National Insurance Company Limited CIN - U10200WB1906GOI IRDAI Regn. No. - 58

Transcription

1 National Insurance Comp Limited CIN - U10200WB1906GOI IRDAI Regn. No S No. TITLE DESCRIPTION Customer Information Sheet 1. Product Name 2. What am I covered for? is a high deductible indemnity health insurance product, covering the members of a family under a single sum insured on floater basis or each member on individual sum insured basis. Claim under the Policy is payable provided the cumulative medical expenses covered under the Policy, for the insured (individual basis) or the family (floater basis) in a policy period exceeds the threshold. The Policy covers expenses in respect of inpatient treatment (allopathy, ayurveda and homeopathy) reasonably and customarily incurred for treatment of a disease or an injury contracted/sustained during the policy period. The Policy also covers pre and post expenses, 140+ day care procedures/surgeries, organ donor s medical expenses, hospital cash, doctor s home visit, nursing, aya and attendant charges, ambulance charges, HIV/ AIDS treatment, bariatric surgery and maternity. Threshold and Sum insured shall be subject to: a. In patient treatment (more than 24 hrs) Expenses for room charges, nursing care, ICU charges, medical practitioner, anaesthesia, blood, oxygen, OT charges, surgical appliances, medicines, drugs, consumables, diagnostic procedures and cost of prosthetic and other devices or equipment if implanted internally during a surgical procedure. b. Pre hosopitalisation - Expenses incurred thirty days immediately before for the same condition which resulted in, and in patient treatment claim is admissible. c. Post hosopitalisation - Expenses incurred sixty days immediately after discharge from hospital for the same condition which resulted in, and in patient treatment claim is admissible. d. Day care procedures Expenses for 140+ day care procedures, listed in the policy, which require less than twenty four hours e. Ayurveda and homeopathy f. Organ donor s medical expenses, pre and post hospitalization expenses g. HIV treatment h. Morbid Obesity treatment i. Maternity j. Modern Treatment k. Mental Illness Cover l. Correction of Refractive Error Refer to policy clause number What are the Major exclusions in the policy? Sum insured shall be subject to (only for claims admissible under the Policy): m. Hospital cash Up to SI 10L, INR 1000 per day for 5 days Above SI 10L, INR 2000 per day for 5 days n. Doctor s Home Visit/ Aya/ Nurse/ attendant Charges during Post Hospitalisation Up to SI 10L, INR 1000 per day for 10 days Above SI 10L, INR 2000 per day for 10 days o. Ambulance charges Actual expense a. Treatment outside India b. Sexually transmitted diseases c. Sterility d. Naturopathy and experimental treatment e. Surgery for correction of eye sight due to refractive error, spectacles, contact lens, hearing aid, cochlear implants f. Any hospital admission primarily for investigation / diagnostic purpose Page 1 of 4

2 g. Drug/ alcohol abuse, h. Any kind of service charges, admission fees/ registration charges levied by the hospital i. War j. Radioactivity (Note: the above is a partial listing of the policy exclusions. Please refer to the policy clauses for the full listing). 4. Waiting period a. Pre-existing diseases if declared and accepted will be covered after a waiting period of one year. After expiry of twelve months claim arising out of preexisting diseases or complications thereof will be paid as per the table given below Months from inception Limit of claim months 50% of the admissible claim months 75% of the admissible claim After 36 months 100% of the admissible claim b. Any disease contracted within the first thirty (30) days from the inception of the policy shall not be payable. This Waiting Period shall not apply to accidental injuries. c. Specified surgeries/treatments/diseases are covered after specific waiting period of 90 days/ one year/ two year/ four years Payout basis 6. Loss sharing 7. Renewal Conditions Reimbursement of covered expenses up to specified limits Cashless payment of covered expenses up to specified limits in network providers In case of a claim, this Policy requires you to share the following costs. Cumulative medical expenses up to the Threshold Limit Claims arising out of preexisting diseases after first 12 months Months from inception Loss Sharing months 50% of the admissible claim months 25% of the admissible claim After 36 months Nil Claims arising out of Osteoarthritis and osteoporosis after first 24 months Months from inception Loss Sharing months 50% of the admissible claim After 36 months Nil The policy can be renewed annually throughout the lifetime of the insured person. The policy may be renewed by mutual consent. The comp is not bound to give notice that it is due for renewal. Renewal of the policy can not be denied other than on grounds of fraud, moral hazard or misrepresentation or noncooperation. In the event of break in the policy a grace period of thirty days is allowed Renewal Benefits: Cumulative Bonus (CB) CB shall increase by 5% of SI for every claim free year, subject to maximum of 50% of SI CB shall decrease by 5% of SI, in the case of a claim is made during a policy period 9. Cancellation i. The Comp may at time cancel the Policy (on the grounds of fraud, moral hazard, misrepresentation or noncooperation) by sending the insured thirty days notice by registered letter at insured's last known address, and in such an event, the Comp shall not allow refund. ii. The insured may at time cancel the Policy and in such an event, the Comp shall allow refund of premium after charging premium at Comp s short period rate mentioned below, provided claims are not reported up to the date of cancellation Period of risk Up to 1month Up to 3 months Up to 6 months Exceeding 6 months Rate of premium to be charged 1/4 of the annual rate 1/2 of the annual rate 3/4 of the annual rate Full annual rate Page 2 of 4

3 This policy would be cancelled, and no claim or refund would be due to you if: you have not correctly disclosed details about your current and past health status OR have otherwise encouraged or participated in fraudulent claims under the policy. 10. Claims For Cashless Service i. Notification of claim to be provided as per table below. Notification of claim for TPA must be informed: Cashless facility In the event of planned At least seventy two hours prior to the insured person s admission to network provider/ppn In the event of emergency Within twenty four hours of the insured person s admission to network provider/ppn ii. Cashless facility for treatment in network hospitals can be availed, if TPA service is opted. iii. Treatment may be taken in a network provider and is subject to pre authorization by the TPA. Booklet containing list of network provider shall be provided by the TPA. Updated list of network provider is available on website of the Comp and the TPA mentioned in the schedule. iv. Cashless request form available with the network provider and TPA shall be completed and sent to the TPA for authorization. v. The TPA upon getting cashless request form and related medical information from the insured person/ network provider shall issue pre-authorization letter to the hospital after verification. vi. At the time of discharge, the insured person has to verify and sign the discharge papers, pay for non-medical and inadmissible expenses. vii. The TPA reserves the right to deny pre-authorization in case the insured person is unable to provide the relevant medical details. viii. In case of denial of cashless access, the insured person may obtain the treatment as per treating doctor s advice and submit the claim documents to the TPA for processing. ix. For the first claim under the Policy (i.e., the claim in which cumulative medical expenses exceeds the threshold) cashless facility shall be available provided all evidences and documents are produced prior to cashless authorization, to substantiate that the Cumulative Medical Expenses (CME) exceeds the Threshold. For all subsequent claims under the Policy cashless facility shall be available as usual, subject to sl. no ii to viii below. x. In case of where the expenses are likely to cross the threshold limit, pre authorization request shall be sent to the TPA mentioned in the schedule xi. In case of where initially the expenses are not foreseen to cross the threshold limit, but subsequently crosses and pre authorization request shall be sent to the TPA mentioned in the schedule, immediately For Reimbursement of Claim i. Notification of claim to be provided as per table below. Notification of claim for Comp/TPA must be informed: Reimbursement In the event of planned At least seventy two hours prior to the insured person s admission to hospital In the event of emergency Within twenty four hours of the insured person s admission to hospital ii. For reimbursement of claims the insured person may submit the necessary documents to TPA (if claim is processed by TPA)/Comp (if claim is processed by the Comp) within the prescribed time limit. Type of claim Time limit for submission of documents to Comp/TPA Reimbursement of hospitalization, pre Within fifteen days from date of expenses and discharge from hospital ambulance charges Reimbursement of post expenses Within fifteen days from completion of post treatment iii. On receipt of the final document(s) and investigation report (if required), the Page 3 of 4

4 11. Policy Servicing/ Grievances/Comp laints Comp shall within a period of thirty days offer a settlement of the claim to the insured. iv. If the Comp, for reasons, rejects a claim, it shall communicate to the insured in writing within a period of thirty days from the receipt of the document(s) and investigation report (if required). v. Upon the acceptance of an offer of settlement by the insured, the payment of the amount of claim shall be made within seven days from the date of acceptance of the offer by the Comp. vi. In the cases of delay in the payment, the Comp shall pay interest at a rate 2% above the bank rate prevalent at the beginning of the financial year in which the claim is paid In case of grievance the insured person may contact the comp through Website: Toll free: Phn : (033) Courier:, 6A Middleton Street, 7th Floor, CRM Dept., Kolkata IRDAI Integrated Grievance Management System - Insurance Ombudsman As per Annexure attached to Policy Insured s Rights Free Look Period The policy allows you a period of 15 days from the date of receipt, to review the terms and conditions, and to return the same if not acceptable. Implied renewability (except on certain specific grounds) Policy can be renewed annually throughout the lifetime of the insured person. Renewal of Policy can be denied on grounds of fraud, moral hazard or misrepresentation or noncooperation. Migration and Portability: Portability to similar top up/ super top up products is allowed Migration to nil deductible indemnity policy of the Comp is allowed, subject to Section 3.1 of Policy Increase in Sum Insured, Threshold during the Policy term: i. Sum insured and/ or Threshold can be enhanced only at the time of renewal, to the next slab. ii. For the incremental portion of the sum insured, the waiting periods and conditions as mentioned in exclusion 4.1, 4.2, 4.3 shall apply. Coverage on enhanced sum insured shall be available after the completion of waiting periods. Turn Around Time (TAT) for issue of Pre- Auth and settlement of Reimbursement Issuance of pre-authorisation Within 24 hours, provided all necessary information is received by the TPA Settlement of Claim Within 7 days of acceptance of offer of settlement by the insured 11 Insured s Obligations Please disclose all pre-existing disease/s or condition/s before buying a policy. Nondisclosure may result in rejection of claim. Disclosure of Material Information during the policy period. Fresh proposal form may be submitted. Legal Disclaimer The information must be read in conjunction with the product brochure and policy document. In case of conflict between the CIS and the policy document the terms and conditions mentioned in the policy document shall prevail. Insurance is the Subject matter of Solicitation Page 4 of 4

5 Note: rates specified in the above illustration are standard premium, inclusive of TPA charges and exclusive of taxes applicable. Additional Discounts, if, will be applicable as per terms and condition. Benefit Illustration in respect of (UIN: NICHLIP21167V032021) Illustration 1 Age of the members insured Coverage opted on individual basis covering each member of the family separately (at a single point in time) Sum insured 65 9, , , ,898 10* 1,077 5* 1,077 Total for all members of the family is 20,681/-, when each member is covered separately. Sum insured available for each individual is. Threshold under the policy is. Coverage opted on individual basis covering multiple members of the family under a single policy (Sum insured is available for each member of the family) Discount, if after discount Sum insured Coverage opted on family floater basis with overall Sum insured (Only one sum insured is available for the entire family) or consolidated premium for all members of family 9,124 5% 8,668 9,124 Floater discount, if after discount In Built 1,898 5% 1, ,124 5,097 5% 4,842 1,779 1,779 2,408 5% 2, ,077 5% 1, ,077 5% 1, Total for all members of the family is 19,647/-, when they are covered under a single policy. Sum insured available for each family member is. Threshold under the policy is. Sum insured Threshold Total when policy is opted on floater basis is 12,111/-. Sum insured of is available for the entire family. Threshold under the policy is. *Policy for age 5 and 10 is for illustration only. Separate policy cannot be issued to minors, without covering parent (s) at the same time.

6 Note: rates specified in the above illustration are standard premium, inclusive of TPA charges and exclusive of taxes applicable. Additional Discounts, if, will be applicable as per terms and condition. Benefit Illustration in respect of (UIN: NICHLIP21167V032021) Illustration 2 Age of the members insured Coverage opted on individual basis covering each member of the family separately (at a single point in time) Sum insured 40 2, ,898 10* 1,077 5* 1,077 Total for all members of the family is 6,460/-, when each member is covered separately. Sum insured available for each individual is. Threshold under the policy is. Coverage opted on individual basis covering multiple members of the family under a single policy (Sum insured is available for each member of the family) Discount, if after discount Sum insured Coverage opted on family floater basis with overall Sum insured (Only one sum insured is available for the entire family) or consolidated premium for all members of family 2,408 5% 2,288 2,408 Floater discount, if after discount In Built 1,898 5% 1, ,077 5% 1, ,077 5% 1, Total for all members of the family is 6,137/-, when they are covered under a single policy. Sum insured available for each family member is. Threshold under the policy is. 2,408 Sum insured Threshold Total when policy is opted on floater basis is 3,031/-. Sum insured of is available for the entire family. Threshold under the policy is. *Policy for age 5 and 10 is for illustration only. Separate policy cannot be issued to minors, without covering parent (s) at the same time.