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Health Insurance ; Asha Kiran

1. Who can take this policy?
This policy is designed to the parents with only one girl child. This insurance is available to persons between the age of 18 years and 65 years. Daughter(s)from 3 months up to 25 years can be covered provided they are financially dependent on the parents and one or both parents are covered simultaneously. The upper age limit will not apply to mentally challenged daughter(s) and unmarried dependent daughter(s). The persons beyond 65 years can continue their insurance provided they are insured under the Policy with us without any break.
2. Can i cover my family members in one policy?
Yes. You and Your entire family will be covered under a Single Sum Insured (Floater). The members of the family who could be covered under the Policy are:
    a. Proposer
    b. Proposer's Spouse
    c. Proposer's Dependent daughter (Maximum two)
Minimum two members, with at least one daughter, are required in this policy. This policy cannot be given to a single person. Maximum four members can be covered in a single policy. Midterm inclusion is allowed only for new born 2nd baby girl child on payment of pro - rata additional premium.

3. What does the policy cover?
This Policy is designed to give You and Your family, protection against unforeseen Hospitalization expenses and Accident cover to Proposer and Spouse.

4. What are the expenses covered under this policy?
A. Policy covers following Hospitalisation Expenses:
    i. Room Rent / Boarding/ Nursing Expenses and other expenses as specified in policy up to 1% of Sum Insured per day. This also includes Nursing Care, RMO Charges, IV Fluids/Blood Transfusion/Injection administration charges and the like, but does not include cost of materials.
    ii. ICU up to 2% of Sum Insured per day.
    iii. Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees
    iv. Anesthetist, Blood, Oxygen, Operation Theatre Charges, surgical appliances, Medicines & Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, cost of prosthetic devices implanted during surgical procedure like Pacemaker, relevant laboratory diagnostic tests, etc.& similar expenses.
    v. All Hospitalisation Expenses (excluding cost of organ, if any) incurred for donor in respect of Organ transplant.
    vi. For cataract claims, the liability of the company will be restricted to 10% of Sum Insured or Rs. 50000 whichever less, for each eye.
Note: Procedures/treatments usually done in outpatient department are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours or carried out in Day Care Centers.
B. Policy also covers the Personal Accident as per the table below:

1Accidental Death ofProposer or Spouse100% of Sum Insured
Proposer and Spouse200% of Sum Insured
2Permanent Total Disablement ofProposer or Spouse100% of Sum Insured
Proposer and Spouse200% of Sum Insured
3Loss of one limb and one eye or loss of both eyes and/or loss of both limbs ofProposer or Spouse100% of Sum Insured
Proposer and Spouse200% of Sum Insured
4Loss of one limb / sight in one eye ofProposer or Spouse50% of Sum Insured
Proposer and Spouse100% of Sum Insured
5. What is hospital cash benefit?
This policy provides for payment of Hospital Cash at the rate of 0.1% of Sum Insured per day of Hospitalisation. This benefit will be given in every case of admissible claim and for each member. This benefit is applicable only where Hospitalisation exceeds twenty four consecutive hours.
The total payment for Any One Illness shall not exceed 1% of the Sum Insured. This benefit shall be directly given by TPA/underwriting office, as the case may be.
6. What is critical care benifit
If during the Period of Insurance any Insured Person is diagnosed to be suffering from any Critical Illness as listed below, we will pay flat 10% of Sum Insured as additional benefit i.e. other than the admissible claim:
  1. Cancer
  2. First Heart attack of specified severity
  3. Open chest CABG
  4. Open Heart replacement or repair of Heart valves
  5. Coma of specified severity
  6. Kidney failure requiring regular dialysis
  7. Stroke resulting in permanent symptoms
  8. Major organ / bone marrow transplant
  9. Permanent paralysis of limbs
  10. Motor neurone disease with permanent symptoms
  11. Multiple sclerosis with persisting symptoms
This will be paid only if the Hospitalisation is more than 24 hours. Any payment under this clause would be in addition to the Sum Insured and shall not deplete the Sum Insured. This benefit will be paid once in lifetime of any Insured Person. This benefit is not applicable for those Insured Persons for whom it is a pre-existing disease.
7. Is pre-acceptance medical check-up required?
Pre-acceptance test is required for all the members entering after the age of 50 for the first time. A person also needs to undergo this pre-acceptance medical check-up if he has an adverse medical history. The cost of this check-up will be borne by the proposer. But if the proposal is accepted, then 50% of the cost of this check-up will be reimbursed to the proposer.
8. Does it cover all cases of hospitilisation?
No. This Policy does NOT cover ALL cases of Hospitalisation.
The exclusions under the policies are
  1. Treatment of any Pre-existing Condition/Disease, until 48 months of Continuous Coverage of such Insured Person have elapsed, from the Date of inception of his/her first Policy as mentioned in the Schedule.
  2. Any Illness contracted by the Insured person during the first 30 days of the commencement date of this Policy. This exclusion shall not however, apply if the Insured person has Continuous Coverage for more than twelve months.
3.1 Unless the Insured Person has Continuous Coverage in excess of twenty four months, expenses on treatment of the following Illnesses are not payable:
  1. Cataract and age related eye ailments
  2. Benign prostate hypertrophy
  3. Benign ear, nose, throat disorders
  4. Treatment for Menorrhagia/Fibromyoma, Myoma and Prolapsed uterus
  5. Hernia of all types
  6. Piles, Fissures and Fistula in anus
  7. Stones in Urinary system
  8. All internal and external benign tumours, cysts, polyps of any kind, including benign breast lumps.
  9. Gastric/ Duodenal Ulcer
  10. Hydrocele
  11. Stone in Gall Bladder and Bile duct, excluding malignancy
  12. Pilonidal sinus, Sinusitis and related disorders
  13. Non Infective Arthritis
  14. Gout and Rheumatism
  15. Prolapse inter Vertebral Disc and Spinal Diseases unless arising from accident
  16. Skin Disorders
  17. Varicose Veins and Varicose Ulcers
  18. Hypertension
  19. Diabetes Mellitus
Note: Even after twenty four months of Continuous Coverage, the above illnesses will not be covered if they arise from a Pre-existing Condition, until 48 months of Continuous Coverage have elapsed since inception of the first Policy with the Company.
3.2 Unless the Insured Person has Continuous Coverage in excess of forty eight months with Us, the expenses related to treatment of
  1. Joint Replacement due to Degenerative Condition, and
  2. Age-related Osteoarthritis & Osteoporosis are not payable.
4.1 Injury / Illness / Death/ Disability directly or indirectly caused by or arising from or attributable to War, invasion, Act of Foreign enemy, War like operations (whether war be declared or not), nuclear weapon/ ionising radiation, contamination by Radioactive material, nuclear fuel or nuclear waste or from the combustion of nuclear fuel.
  1. Circumcision unless necessary for treatment of a Illness not excluded hereunder or as may be necessitated due to an accident
  2. Change of life or cosmetic or aesthetic treatment of any description such as correction of eyesight, etc.
  3. Plastic Surgery other than as may be necessitated due to an accident or as a part of any Illness.
4.3 Vaccination and/or inoculation
4.4 Cost of braces, equipment or external prosthetic devices, non-durable implants, eyeglasses, Cost of spectacles and contact lenses, hearing aids including cochlear implants, durable medical equipment.
4.5 Dental treatment or Surgery of any kind unless necessitated by accident and requiring Hospitalisation.
4.6 Convalescence, general debility, 'Run-down' condition or rest cure, obesity treatment and its complications, infertility, sterility, Venereal disease.
4.7 Treatment or Death or Disability relating to or arising out of all psychiatric and psychosomatic disorders and/or caused by the use of intoxicating drugs/alcohol.
4.8 Congenital Internal and External Disease or Defects or anomalies. However, the exclusion for Congenital Internal Disease or Defects or anomalies shall not apply after twenty four months of Continuous Coverage, if it was unknown to You or to the Insured Person at the commencement of such Continuous Coverage.
4.9 Bodily Injury or Illness or Death or Disability due to willful or deliberate exposure to danger (except in an attempt to save human life), intentional self-inflicted Injury, attempted suicide, arising out of non-adherence to medical advice.
4.10 Treatment of any Bodily Injury or Illness or Disablement or Death, sustained whilst or as a result of active participation in any hazardous sports of any kind.
4.11 Treatment of any Injury or Illness or Disablement or Death, sustained whilst or as a result of participating in any criminal act.
4.12 Sexually Transmitted Diseases, any condition directly or indirectly caused to or associated with Human T-Cell Lymphotropic Virus Type III (HTLB - III) or lymphadenopathy Associated Virus (LAV) or the Mutants Derivative or Variation Deficiency Syndrome or any syndrome or condition of a similar kind commonly referred to as AIDS.
4.13 Charges incurred at Hospital 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 Illness or Injury for which confinement is required at a Hospital.
4.14 Expenses on vitamins and tonics unless forming part of treatment for Injury or Illness as certified by the attending physician.
4.15 Maternity Expenses, treatment arising from or traceable to pregnancy, miscarriage, abortion or complications; except abdominal operation for extra uterine pregnancy (Ectopic Pregnancy), which is proved by submission of Ultra Sonographic Report and Certification by Gynaecologist that it is life threatening one if left untreated.
4.16 Naturopathy Treatment.
4.17 External and or durable Medical / Non-medical equipment of any kind used for diagnosis and or treatment including CPAP (Continuous Positive Airway Pressure), SleepApnoea Syndrome, CPAD(Continuous Peritoneal Ambulatory Dialysis), Oxygen Concentrator for Bronchial Asthmatic condition, Infusion pump etc. Ambulatory devices i.e., walker, crutches, Belts, Collars, Caps, Splints, Slings, Stockings, Elasto crepe bandages, external orthopaedic pads, sub cutaneous insulin pump, Diabetic foot wear, Glucometer / Thermometer, alpha / water bed and similar related items etc., and also any medical equipment, which is subsequently used at home.
4.18 Genetic disorders and stem cell implantation/Surgery.
4.19 Domiciliary Hospitalisation
4.20 Acupressure, acupuncture, magnetic therapies
4.21 Unproven / Experimental Treatment.
4.22 Change of treatment from one system of medicine to another unless recommended by the consultant/ Hospital under whom the treatment is taken.
4.23 Any expenses relating to cost of items detailed in Annexure I.
4.24 Any kind of Service charges, Surcharges, Luxury Tax and similar charges levied by the Hospital.
4.25 Treatment for Age Related Macular Degeneration (ARMD) , treatments such as Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy.
4.26 Payment or compensation in respect of death, Injury or disablements directly or indirectly arising out of or contributed to or traceable to any disability already existing on the date of commencement of this policy.
9. What is a pre existing disease?
The term Pre-existing condition/disease is defined in the Policy. It is defined as:
"Any condition, ailment or Injury or related condition(s) for which the Insured Person had:
  1. Signs or symptoms, or
  2. Been diagnosed or received Medical Advice, or
  3. Been Treated for any condition or disease,
Within forty eight months prior to the commencement of the first policy.” Such a condition or disease shall be considered as Pre-existing. Any Hospitalisation arising out of such pre-existing disease or condition is not covered under the Policy.
10. Is hospitilisation always a neccessary to get claim?
Yes. Unless the Insured Person is Hospitalised for a condition warranting Hospitalisation, no claim is payable under the Policy. The Policy does not cover outpatient treatments.
In case of Death Claim, Hospitalisation is not required but the death certificate, post mortem report and police report is required.
In case of Disability, Hospitalisation is not required but medical certificate certifying the disablement and police report (if any) is required.
11. How long does the insured person need to be hospitalized for mediclaim purposes?
The Policy pays only where the Hospitalisation is for more than twenty four hours. But for certain treatments specified in the Policy, period of stay at the Hospital could be less than twenty four hours. The 24 hours treatments are according to the table given in Point 12 below.
12. What are the day care treatments covered under this policy?
Following are the day-care treatments covered under this policy (treatments done within 24 hours)
3Anti-Rabies Vaccination
4Coronary angiography
5Coronary angioplasty
6Dilatation & Curettage
7ERCP (Endoscopic Retrograde Cholangiopancreatography)
8ESWL ( Extracorporeal Shock Wave Lithotripsy)
9Excision of Cyst/granuloma/lump
ACataract Surgery (Extra Capsular Cataract Excision or Phacoemulsification + Intra Ocular Lens
BCorrective surgery for blepharoptosis when not congenital/cosmetic
CCorrective Surgery for entropion/ectropion
DDacryocystorhinostomy [DCR]
EExcision involving one-fourth or more of lid margin, full-thickness
FExcision of lacrimal sac and passage
GExcision of major lesion of eyelid, full-thickness
HManipulation of lacrimal passage
IOperations for pterygium
JOperations of canthus and epicanthus when done for adhesions due to chronic Infections
KRemoval of a deeply embedded foreign body from the conjunctiva with incision
LRemoval of a deeply embedded foreign body from the cornea with incision
MRemoval of a foreign body from the lens of the eye
NRemoval of a foreign body from the posterior chamber of the eye
ORepair of canaliculus and punctum
PRepair of corneal laceration or wound with conjunctival flap
QRepair of post-operative wound dehiscence of cornea
RPenetrating or Non-Penetrating Surgery for treatment of Glaucoma
11Pacemaker insertion
13Excision of pilonidal sinus
14Therapeutic endoscopic surgeries
15Conisation of the uterine cervix
16Medically necessary Circumcision
17Excision or other destruction of Bartholin's gland (cyst)
21PCNL(percutaneous nephrolithotomy)
22Reduction of dislocation under General Anaesthesia
23Transcatherter Placement of Intravascular Shunts
24Incision Of The Breast, lump excision
27Vocal cord surgery
29Tympanoplasty& revision tympanoplasty
30Arthroscopic Knee Aspiration if Proved Therapeutic
31Perianal abscess Incision & Drainage
32DJ stent insertion
33FESS (Functional Endoscopic Sinus Surgery)
34Fissurectomy / Fistulectomy
35Fracture/dislocation excluding hairline fracture
36Haemo dialysis
39Inguinal/ventral/ umbilical/femoral hernia repair
40Laparoscopic Cholecystectomy
42Liver aspiration
44Parenteral chemotherapy
ATUMT(Transurethral Microwave Thermotherapy)
BTUNA(Transurethral Needle Ablation)
CLaser Prostatectomy
DTURP( transurethral Resection of Prostate)
ETransurethral Electro-Vaporization of the Prostate(TUEVAP)
51Surgery for Sinusitis
52Varicose Vein Ligation
54Surgical treatment of a varicocele and a hydrocele of the spermatic cord
55Retinal Surgeries
57Ascitic/pleural therapeutic tapping
58therapeutic Arthroscopy
60Surgery for Carpal Tunnel Syndrome
61Cystoscopic removal of urinary stones / DJ stents
62AV Malformations (Non cosmetic only)
64Cystoscopic fulguration of tumour
65Amputation of penis
66Creation of Lumbar Subarachnoid Shunt
67Radical Prostatectomy
68Lasik surgery (non-cosmetic)
69Orchidopexy (non-congenital)
71Palatal surgery
72Stapedectomy& revision of stapedectomy
74Or any other surgeries / procedures agreed by the TPA and the Company which require less than 24 hours Hospitalisation and for which prior approval from TPA is mandatory.
13. What do i need to do if anybody covered in the policy need to get hospitalized?
For Mediclaim
Upon the happening of any event which may give rise to a claim under the policy, please immediately intimate the TPA or underwriting office or nearest office of “The New India Assurance Co. Ltd.”,, whichever is applicable, named in the schedule with all the details such as name of the Hospital, details of treatment, patient name, policy number etc. In case of emergency Hospitalisation, this information needs to be given to the TPA or underwriting office, whichever applicable, within 24 hours from the time of Hospitalisation.
For Personal Accident
Incase of death claim
  1. Nominee as specified in the policy schedule should immediately notify the policy issuing office.
  2. Submit the claim form along with death certificate, post mortem report, police report and original policy.
In case of Injury claim:
  1. Notify the policy issuing office immediately.
  2. Submit Police report if any.
  3. Submit claim form along with medical certificate certifying the disablement. This is an important condition that you need to comply with.
14. What are the ambulance charges paid under this policy?
Company will pay ambulance charges up to 1% of SI or actual whichever is less. These charges are available in case of emergency extraction from anywhere to Hospital or Hospital to Hospital.
15. Incase of ayurvedic treatment, will the entire amount be paid?
The liability of the company in case of Ayurvedic/Homoeopathic/ Unani treatment will be 25% of the Sum Insured provided the treatment is taken in a government Hospital or in any institute recognized by government or accredited by Quality Council Of India or National Accreditation Board on Health, excluding centers for spas, massage and health rejuvenation procedures.
16. Is payment availabe for expenses incurred before hospiltalisation?
Yes. Medical Expenses incurred immediately before, but not exceeding thirty days, the Insured Person is Hospitalised will be paid, provided that:
  1. Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalisation was required, and
  2. The In-patient Hospitalisation claim for such Hospitalisation is admissible by Us.
17. Is payment available for expenses incurred after hospitalisation?
Yes. Medical Expenses incurred immediately after, but not exceeding sixty days, the Insured Person is discharged from the Hospital will be paid, provided that:
  1. Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalisation was required, and
  2. The In-patient Hospitalisation claim for such Hospitalisation is admissible by Us.
18. Is there a limit to what the company will pay for hospitalisation?
Yes. We will pay Hospitalisation expenses up to a limit, known as Sum Insured. In cases where the Insured Person was Hospitalised more than once, the total of all amounts paid
  1. for all cases of Hospitalisation,
  2. expenses paid for medical expenses prior to Hospitalisation, and
  3. expenses paid for medical expenses after discharge from Hospital shall not exceed the Sum Insured.
The Sum Insured under the policy is available for any or all the members covered for one or more claims during the tenure of the policy. For Personal accident, the cover will be as described in point 4(B).
19. Can i get treated anywhere?
The Policy covers treatment only in India. Even within India, if premium is paid for lower zone and treatment taken in higher zone, our liability towards any claim will be
  1. 80% of admissible claim amount
  2. Sum Insured
Whichever is less.
  1. Insured XYZ, Sum Insured: Rs. 200000, Zone Selected: Zone III Admissible Claim: Rs. 80000, Treatment taken in: Zone II In such case Our liability will be 80% of the admissible claim amount i.e. Rs. 64000 (80% of Rs. 80000). Rest of the amount will be borne by the Insured i.e. Rs. 16000.
  2. Insured ABC, Sum Insured: Rs. 200000, Zone Selected: Zone II Admissible Claim: Rs. 300000, Treatment taken in: Zone I In such case, our liability will be 80% of admissible claim amount i.e. Rs. 240000 (80% of Rs. 300000). But the claim amount cannot exceed the Sum Insured viz. Rs. 200000. Thus our total liability will be Rs. 200000. Note: Co-pay will not be applied on the Sum Insured, it is always applicable on the admissible claim amount.
(The Cities mentioned below would include their Urban Agglomeration)
Zone - IGreater Mumbai (includes Mira-Bhayandar, Thane, Navi Mumbai, Kalyan-Dombivli, Ulhasnagar, Ambarnath, Badlapur) and state of Gujarat
Zone - IIDelhi NCR (includes Faridabad, Gurgaon, Mewat, Rohtak, Sonepat, Rewari, Jhajjhar, Panipat and Palwal, Meerut, Ghaziabad, GautamBudha Nagar, Bulandshahr, and Baghpat, Alwar and NCT of Delhi) Bangalore, Chennai, Hyderabad and Secunderabad, Pune and Kolkata
Zone - IIIRest of India (other than those areas specified in Zone I and II)
The Insured Person can choose the Zone at the time of proposal, and can also change it at the time of renewal.
It is therefore in your interest to choose the appropriate Zone and pay the necessary premium depending upon your preference for coverage.
20. What sum insured should i choose?
You are free to choose any Sum Insured from Rs. 2 lakhs, 3 lakhs, 5 lakhs, and8 Lakhs. The premium payable is determined on the following criteria:
  1. The premium for the eldest member of the family. (Premium from Primary Member Premium Table)
  2. Premium for All additional members to be covered in this policy. (Premium from Additional Member Premium Table)
  3. Premium for the daughter(s) shall be 50% of her premium from Additional Member Premium Table.
  4. Sum Insured
  5. Zone (As per point 19 above)
You are free to choose any Sum Insured available as specified above. But it is in your own interest to choose the Sum Insured which could satisfy your present as well as future needs.
21. How long is the policy valid?
The Policy is valid during the Period of Insurance stated in the Schedule attached to the Policy. It is usually valid for a period of one year from the date of beginning of insurance.
22. Can the policy be renewed when thr present policy expires?
Yes. You can and to get all Continuity benefits under the Policy, you should renew the Policy before the expiry of the present policy. For instance, if Your Policy commences from 2nd October, 2011 date of expiry is usually on 1st October, 2012. You should renew Your Policy by paying the Renewal Premium on or before 1st October 2012.
23. What is continuity benifit?
There are certain treatments which are payable only after the Insured Person is continuously covered for a specified period. For example, Cataract is covered only after twenty four months of Continuous Coverage. If an Insured took a Policy in October, 2008, does not renew it on time and takes a Policy only in December 2009, and renewed it on time in December 2010, any claim for Cataract would not become payable, because the Insured Person was not continuously covered for twenty four months. If, he had renewed the Policy in time in October 2009 and then in October 2010, then he would have been continuously covered for twenty four months and therefore his claim for Cataract in the Policy beginning from October 2010 would be payable. Therefore, you should always ensure that you pay your renewal Premium before Your Policy expires.
24. Is there any grace period for renewal of the policy?
Yes. If Your Policy is renewed within thirty days of the expiry of the previous Policy, then the Continuity Benefits would not be affected. But even if You renew Your Policy within thirty days of expiry of previous Policy, any Illness contracted or Injury sustained or Hospitalisation commencing during the break in insurance is not covered. Therefore it is in your own interest to see that you renew the Policy before it expires.
25. Can the sum insured be increased at the time of renewal?
Yes. You may seek enhancement of Sum Insured in writing before payment of premium for renewal, which may be granted at Our discretion. Before granting such request for enhancement of Sum Insured, We have the right to have You examined by a Medical Practitioner authorized by Us or the TPA (50% of Medical examination cost will be reimbursed to the Insured Person).Ourconsent for enhancement of Sum Insured is dependent on the recommendation of the Medical Practitioner. Sum Insured can be enhanced to the next Sum Insured band only.
Enhancement of Sum Insured will not be considered for:
  1. Insured Persons over 65 years of age.
  2. Insured Person who had undergone Hospitalization in the preceding two years.
  3. Insured Persons suffering from one or more of the following Illnesses/Conditions:
    1. Diabetes
    2. Hypertension
    3. Any chronic Illness/ Ailment
    4. Any recurring Illness/ Ailment
    5. Any Critical Illness
In respect of any increase in Sum Insured, exclusion 4.1, 4.2, 4.3.1 and 4.3.2as mentioned in point 8 would apply to the additional Sum Insured from the date of such increase.
26. Is there an age limit upto which the policy would be renewed?
No. Your Policy can be renewed, as long as you pay the Renewal Premium before the date of expiry of the Policy. There is an age limit for taking a fresh Policy, but there is no age limit for renewal. However, if you do not renew Your Policy before the date of expiry or within thirty days of the date of expiry, the Policy may not be renewed, and only a fresh Policy could be issued, subject to our underwriting rules. In such cases, it is possible that a fresh Policy could not be issued by us. It is therefore in your interest to ensure that Your Policy is renewed before expiry.
27. Can the insurance company refuse to renew the policy?
We may refuse to renew the Policy only on rare occasions such as fraud, misrepresentation ornon-disclosureof material facts or non-cooperation being committed by You or any one acting on Your behalf in obtaining insurance or subsequently in relation thereto. If we discontinue selling this Policy, it might not be possible to renew this Policy on the same terms and conditions. In such a case you shall, however, have the option for renewal under any similar Policy being issued by the Company, provided the benefits payable shall be subject to the terms contained in such other Policy.
28. Can i make a claim immediately after taking a policy?
Claims for Illnesses cannot be made during the first thirty days of a fresh Insurance policy. However, claims for Hospitalisation due to accidents occurring even during the first thirty days are payable. There are certain treatments where the waiting period is two years or four years.
29. Who will settle the claim?
Health claims are generally processed by Third Party Administrator (TPA).TPA is a service provider to facilitate service to you for providing Cashless facility for all Hospitalisation that come under the scope of the policy. The TPA also processes reimbursement claims within the scope of the Policy.
The person can also opt for servicing through underwriting office. In such event the insured cannot avail cashless facility. No discount will be offered for not opting TPA.
Personal Accident claims will only be processed by the underwriting office.
30. What is cashless hospitalisation?
Cashless Hospitalisation is service provided by the TPA on Our behalf whereby you are not required to settle the Hospitalisation expenses at the time of discharge from Hospital. The settlement is done directly by the TPA on Our behalf. However those expenses which are not admissible under the Policy would not be paid and you would have to pay such inadmissible expenses to the Hospital. Cashless facility is available only in Networked Hospitals. Prior approval is required from the TPA before the patient is admitted into the Networked Hospital. You may visit our Website at http://newindia.co.in/listofhospitals.aspx. The list of Networked Hospitals can also be obtained from the TPA or from their website. You will have full freedom to choose the hospitals from the Networked Hospitals and avail Cashless facility on production of proof of Insurance and Your identity, subject to the claim being admissible. The TPA might not agree to provide Cashless facility at a Hospital which is not a Network Hospital. In such cases you may avail treatment at any Hospital of Your choice and seek reimbursement of the claim subject to the terms and conditions of the Policy. In cases where the admissibility of the claim could not be determined with the available documents, even if the treatment is at a Network Hospital, the TPA may refuse to provide Cashless facility. Such refusal may not necessarily mean denial of the claim. You may seek reimbursement of the expenses incurred by producing all relevant documents and the TPA may pay the claim, if it is admissible under the terms and conditions of the Policy. Note: This facility is available only for Mediclaim purposes.
31. Can i change hospitals during the course of my treatment?
Yes, it is possible to shift to another Hospital for reasons of requirement of better medical procedure. However, this will be evaluated by the TPA on the merits of the case and as per policy terms and conditions.
32. How to get reimbursements in case of treatment in non-network hospitals or dental of cashless facility?
In case of treatment in a non-Network Hospital, you must ensure that the Hospital where treatment is taken fulfills the conditions of definition of Hospital in the Policy. Within twenty four hours of Hospitalisation the TPA should be intimated. The following documents in original should be submitted to the TPA within seven days from the date of Discharge from the Hospital:
  • Claim Form duly filled and signed by the claimant.
  • Discharge Certificate from the hospital.
  • All documents pertaining to the illness starting from the date it was first detected i.e. Doctor's consultation reports/history.
  • Bills, Receipts, Cash Memos from hospital supported by proper prescription.
  • Receipt and diagnostic test report supported by a note from the attending medical practitioner/surgeon justifying such diagnostics.
  • Surgeon's certificate stating the nature of the operation performed and surgeon's bill and receipt.
  • Attending doctor’s / consultant’s / specialist’s / anesthetist's bill and receipt, and certificate regarding diagnosis.
  • Details of previous policies, if the details are not already with TPA or any other information needed by the TPA for considering the claim.
For Personal Accident cases, the Insured Person needs to submit the following documents:
  • Claim form duly filled and signed.
  • Police report
  • Death Certificate and post mortem report (only in case of death)
  • Proof of disablement
33. How to get reimbursement for pre and post hospitalisation expenses?
The Policy allows reimbursement of medical expenses incurred before and after admissible Hospitalisation up to a certain number of days. For reimbursement, send all bills in original with supporting documents along with a copy of the discharge summary and a copy of the authorization letter to his/her TPA/underwriting office, whichever applicable. The bills must be sent to the TPA/underwriting office within 7 days from the date of completion of treatment. You must also provide the TPA/underwriting office with additional information and assistance as may be required by the Company/TPA in dealing with the claim.
34. Will the entire amount of the caliamed expenses be paid?
The entire amount of the claim is payable, if it is within the Sum Insured and is related with the Hospitalisation as per Policy conditions and is supported by proper documents, except the expenses which are excluded. Personal Accident claims will be paid as mentioned in Point 4(B) without any deductions. Hospitalisation cover is independent of Personal Accident cover. Upon happening of accident if the Insured Person is Hospitalised, Hospitalisation will be paid in addition to compensation being paid under Personal Accident coverage.
35. Can my claim be rejected or refused?
Yes. A claim, which is not covered under the Policy conditions, can be rejected. Claims may also be rejected in the event of misrepresentation, misdescription or nondisclosure of any material fact/particular. In case You are not satisfied by the reasons for rejection, You can represent to Us within 15 days of such denial. If You do not receive a response to Your representation or if You are not satisfied with the response, You may write to our Grievance Cell, the details of which are provided at our website at http://newindia.co.in/Content.aspx?pageid=73. You may also call our Call Centre at the Toll free number 1800-209-1415, which is available 24x7. You also have the right to represent Your case to the Insurance Ombudsman. The contact details of the office of the Insurance Ombudsman could be obtained from http://www.irda.gov.in/ADMINCMS/cms/NormalData_Layout.aspx?page=PageNo234&mid=7.2
36. Can i cancel the policy?
Yes, You can. But the Refund that would be made in case the Policy is cancelled would not be proportionate to the unexpired term of the Policy. Such Refund would be made only if no claim has been made or paid under the Policy, and the Refund would be at our Short Period rate table given below:
Up to one month1/4th of the annual rate
Up to three months1/2 of the annual rate
Up to six months3/4th of the annual rate
Exceeding six monthsFull annual rate
We may also at any time cancel the Policy on grounds of misrepresentation, fraud, non-disclosure of material fact or non-cooperation by You by sending fifteen days’ notice in writing by Registered A/D to You at the address stated in the Policy. Even if there are several insured persons, notice will be sent to You. On such cancellation, other than on grounds of fraud premium corresponding to the unexpired period of Insurance will be refunded, if no claim has been made or paid under the Policy.
Mid-term Deletion of members will be on short scale basis.
37. What is free look period?
The free look period shall be applicable at the inception of first policy. You will be allowed a period of 15 days from the date of receipt of the policy to review the terms and conditions of the policy and to return the same if not acceptable.
If You have not made any claim during the free look period, then You shall be entitled to:
  1. A refund of the premium paid less any expenses incurred by Us on medical examination of the insured persons and the stamp duty charges or;
  2. Where the risk has already commenced and the option of return of the policy is exercised by the policyholder, a deduction towards the proportionate risk premium for period on cover.
38. Is there any benifit under the income tax act for the premium paid for this insurance?
Yes. Payments made for health insurance in any mode other than cash are eligible for deduction from taxableincome as per Section 80 D of the Income Tax Act, 1961. For details, please refer to the relevant Section of the Income Tax Act.
39. Is congential diseases covered in the policy?
Yes. Congenital Internal Disease or Defects or anomalies shall be covered after twenty four months of Continuous Coverage, if it was unknown to You or to the Insured Person at the commencement of such Continuous Coverage. Exclusion for Congenital Internal Disease or Defects or Anomalies would not apply to a New Born Baby during the year of Birth and also 16 subsequent renewals, if Premium is paid for such New Born Baby and the renewals are effected before or within thirty days of expiry of the Policy.
Congenital External Disease or Defects or anomalies shall be covered after forty eight months of Continuous Coverage, but such cover for Congenital External Disease or Defects or anomalies shall be limited to 10% of the average Sum Insured in the preceding four years.
40. If the claim event fails within two policy periods,how much will be paid?
If the claim event falls within two policy periods, the claims shall be paid taking into consideration the available sum insured in the two policy periods, including the deductibles for each policy period. Such eligible claim amount to be payable to the insured shall be reduced to the extent of Premium to be received for the renewal/due date of premium of health insurance policy, if not received earlier.
41. How much will be reimbursed if the person has more than one policy?
If the Insured Person is covered by more than one policy issued by Us or by any other insurer, where such policies indemnify treatment cost, the Insured Person shall have the right to require a settlement of his claim in terms of any of his policies, provided the admissible claim is within the limits of and according to the terms of the chosen policy.
If the amount to be claimed exceeds the Sum Insured under a single policy after considering Deductibles or Co-Pay, the Insured Person shall have the right to choose insurers by whom the claim is to be settled. In such cases the Company shall not be liable to pay or contribute more than its ratable proportion of the admissible claim. 
Note: The insured Person must disclose such other insurance at the time of making a claim under this Policy.

None of the provisions of this Clause shall apply for payments under Personal Accident Section, Hospital cash benefit and Critical care benefit.
 42. What will happen to the policy when the daughter/son becomes financially dependent or a boy child is born after taking the policy?
The Company shall offer an option to migrate to suitable Health Insurance policy once the Daughter/s become financially independent or a Boy child is born after taking the policy.

How to claim ?

If the Insured intend to make any claim under this Policy
  1. Intimate TPA in writing on detection of any Illness/Injury being suffered immediately or forty eight hours before Hospitalisation.
  2. Intimate within twenty four hours from the time of Hospitalisation in case of Hospitalisation due to medical emergency.
  3. Submit following supporting documents TPA relating to the claim within seven days from the date of discharge from the Hospital:       
    • Bill, Receipt and Discharge certificate / card from the Hospital.
    • Cash Memos from the Hospitals (s) / Chemists (s), supported by proper prescriptions.
    • Receipt and Pathological test reports from Pathologist supported by the note from the attending Medical Practitioner / Surgeon recommending such Pathological tests / pathological.
    • Surgeon's certificate stating nature of operation performed and Surgeons’ bill and receipt.
    • Attending Doctor's/ Consultant's/ Specialist's / Anesthetist’s bill and receipt, and certificate regarding diagnosis.
  4. In case of Post-Hospitalisation treatment (limited to sixty days), submit all claim documents within 7 days after completion of such treatment.
  5. Provide TPA with authorization to obtain medical and other records from any Hospital, Laboratory or other agency.
The Insured person shall submit to the TPA all original bills, receipts and other documents upon which a claim is based and shall also give the TPA/Us such additional information and assistance as the TPA / We may require.
Any Medical Practitioner authorised by the TPA/Us shall be allowed to examine the Insured Person, at our cost, if We deem Medically Necessary in connection with any claim.