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Any One Illness will be deemed to mean continuous period of illness and it includes relapse within 45 days from the date of last consultation with the Hospital/Nursing Home where treatment may have been taken. Occurrence of same illness after a lapse of 45 days as stated above will be considered as fresh illness for the purpose of this policy. |
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3.1 |
Pre-Hospitalization : Relevant medical expenses incurred during period up to 15 days prior to hospitalization on disease/illness/injury sustained will be considered as part of claim mentioned under Hospitalization Expenses. |
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3.2 |
Post-Hospitalization : Relevant medical expenses incurred during period upto 30 days after hospitalization on isease/illness/injury sustained will be considered as part of claim mentioned under Hospitalization Expenses |
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3.3 |
Medical Practitioner means a person who holds a degree/diploma from a recognized institution and is registered by the Medical Council of India or the respective State Councils. The term Medical Practitioner would include Physician, Specialist and Surgeon. |
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3.4 |
Qualified Nurse means a person who holds a certificate of a recognized Nursing Council and who is employed on the recommendations of the attending Medical Practitioner. |
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3.5 |
TPA means a Third Party Administrator who is licensed by the Insurance Regulatory and Development Authority, and is engaged, for a fee or remuneration, by whatever name called as may be specified in the agreement with the Company, for the provision of health services. |
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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 : |
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4.1 |
All diseases/injuries which are pre-existing when the cover incepts for the first time. However, those diseases will be covered after four continuous claim free policy years. For the purpose of applying this condition, the period of cover under Mediclaim policy taken from National Insurance Company only will be considered. Pre-existing disease like Diabetes and Hypertension will be covered from the inception of the policy on payment of additional premium by the insured. |
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| 4.4.1 |
Insured shall bear 10% of any admissible claim if he is suffering from either Diabetes or Hypertension and 25% of the admissible claim amount in case he is suffering from both diabetes and hypertension. This provision is applicable only for claims arising out of Diabetes and/or Hypertension.
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4.2 |
Any disease other then those stated in Clause 4.3, contracted by the Insured Person during the first 30 days from the commencement date of the policy. This condition 4.2 shall not however, apply in case of hospitalization due to accidental injury or if the Insured Person having been covered under this scheme or a similar Health Insurance Scheme with any of the Indian Insurance Companies for a continuous period of preceding 12 months without any break. |
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4.3 |
During the first 2 years of the operation of the policy the expenses incurred on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy, Hernia, Hydrocele, Congenital Internal Disease, Fistula in anus, Chronic fissure in anus, Piles, Pilonidal Sinus, Sinusitis, Stone disease of any site, Benign Lumps/growths in any part of the body, CSOM(Chronic Suppurative Otitis Media), joints replacements of any kind unless arising out of accident, surgical treatment of Tonsils, Adenoids and deviated nasal septums and related disorders are not payable. If these diseases (other than Congenital Internal Disease/Defects) are pre-existing at the time of proposal, they will be covered only after four continuous claim free years as mentioned in column 4.1 above. |
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If the Insured is aware of the existence of Congenital Internal Disease/Defect before inception of the policy, the same will be treated as pre-existing. |
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4.4 |
Injury or disease directly or indirectly caused by or arising from or attributable to War Invasion Act of Foreign Enemy Warlike operations (whether war be declared or not). |
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Injury or disease directly or indirectly caused by or contributed to by nuclear
weapons/materials. |
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4.5 |
Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident, vaccination or inoculation or change of life or cosmetic or aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as part of any illness. |
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4.6 |
The cost of spectacles, contact lenses and hearing aids.
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