JANUARY 3, 2018 BY HEALTHINSURANCEADVISOR
A B Arogyadan Group Health Insurance Scheme
In the event of any claim becoming admissible under this scheme, the company will pay through TPA to
the Hospital / Nursing Home or insured person the amount of such expenses as would fall under different heads mentioned below and as are reasonably and medically necessary incurred thereof by or on behalf of such insured person but not exceeding the Sum Insured in aggregate mentioned in the schedule hereto.
A. Room, Boarding and Nursing expenses as provided by the Hospital/Nursing Home not exceeding 1% of the sum insured per day or the actual amount whichever is less. This also includes nursing care, RMO charges, IV Fluids/Blood transfusion/injection administration charges and similar expenses.
B. Intensive Care Unit (ICU) expenses not exceeding 2% of the sum insured per day or actual amount whichever is less.
C. Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees.
D. Anaesthetic, Blood, Oxygen, Operation Theatre Charges, surgical appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Cost of Artificial Limbs, cost of prosthetic devices implanted during surgical procedure like pacemaker, orthopaedic implants, infra cardiac valve replacements, vascular stents, relevant laboratory/diagnostic tests, X ray and such similar expenses that are medically necessary.
E. Hospitalisation expenses (ex cluding cost of organ) incurred on donor in respect of organ transplant to the insured.
Note :
1. The amount payable under 1.2 C & D above shall be at the rate applicable to the entitled room category. In case the Insured person opts for a room with rent higher than the entitled category as in 1.2 A above, the charges payable under 1.2 C & D shall be limited to the charges applicable to the entitled category. This will not be applicable in respect of medicines & drugs and implants.
2. No payment shall be made under 1.2 C other than as part of the hospitalisation bill.
1.2.1
Expenses in respect of the following specified illnesses/surgeries will be restricted as detailed
Hospitalisation Benefits LIMITS per surgery RESTRICTED TO
a.Cataract,Hernia, Hysterectomy a. Actual expenses incurred or 25% of the sum insured
whichever is less
b. Major surgeries* b.Actual expenses incurred or 70% of the Sum Insured
whichever is less
* Major surgeries include Cardiac surgeries, Brain Tumor surgeries, Pacemaker implantation for sick sinus syndrome, Cancer surgeries, Hip, Knee, joint replacement surgery, Organ Transplant.
* The above limits specified are applicable per hospitalization/surgery.
1.3 Pre and Post Hospitalisation expenses payable in respect of each hospitalisation shall be the actual expenses incurred subject to a maximum of 10% of the Sum Insured.
In addition to the above, the following would apply to claims arising out of persons aged more than 60 years EXPENSES ON MAJOR ILLNESSES CHARGED AS A TOTAL PACKAGE TO BE SETTLED WITH A CO PAY ON 80:20 BASIS. The co pay of 20% will be applicable on the admissible claim amount.
COVERAGES:
Expenses on Hospitalisation for minimum period of 24 hours are admissible. However, this time limit is
not applied to specific treatments,
such as
- Adenoidectomy
- FESS
- Appendectomy
- Haemo dialysis
- Ascitic/Pleural tapping
- Fissurectomy / Fistulectomy
- Auroplasty
- Mastoidectomy
- Coronary angiography
- Hydrocele
- Coronary angioplasty
- Hysterectomy
- Dental surgery
- Inguinal/ventral/
- umbilical/femoral
- hernia
- D&C
- Parenteral chemotherapy
- Endoscopies
- Polypectomy
- Excision of Cyst/granuloma/lump
- Septoplasty
- Eye surgery
- Piles/ fistula
- Fracture/dislocation excluding hairline fracture
- Prostrate
- Radiotherapy
- Sinusitis
- Lithotripsy
- Tonsillectomy
- Incision and drainage of abcess
- Liver aspiration
- Colonoscopy
- Sclerotherapy
- Varicocelectomy
- Varicose Vein Ligation
- Wound suturing
Or any other surgeries/procedures agreed by the TPA/Company which require less than 24 hours hospitalisatio n and for which prior approval from TPA/Company is mandatory. This condition will also not apply in case of stay in hospital of less than 24 hours provided
a) The treatment is such that it necessitates hospitalisation and the procedure involves specialised
infrastructural facilities available in hospitals.
b) Due to technological advances hospitalisation is required for less than 24 hours only.
c) They are carried out in Day Care Centre networked by TPAs where requirement of minimum number
of beds is overlooked but having (i) fully equipped Operation Theatre, (ii) fully qualified Day Care
Staff (c) fully qualified Surgeons/PostOperative attending Doctors.
Note 1 : Procedures/treatments usually done in out patient department are not payable under the policy even if converted as an in patient in the hospital for more than 24 hours or carried out in Day Care Centres.
Note 2: When treatment such as dialysis, Chemotherapy, Radiotherapy., etc is taken in the hospital / nursing home/Day care centre and the insured is di scharged on the same day the treatment will be considered to be taken under hospitalisation benefit section
Domiciliary Hospitalisation means medical treatment for a period exceeding three days for such an
illness/disease/injury which in the normal course would require care and treatment at a hospital but is
actually taken while confined at home under any of the following circumstances :
a. The condition of the patient is such that he/she is not in a condition to be removed to a hospital
or
b.The patient takes treatment at home on account of non availability of room in a hospital.
Subject however that domiciliary hospitalisation benefits shall not cover:
i) Expenses incurred for pre and post hospital treatment and
ii)Expenses incurred for treatment for any of the following diseases:
a. Asthma
b. Bronchitis
c. Chronic Nephritis and Nephritic Syndrome
d. Diarrhoea and all type of Dysenteries including Gastroenteritis
e. Diabetes Mellitus and Insipidus
f. Epilepsy
g. Hypertension
h. Influenza, Cough and Cold
i. All Psychiatric or Psychosomatic Disorders
j. Pyrexia of unknown Origin for less than 10 days
k. Tonsillitis and Upper Respiratory Tract infection including Laryngitis and pharangitis
l. Arthritis, Gout and Rheumatism
Liability of the company under this clause is restricted as stated in the Schedule attached hereto
For Ayurvedic Treatment, hospitalisation expenses are admissible only when the treatment has been
undergone in a Government Hospital or in any Institute recognised by the Government and/or accredited by Quality Council of India/National Accreditation Board on Health.
Company’s Liability for all claims admitted in respect of any/all insured person/s during the period of insurance shall not exceed the Sum Insured stated in the schedule.