaim,
does a sickness for which a claim is lodged get covered under a future
insurance policy or does it become pre-existent for the next policy term
?
Under Mediclaim, a
sickness for which a claim is lodged does not become pre-existent. It
is covered provided the policy is renewed within time limits and there
is no break in the term of the insurance policy. In case there is a break
in the term of insurance (up to 7 days allowed subject to certain conditions)
then it will definitely become pre-existent and exclusions will apply.
Top
Is the maternity
benefit extension available under an individual Mediclaim policy ?
No maternity benefit
extension is available under an individual Mediclaim policy.
Top
What is family
discount under Mediclaim ?
Under Mediclaim,
when the husband or the wife and children or dependant parents are covered
under same policy, a discount of 10 percent is given on the total premium
by way of family discount.
Top
What are the factors
which determine the premium payable under Mediclaim ?
Under Mediclaim, the
age and the amount of cover are the factors that decide the premium.
Top
What are the minimum
and maximum amounts for which a Mediclaim policy can be taken ?
Under Mediclaim, the
minimum amount that can be insured for is Rs.15,000/- and the maximum
amount is Rs.5,00,000/- In any case, the amount for which the insurance
company may grant insurance is at their own discretion.
Top
Does Mediclaim
offer any advantages on renewal ?
On renewal of Mediclaim
for every claim free year. a bonus of five percent per year (maximum 50
percent) is allowed and after four continuous renewals, the cost of medical
check up to the extent of one percent of cumulative insurance for the
last four years is allowed.
Top
Who will receive
the claim amount under Mediclaim if the policyholder dies during the time
of treatment ?
Under Mediclaim, the
claim amount is paid to the nominee of the policyholder. In case there
is no nominee made under the policy, then the insurance company will insist
upon a succession certificate from a court of law for disbursing the claim
amount. Alternatively, the insurers can deposit the claim amount in the
court for disbursement to the next legal heirs of the deceased.
Who
should the policyholder contact in the event of claim under Overseas Mediclaim
Policy ?
In the event of claim
under Overseas Mediclaim Policy the policyholder can contact
Mercury International Assistance and Claims Limited
P.O.Box 673, Brighton,
Sussex, BNI 4, EZ,
England.
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What
compensation is provided under the Individual Personal Accident Policy?
Under the Individual
Personal Accident Policy:
- If the accident
results in death, the full Capital Sum Insured must be paid to the Insured%u2019s
beneficiaries.
- In the accident
results in permanent disablement that involves the total loss of both
eyes or two limbs or one eye and one limb, the full Capital Sum Insured
is payable.
- In case the accident
results in loss of one eye and one limb, then only 50 percent of the
Capital Sum Insured will be paid.
- In case the accident
results in partial disablement of certain parts of the insured%u2019s body,
only a specified percentage of the Capital Sum Insured will be paid.
- In case there
is disablement excluding injuries that are not visible or verifiable
through medical tests like sprains, muscular spasms, etc ALL the benefits
listed above have to be paid PLUS 1 percent of the Capital Sum Insured
subject to a maximum of Rs.3000 per week over the Capital Sum Insured.
However the total period of compensation will not exceed 104 weeks or
2 years approximately.
Top
Which
discounts are available under the Group scheme for the Personal Accident
Policy?
There are chiefly
two types of Group Schemes, first called Group A where an employer-employee
relationship exists as in corporate firms, companies, etc. The second
known as Group B is where an employer-employee relationship does NOT exist
as in a club, association, club or any social institution.
Group discounts are
applicable for groups of people not exceeding 500. The larger the group,
the higher are the discounts given by the insurance company.
| 101-300
people |
15
percent of the total premium |
| 301-500
people |
25
percent of the total premium |
| 501-1000
people |
30
percent of the total premium |
| 1001-5000
people |
35
percent of the total premium |
| 5001-50000
people |
40
percent of the total premium |
| >
50000 people |
50
percent of the total premium |
|
The benefits mentioned
within the Group scheme are all those mentioned in the Personal Accident
Policy except the Cumulative Bonus and the Education Fund.
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What
are the different benefits that can be claimed under the Mediclaim insurance
policy in event of hospitalisation?
Different heads of
benefits under hospitalisation:
- Room boarding expenses
by the hospital nursing home
- Nursing expenses
- Surgeon, anaesthetist,
medical practitioner, consultants, specialist%u2019s fees
- Anaesthesia, blood,
oxygen, operation charge, surgical appliances, medicines and drugs,
diagnostic material and x-rays, dialysis and chemotherapy, radiotherapy,
pacemaker, artificial limbs and cost of organs and similar expenses
All the above benefits
are limited to the max sum insured
The minimum period
of hospitalisation should be for 24 hours. However for certain treatments
this limit is not applicable when a package charges are levied for treatment
by the hospital.
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Who
is entitled to an overseas mediclaim policy?
Anyone traveling abroad
for business or pleasure or as student going for higher studies can qualify
for an Overseas Mediclaim. Needless to say, this policy does not cover
trips abroad for pre-planned medical treatment.
Top
What
is the extent of liability under an overseas mediclaim policy?
For trips where the
destination does NOT include the United States of America and its Northern
neighbour, Canada, the extent of liability is limited to $50000.
For trips where the
destination does include the USA and Canada, the extent of liability can
be as high as $100000.
Top
What
is the procedure to be followed to apply for cover under an Overseas Mediclaim
policy?
To acquire cover under
an Overseas Mediclaim policy, the traveler must submit his
- Visa details and
its validity
- Country of visit
- Passport details
- Name and address
of the sponsor, a certificate giving details of employment / studies
and its duration
- Period of cover
required
- Medical examination
certificate as per the prescribed guideline
- Income certificate
of the sponsor in case of student
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What
benefits can be made available to the insured under a Gramin Accident
Insurance policy?
Any individual aged
between 10 to 70 years of age irrespective of his or her occupation can
qualify for protection under the Gramin Accident insurance scheme.
The benefits are subject
to the level of the loss suffered by the insured individual.
|
Death by accident |
Rs.10000/- |
|
Totally irrecoverable loss of use of both eyes or two limbs
or one eye and one limb due to accident |
Rs.10000/- |
|
Total irrecoverable loss of use of one eye or one limb due to
accident |
Rs.5000/- |
|
Permanent total disablement due to accident |
Rs.10000/- |
|
Top
What
is the Premium Payable under the Gramin Accident insurance scheme?
The Premium Payable
under the Gramin Accident scheme increases directly with the number of
years that the cover is sought for.
|
No of
Years |
Single
Gross Premium
(In Rupees) |
|
1 |
5/- |
|
2 |
10/- |
|
3 |
12.50 |
|
4 |
15.60 |
|
5 |
19/- |
|
Top
What
are the benefits available to the insured under the Janata Personal Accident
Policy?
Under the Janata Personal
Accident Policy, any individual between the age of 10 to 70 years of age
irrespective of his occupation can qualify for protection against any
untoward mishap
| Benefits
|
Amount
of indemnity |
| Death
due to accident |
Rs.25000
|
| Loss
of use of 2 limbs/sight in both eyes |
Rs.25000 |
| Total
and irrecoverable loss of use of one limb/sight in one eye due
to accident |
Rs.12500 |
| Permanent
total disablement due to accident |
Rs.25000 |
|
Top
What
is the Premium Payable under the Janata Personal Accident scheme?
Under the Janata PAP
scheme, the Premium Payable increases with the number of years that the
cover is sought for.
| No
of Years |
Single
Gross Premium (In Rupees) |
| 1 |
15/- |
| 2 |
28/- |
| 3 |
40/- |
| 4 |
51/- |
| 5 |
57/- |
|
What
is the meaning of "Personal Accident" in legal insurance terminology?
Personal Accident is defined as an accident owing to external, violent
and visible means in legal insurance terminology.
Top
What
does 'External' mean with regards to personal accident insurance policies?
With reference to personal accident insurance policies, 'External' is
any impact that is outward and on the exterior. Internal impact like diseases
and natural causes of sickness is not covered under this policy.
Top
What
does 'violent' mean with reference to personal accident policies?
The force of the impact that caused injury in relation to the compensation
claimed can be termed as 'violent' when referring to personal accident
policies
Top
What
does 'visible' signify with reference to personal accident policies?
With respect to personal
accident policies, 'visible' is denoted by the result of the impact, which
caused the injury. The injury must be either physically or clinically
visible.
Top
What
is Permanent Total Disablement?
Permanent Total Disablement
refers to the absolute disability of an injured person after which he
or she cannot engage in any employment or occupation of any description
on a permanent basis.
Top
What
does 'Loss of limbs' mean with reference to Permanent Total Disablement?
An actual loss by physical separation of the hand's and/or leg's, clearly
discernible as loss of hand up to the wrist and/or foot up to the ankle
can be classified as a 'Loss of limbs' while referring to Permanent Total
Disablement.
Top
What
does 'Loss of eyes' mean with reference to Permanent Total Disablement?
An actual loss of
sight of eye and or eyes can be classified as a 'Loss of eye/s' while
referring to Permanent Total Disablement.
Top
What
is Temporary Total Disablement?
Any accidental injury
that is the sole and or direct cause of total, yet temporary disablement
as long as the injured person is totally and completely unable to engage
in any employment or occupation of any description can be termed as Temporary
Total Disablement.
Top
What
is "Cumulative Bonus"?
The compensation payable
for the death, loss of limb's or sight or permanent total disablement
is normally increased by 5 percent of the Capital Sum Insured for every
completed year of insurance.
This compensation payable in event of any of the abovementioned medical
contingencies is known as Cumulative Bonus.
However, the cumulative bonus is subject to a amount that can never exceed
50 percent of the Capital Sum Insured.
Top
What
is Mediclaim insurance?
Mediclaim insurance
consists of the reimbursement of hospitalisation and/or domiciliary hospitalisation
expenses for any illness/diseases or injury sustained by the insured individual.
Top
What
does 'Hospital' mean with regards to mediclaim insurance policies?
Any institution established
for the indoor care and treatment of sickness and/or injuries, which is
duly registered and supervised actively by a registered medical practitioner
OR
Any establishment
- With at least
15 patient beds
- With a fully equipped
operation theatre of its own if surgical procedures are carried out
- Employing fully
qualified nursing staff around the clock
- Having fully qualified
doctors in charge around the clock
can be classified
as a 'Hospital'.
Note: For Class 'C' towns, the number of beds is relaxed to 10 (ten)
Ayurvedic or institutions practising alternative medicine therapy also
qualify as 'Hospitals'
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What
is meant by 'Hospitalisation'?
Any instance when
and where the insured individual is hospitalised for a minimum period
of 24 hours can be termed as 'Hospitalisation'.
However, for
specific treatment like dialysis, chemotherapy, radiotherapy, laser eye
surgery, dental surgery, etc when the patient is discharged on the same
day is also considered as 'Hospitalisation'.
Top
What
is 'Domiciliary Hospitalisation'?
"Domiciliary Hospitalisation'
is any instance when and where the insured individual requires medical
treatment for more than three days for an illness / disease / injury that
in the normal course would require hospitalisation and is conducted at
his or her home within India due to
- The condition
of the patient being such that he cannot be moved to the hospital
- Lack of hospital
accommodation
Top
What is 'Any one illness' with reference to mediclaim policies?
'Any one illness'
would mean the continuous period of illness, including relapse within
45 days from the last consultation with the hospital where the treatment
was taken with respect to any mediclaim policy.
Top
What
is meant by Pre-hospitalisation and Post-hospitalisation expenses?
The relevant medical
expenses incurred during 30 days prior to hospitalisation are known as
'Pre-hospitalisation expenses'.
Medical expenses incurred
for 60 days after hospitalisation are known as 'Post-hospitalisation expenses'.
Top
What
are the health check-up benefits available under the mediclaim policy?
The Mediclaim policy
provides reimbursement of medical expenses for health check-up at the
end of every 4 claim-free years at the rate of 0.1 percent of the Capital
Sum Insured.
