Standard Group Mediclaim Policy 2007 (Cashless Facility Available)

Salient features of the Policy

1.0 COVERAGE:The Policy covers reimbursement of Hospitalisation Expenses for Illness/ Injury sustained.

2.0 In event of any claim being admissible, following Reasonable and Customary expenses are reimbursable under the policy:

2.1 Room, boarding and nursing expenses as provided by the Hospital not exceeding 1.0 % of the Sum Insured per day or actual, whichever is less.

2.2 Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) expenses not exceeding 2.0 % of the Sum Insured per day, or actual, whichever is less.

2.3 Surgeon, Anesthetist, Medical Practitioner, Consultants’ Specialist fees.

2.4 Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, Cost of Prosthetic devices implanted during surgical procedure like pacemaker, Relevant Laboratory/Diagnostic test, X-Ray and other medical expenses related to the treatment.

2.5 Pre-hospitalization medical expenses up to 30 days period.

2.6 Post hospitalization medical expenses up to 60 days period.

NOTE:

1. The amounts payable under 2.3 and 2.4 shall be at the rate applicable to the entitled room category. In case of admission to a room/ICU/ICCU at rates exceeding the limits as mentioned under 2.1 and 2.2, the reimbursement/payment of all other expenses incurred at the Hospital, with the exception of cost of medicines, shall be affected in the same proportion as the admissible rate per day bears to the actual rate per day of room rent/ICU/ICCU charges.
2. No payment shall be made under 2.3 other than as part of the hospitalization bill.
3. However, the bills raised by Surgeon, Anesthetist directly and not included in the hospitalization bill may be reimbursed in the following manner:
   1. The Reasonable, Customary and Medically Necessary Surgeon fee and Anesthetist fee would be reimbursed, limited to the maximum of 25% of Sum Insured. The payment shall be reimbursed provided the insured pays such fee(s) through cheque and the Surgeon / Anesthetist provides a numbered bill. Bills given on letter-head of the Surgeon, Anesthetist would not be entertained.
   2. Fees paid in cash will be reimbursed up to a limit of INR 10,000/- only, provided the Surgeon/Anesthetist provides a numbered bill.

2.7 LIMIT ON PAYMENT FOR CATARACT

Company’s liability for payment of any claim relating to Cataract shall be limited to Actual or maximum of INR 24,000 (inclusive of all charges, excluding service tax), for each eye, whichever is less.

2.8 AYUSH:Expense incurred for Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy system of medicines are covered 100% of Sum insured.

2.9 Ambulances services – 1.0 % of the sum insured or actual, whichever is less, subject to maximum of INR 2,500/- in case patient has to be shifted from residence to hospital for admission in Emergency Ward or ICU or from one Hospital to another Hospital by fully equipped ambulance for better medical facilities.

2.10 Hospitalization expenses (excluding cost of organ) incurred on the donor during the course of organ transplant to the insured person. The Company’s liability towards expenses incurred on the donor and the insured recipient shall not exceed the sum insured of the insured person receiving the organ.

2.11 Zones

Persons paying Zone I premium can avail treatment in any Zone. There will not be any zone deduction in such cases.

Persons paying Zone II premium can avail treatment in Zone II, Zone III and Zone IV. There will not be any zone deduction in such cases.

Persons paying Zone II premium but availing treatment in Zone I will have to bear 10% as Co-Pay for each admissible claim.

Persons paying Zone III premium can avail treatment in Zone III and Zone IV. There will not be any zone deduction in such cases.

Persons paying Zone III premium but availing treatment in Zone II will have to bear 10% as Co-Pay for each admissible claim.

Persons paying Zone III premium but availing treatment in Zone I will have to bear 20% as Co-Pay for each admissible claim.

Person paying Zone IV premium can avail treatment in Zone III and Zone IV. There will not be any zone deduction in such cases.

Person paying Zone IV premium but availing treatment in Zone II, will have to bear 10% as Co-Pay for each admissible claim.

Person paying Zone IV premium but availing treatment in Zone I, will have to bear 20% as Co-Pay for each admissible claim.