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Group Medical Policy
Group Mediclaim Policies can be issued only to any of the following seven notified categories:
  • Employee-Employer relationship including dependents of employee
  • Pre-identified groups where premium is paid by the State/Central Government.
  • Members of Registered Cooperative Society
  • Members of Registered Service Club
  • Credit card holders of banks / Diners / Master / Visa.
  • Holders of deposit certificates issued by Banks / NBC's .
  • Shareholders of Banks / Public Companies.

The policy covers reimbursement of all hospitalisation expenses like room/boarding charges, nursing expenses, doctors/anaesthetists/surgeons fees, lab and investigation charges and cost of medicines and drugs incurred for illness/injury sustained during the policy period.

Normally hospitalisation should be for a minimum period of 24 hours. Hospital would mean any hospital/nursing home in India, registered with the local authorities and under the supervision of a registered and qualified medical practitioner, with minimum 15 inpatient beds (10 in case of class 'c' towns), and should be equipped with an operation theatre where operations are carried out, and has qualified nurses and doctor( s) round the clock.

age limit

Persons between the age of 5 and 80 can be covered under the policy. Children between the age of 3 months and 5 years can be covered provided one or both parents are covered concurrently.

SUM INSURED:

The sum insured can be selected from Rs.15,000/- to Rs.5,00,000/- and the premium payable depends on the sum insured selected and the age of the person to be covered.

DOMICILIARY HOSPIT ALISATION:-

In addition to hospitalisation, upto a certain limit of the sum insured, treatment taken for more that three days for illness/disease/injury which normally needs hospitalisation but treated at home is also reimbursable only due to one of the following reasons:-

  • The condition of the patient being such that he cannot be shifted to a hospital
  • patient cannot be removed to a hospital/nursing home for lack of accommodation.
    • Treatment should be for a period exceeding three days
    • Domiciliary hospitalisation does not cover pre and post hospital treatment; asthma, bronchitis, chronic nephritis and nephritic syndrome, diarrhea / dysenteries / gastroenteritis, diabetes mellitus and insipid us, epilepsy, hypertension, influenza, cough, cold, all physiatrist or psychosomatics disorders, Pyrexia, tonsillitis and DR!, laryngitis, pharingitis, arthritis, gout and rheumatism
    • Liability - would be restricted to the amount stated in the policy for domiciliary hospitalisation benefits.
OTHER DETAILS:
  • Hospitalistaion as an in-patient is a must
  • Admission can be sought in any hospital/nursing home in India
  • Relevant medical expenses incurred during 30 days prior to hospitalisation and 60 days after hospitalisation in respect of disease/injury/illness would form part of the claim as pre and post hospitalisation expenses.
MATERNITY BENEFITS:

The Group Mediclaim Policy offers an option to cover maternity expenses upto Rs.50,000/- or the sum insured, which ever is lower, by payment of an additional premium of 10% of the total group premium.

  • Claims are admissible only in respect of the first two children.
  • A waiting period of nine months would be applicable for payment of claims relating to delivery. But it can be relaxed where delivery, miscarriage or abortion is induced by accident or a medical emergency.
  • Expenses for termination of pregnancy are not covered unless under medical emergency.
  • Prenatal and postnatal expenses are not covered unless treatment is taken in a hospital/nursing home.
GENERAL EXCLUSIONS:-
  • All diseases, injuries, which are preexisting when the cover incepts for the first time.
  • Normally diseases which are contracted in the first 30 days of the payment of premium (waiting period)
  • Routing eye examination and cot of glasses and contact lenses
  • Dental treatment or surgery of any kind unless requiring hospitalisation.
  • Nature cure or other rest cure, V.D., self injury, drugs, sterility, congenital external diseases.
  • Expenses on vitamins and tonics unless forming part of hospital treatment.
  • Treatment arising from or traceable to pregnancy,childbirth, including cesarean section,voluntary medical termination of pregnancy (unless maternity benefits opted for)
  • Expenses incurred primarily for diagnostic X-ray or laboratory examination
  • Plastic surgery unless necessitated by accident or forming part of treatment
  • Naturopathy treatment
  • Circumcision, vaccination, inoculation, change of life (resulting from or traceable to menopause or in any way associated with it), cosmetic or aesthetic treatment of any description.
GENERAL EXCLUSIONS:-

During the first year when cover incepts for the first time, the following are excluded:

  • Cataract
  • Benign prostatic hypertrophy
  • Hysterectomy for menorrhagia or fibromyoma
  • Hernia
  • Hydrocele
  • Congenital internal diseases
  • Fistula in anus, piles
  • Sinusitis and related disorders

If these are preexisting then they cannot be covered during subsequent renewals too.