Varishtha Mediclaim Policy for Senior Citizens

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Policy Details: 

This policy covers for In-patient treatment (minimum 24 hour hospitalization) and domiciliary hospitalization expenses along with 140+ Day Care Procedureson Cashless/ Reimbursement basis during the policy period exclusively for Senior Citizens above 60 years of age.The expenses incurred should be reasonable, customary and medically necessary.

The policy has two sections:

Section I

  • Hospitalisation & Domiciliary Hospitalisation Cover - Sum Insured is Rs.1, 00,000/- (one lakh) only.
  • Entry Age between the age of 60 (sixty) years and 80 (eighty) years.
  • Room Rent/ICU charges, Medical practitioners, surgeon, anaesthetist, consultants, specialist’s fees and other charges as per limits mentioned in the policy.
  • Company’s liability in respect of claims arising due to Cataract is up to Rs.10, 000/- (ten thousand) and that of Benign Prostatic Hyperplasia (BHP) is up to Rs.20, 000/- (twenty thousand) only.
  • Company’s liability under Domiciliary Hospitalisation is limited to 20% of the sum insured under Section I
  • Ambulance Charges as per policy.
  • Annual Increase in SI by 5% for each claim free year up to maximum 50% of Sum Insured opted or an Option of discount in renewal premium (5%) up to 10 claim free years.
  • Health Check Up Facility: Expenses of health check-up once at the end of a block of three claim free policy periods @ maximum of 2% of the sum insured.
  • Life Long Renewability
  • Tax Rebate under Section 80D of Income Tax Act 1961 for premium paid

Section II (Optional benefit)

  • Critical Illness cover 8 diseases (-hyperlink to policy)–
  • Sum Insured is Rs.2, 00,000/- (two lakhs) only.

Pre Policy Check Up:

  • For persons availing policy for the first time.
  • No medical check-up is required if covered under any health insurance policy uninterruptedly for preceding three years.

List of Tests/Reports:

1. Physical examination (report to be signed by the Doctor with minimum MD (Medicine) qualification)

2. Blood sugar (fasting/ post prandial)

3. Urine routine and microscopic examination

4. ECHO cardiograph

5. Eye check-up (including retinoscopy)

Note: The date of medical reports should not exceed 30 days prior to the date of proposal. 50% of the expenses incurred for pre policy check-up shall be reimbursed, if the proposal is accepted.

Under Section I

  • Only accidental claims payable for first 30 days of Inception of the Policy
  • All pre-existing diseases excluded for first Twelve (12) months of Policy.
  • Co-payment for all admissible claims as per policy, other than for cataract and BHP.
  • HIV, AIDS, STD, Sterility, infertility, Maternity & assisted conception
  • Intentional self-inflicted injury
  • Cosmetic, plastic surgery
  • Dental treatment and Out Patient Department treatment (OPD treatment)

Under Section II

  • Waiting period of 90 days
  • Pre-existing condition manifested within 90 days
  • Only one claim payable during policy period for particular Critical illness
  • The policy will cease upon payment of the sum insured on the happening of a critical illness and no further payment will be made for any consequent disease or any dependent disease or any critical illness
  • Critical Illness arising out of Non Prescribed drug, Drug addiction and Smoking ,Suicide, AIDS, HIV ,Radioactivity and War Group Risks

How to report a claim?

For Cashless Facility – available only for policies serviced by a Third Party Administrator (TPA)

 1. Check if the hospital falls under the networked hospitals (Preferred provider network/other network Hospitals), as cashless is available only for empanelled network hospitals of the Company/TPA.

2. For planned hospitalisation, intimation is to be sent to the TPA/Company in advance (72 hours prior) with details of Name and address of the hospital and condition requiring hospitalization.

3. In case of an emergency hospitalisation, intimation is to be sent to the TPA/Company within 24 hours of admission.

4. On admission, a Pre-Authorisation Request for cashless will be sent to the TPA by the hospital – duly signed by the insured and Hospital Authorities giving the details of admission, illness, proposed line of treatment and the estimated expenses. Pre and post hospitalisation expenses can be claimed separately after treatment.

5. All documents in original are to be submitted within 15 days to TPA, after completion of Post Hospitalisation treatment.

For Reimbursement Claims:

1. Written intimation/mail/fax about hospitalisation is to be sent to TPA /Company within 72 hours of hospitalisation in the case of emergency hospitalisation and 72 hours prior in case of planned admission.

2. Before leaving the hospital, Discharge Summary, investigation report and other relevant documents (Claim form – Part A& Part B) may be obtained from the hospital authorities. All the documents in original are to be submitted to TPA / Office within 15 days from date of discharge.

3. Pre and post hospitalisation expenses can be claimed separately after treatment.

4. All documents in original to be submitted within 15 days after completion of Post Hospitalisation treatment.

For Critical Illness Claims:

1. Notice of claim in writing to office within 15 days of diagnosis/procedure

2. Documents shall be submitted, along with the completed claim form, at the Policy issuing office within 30 days from the survival period

3. Medical practitioner’s certificate confirming diagnosis of the Critical Illness or undergoing the procedure along with the date of diagnosis or undergoing procedure.

4. Original discharge summary, if any (Certified copy if original not available)

5. Pathological/ radiological/other diagnostic test reports confirming the diagnosis of the Critical Illness.

6. Any other document required by the Company in support of the claim

7. Survival Period (60 days, 90 days and 6 months for specific critical illnesses)

What are the Documents required (originals)?

1. Duly filled Claim form issued by insurer (Part A & Part B)

2. Discharge summary of hospital

3. Doctor's certificates and prescriptions

4. Final hospital bills and receipts 5

. Laboratory and other investigation reports/plates/films and bills

6. Pharmacy bills and receipts

7. Any other document as may be required on case to case basis

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