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GROUP MEDICLAIM
INSURANCE
Group Mediclaim
Insurance
• Group Personal Accident
policy takes care of an event
which relates to an external
peril.
• What if there is an action of
internal peril? The human
life is exposed to a peril
acting from within.
• These are in the nature of
action of a bacteria or a
virus affecting the normal
functions of living.
• We call them action of
disease crippling the normal
life.
• When this leads to a
necessity of hospitalisation
there is a policy to take care
of the bills of
hospitalisation.
• Apart from the action of
internal perils there are also
possibilities of a severe
accident leading to
hospitalisation for correcting
the affected limb.
Group Mediclaim
Insurance
• Scope of cover:
• Policy covers reimbursement
of hospitalization expenses
incurred for diseases
contracted or injuries
sustained in India.
• Medical expenses upto 30
days for Pre – hospital-
ization and upto 60 days for
post – hospitalization are
also admissible
Group Mediclaim
Insurance
• Main Exclusions
• Pre Existing Diseases
• Diseases Contracted During
first 30 Days
• Cost Of Spectacles / Contact
Lenses
• Dental Treatment
• AIDS
• Pregnancy
• Certain specified diseases
during first year of the
policy.
Group Mediclaim
Insurance
• Sum Insured
Group Mediclaim
Insurance
• Premium
• Premium chargeable
depends upon age of the
person and the Sum Insured
selected
• Age limit is 5 to 80 years
• Children above 3 months can
be covered provided one or
both parents are covered
concurrently
Group Mediclaim
Insurance
• Group Discount
• Policy can be given to
Corporate Body
• Institution & Association
• Slab wise group discount is
admissible on standard
premium if the group size
exceeds 100
• Larger the group size higher
is the discount.
Group Mediclaim
Insurance
• Bonus / Malus
Clause
• As always good features
provides eligibility for
discounts and bad features
attracts loading in the
premium. The loading
applied is termed as Malus.
Group Mediclaim
Insurance
• Extension
Group Mediclaim
Insurance
• Domiciliary Hospitalisation:
• The term “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 the
Hospital/Nursing Home but
actually taken whilst
confined at home in India
under any of the following
circumstances namely:
• i) The condition of the
patient is such that he/she
cannot be removed to the
Hospital/Nursing home or
• Ii) The patient can not be
removed to Hospital/
Nursing Home for lack of
accommodation therein
Group Mediclaim
Insurance
• Domiciliary Hospitalisation
does not cover:
• 1. Asthma
• 2. Bronchitis
• 3. Chronic Nephritis and Chronic
Nephritic Syndrome
• 4. Diarrhoea and all types of
Dysenteries including Gastro-enteritis
• 5. Diabetes Mellitus and Insipidus
• 6. Epilepsy
• 7. Hypertension
• 8. Influenza, Cough and Cold
• 9. All Psychiatric or Psychosomatic
Disorders
• 10. Pyrexia of unknown origin for less
than 10 days
• 11. Tonsillitis and Upper Respiratory
Tract Infection including Laryngitis
and Pharingitis
12. Arthritis, Gout and Rheumatism
Group Mediclaim
Insurance
• Exclusions
• Pre existing diseases
• Disease contracted during
the first 30 days of
insurance.
• Certain disease like cataract
hernia etc excluded during
the first year of the policy
• Cosmetic and aesthetic
treatment plastic surgery
etc not covered unless
essentially associated with a
treatment.
• Cost of spectacles
• Dental treatment
• General debility, run down
condition, intentional self
injury, sterility etc
• AIDS, expenses on tonics,
expenses only for
diagnostics etc
Group Mediclaim
Insurance
• Basis of assessment:
• a) Room, and Boarding
Expenses as incurred at the
Hospital/Nursing Home;
• b) Nursing Expenses;
• c) Fee paid to Medical
Practitioner, Surgeon,
Anaesthetics, Consultants,
and Specialists
• d) Anaesthesia, Blood,
Oxygen, Operation Theatre
Charges, Surgical
Appliances, Medicines &
drugs, Diagnostic Materials
and X – Ray, Dialysis,
Chemotherapy,
Radiotherapy, Cost of
Pacemaker, Artificial Limbs
& Cost of Organs and similar
expenses; and /or
e) Pre Hospitalisation and
Post Hospitalisation expenses,
wherever applicable
Group Mediclaim
Insurance
• Claim documents
a) Duly completed claim form
b) Bills, receipts and
discharge certificate/card from
the Hospital
c) Bills from Chemists
supported by proper
prescription.
• d) Test reports and
payment receipts
Group Mediclaim
Insurance
• INTIMATING THE CLAIM:
Group Mediclaim
Insurance