Health Insurance Policy Information
What is covered in your Standard Health Insurance Policy & what is excluded?
Insurance policy is for the protection of the insured against unforeseen circumstances, which in Health Insurance primarily covers hospitalisation for illness / injury / diseases taken in any hospital as an inpatient anywhere in India. The requirement is that the ailment should have been contracted or the injury sustained only during the currency of the policy and they should not fall under any of the specified exclusions.
Besides the hospitalisation benefit some of the policies extend certain additional benefits like ‘Cumulative Bonus’, reimbursement of ‘Cost of Health Check-up’, domiciliary hospitalisation etc. You will find a brief note on the Domiciliary Hospitalisation Benefit here below.
Also mentioned below is the list of Standard Exclusion (that is not covered) of a Standard Mediclaim Policy.
Please note, this is only an extract of a standard policy. The coverage, the Exclusions as well as the Terms and Conditions would vary from Insurer to Insurer and product to product. All terms and conditions as per the policy document issued to you by your insuring Insurance Company is final for all purposes.
Domiciliary hospitalisation benefit
Domiciliary hospitalisation means medical treatment for a period exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at a hospital/nursing home but actually taken whilst confined at home in India under any of the following circumstances namely:
• The condition of the patient is such that he/ she cannot be removed to the hospital/nursing home.
• The patient cannot be removed to the hospital/ nursing home for lack of accommodation therein
Subject however that domiciliary hospitalisation benefits shall not cover:-
• Expenses incurred for pre and post hospital treatment and expenses incurred for treatment for any of the following diseases:
o Chronic Nephritis and Nephrotic Syndrome
o Diarrhoea and all type of Dysenteries including Gastroenteritis
o Diabetes Mellitus and Insipidus
o Influenza, Cough and Cold
o All Psychiatric or Psychosomatic Disorders
o Pyrexia of unknown origin for less than 10 days
o Tonsillitis and Upper Respiratory Tract infection including Laryngitis and Pharyngitis
o Arthritis, Gout and Rheumatism
Unless the policy under which you are covered provides otherwise, this insurance policy will not pay any claims arising from:
1. All diseases/ injuries which are pre existing when the cover incepts for the first time.
2. Any disease other than those stated in the third exclusion below contracted by the insured person during the first 30 days from the commencement date of the policy. This exclusion shall not however apply if in the opinion of the Panel of Medical Practitioners constituted by the Company for this purpose, the insured person could not have known of the existence of the disease or any symptoms or complaints thereof at the time of making the proposal for insurance to the Insurance company. This condition shall not however apply in case of the insured person having been covered under this scheme or group insurance with any of the India Insurance companies for a continuous period of preceding 12 months without any break.
3. During the first year of the operation of Insurance cover, the expenses on treatment of disease such as Cataract, Benign Prostate Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital internal disease/defect, Fistula in anus, piles, Sinusitis and related disorders are not payable. If these diseases (other than congenital internal diseases/defect) are pre existing at the time of proposal they will not be covered even during subsequent period of renewal. If insured is aware of the existence of congenital internal diseases/defect before inception of policy it will be treated as pre-existing. Sometimes the policies exclude some of the diseases/ procedures for a period longer than 1 year like Knee Replacement/ Hip Replacement for 4 years.
4. Injury or disease directly or indirectly caused by or arising from or attributable to War, Invasion, Act of Foreign enemy, war like operations (whether war be declared or not).
5. Circumcision unless for treatment of a disease not excluded hereunder or as may be necessitated due to an accident, vaccination or inoculation or change of life or cosmetic or aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness.
6. Cost of spectacles and contact lenses, hearing aids.
7. Any dental treatment or surgery which is a corrective, cosmetic or aesthetic procedure, including wear and tear, unless arising from disease or injury and which requires hospitalisation for treatment.
8. Convalescence, general debility, "Run-down" condition or rest cure, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self-injury and use of intoxicating drugs/ alcohol.
9. All expenses arising out of condition directly or indirectly caused to or associated with human T cell lymphotropic virus type III (HTLB III) or lymphadinopathy associated virus (LAV) or the mutant’s derivative or variations deficiency syndrome or any syndrome or condition of a similar kind commonly referred to as "AIDS".
10. Charges incurred at hospital or nursing home primarily for diagnostic, X-Ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury for which confinement is required at a hospital/ nursing home.
11. Expenses on vitamins or tonics unless forming part of treatment for injury or disease as certified by the attending physician.
12. Injury or disease directly or indirectly caused by or contributed to by nuclear weapons or materials.
13. Treatment arising from or traceable to pregnancy, childbirth, miscarriage, abortion or complications of any of this, including caesarean section.
14. Naturopathy treatment.
Please note, the above are Standard exclusions only. Please contact the local Vidal Health TPA office or your Insurance Agent/Company for details on Specific exclusions along with your policy copy.