|
|
| Senior Citizens Health Insurance (Mediclaim Policy) in India |
| |
|
|
| 6- VARISTHA Mediclaim for Senior Citizens -National Insurance Company Limited |
|
10.3 At the time of taking this policy, if a person suffers from any of the terminal diseases referred under Critical Illness cover mentioned below, that particular disease will never be covered under Section II of this policy even on payment of additional premium.
10.4 Cover for Paralysis and Blindness under Critical Illness:
Paralysis and Blindness may be covered under Critical Illness by loading the Critical Illness premium by 15% in each case or 25% in case of both covers together.
10.5 Under Group Policy, if the incurred claim ratio of the group exceeds 70% then the renewal premium will be loaded on 70% as if basisi.e. if the incurred claim ratio of any policy year exceeds 70% renewal premium will be loaded in such a way that the incurred claim ratio of expiring policy becomes 70%. |
|
| 11. Claims Procedure |
|
11.1 Section I:
Upon the happening of any event, which may give rise to a claim under this section notice with full particulars shall be sent to the Company within 7 days from the date of Injury / Hospitalization/Domiciliary Hospitalization.
5.1 Claim must be filed within 30 days from date of discharge from the Hospital and where post-hospitalization treatment is not completed, it shall be within 30 days from the date of completion of Post-hospitalization treatment.
NOTE: Waiver of this condition may be considered in extreme cases of hardship where it is proved to the satisfaction of the Company that under the circumstances in which the Insured was placed it was not possible for him or any other person to give such notice or file claim within the prescribed time limit.
Claims will be settled by the Third Party Administrators (TPA). They will send details of the claims procedure for emergency/planned hospitals.
Documents to be submitted:
1. Claim form
2. First consultation document
3. Copy of admission advice
4. Discharge Summary
5. Prescription with bills & receipts
6. Test Reports
7. Any other document required by TPA pertaining to this insurance contract/policy.
Procedure for availing Cashless Access Services in Network Hospital / Nursing Home.
Claims in respect of Cashless Access Services will be through the list of network Hospitals/Nursing Homes and is subject to pre-admission authorization. The TPA shall, upon getting the related medical information from the insured persons/ network provider, verify that the person is eligible to claim under the policy and after satisfying itself will issue a pre-authorisation letter/ guarantee of payment letter to the Hospital/Nursing Home mentioning the sum guaranteed as payable, also the ailment for which the person is seeking to be admitted as a patient.
The TPA reserves the right to deny pre-authorization in case the insured person is unable to provide the relevant medical details as required by the TPA. The TPA will make it clear to the insured person that denial of Cashless Access is in no way construed to be denial of treatment. The insured person may obtain the treatment as per his/her treating doctor’s advice and later on submit the full claim papers to the TPA for reimbursement subject to admissibility of claim under the terms and conditions of the policy.
The TPA may repudiate the claim, giving reasons, if not covered under the terms of the policy. The insured person shall have right of appeal to the insurance company if he/she feels that the claim is payable. The insurance company’s decision in this regard will be final and binding on TPA. |
|
| 11.2 Section II: |
|
Upon detection of any critical illness, which may give rise to a claim under this section, notice with full particulars shall be sent to the Company within 15 days from the date of diagnosis of the disease.
Claim documents as mentioned hereunder must be submitted to the company after 30 days from the date of diagnosis of the disease.
1) Doctor’s certificate confirming diagnosis of the critical illness along with date of diagnosis.
2) Pathological/other diagnostic test reports confirming the diagnosis of the critical illness.
3) Any other documents required by the company |
|
|
|
|
|
|
|
|
|
|
