GMC Policy

Presentation
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Disclaim
er
Salient features of the Policy are given in this
presentation. For Complete Information
Please Refer the Policy Documents.

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What is Mediclaim
Insurance ?
The insurance provides cashless/ reimbursement
of hospitalization expenses incurred in
India for the treatment of illness/diseases or
injuries sustained by the insured person
during the period of insurance .

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Policy Conditions
Sum Insured : The Amount up to which a claim for medical
hospitalization can be made. Coverage is individually
(Rs. 100000 / Rs 200000 / Rs. 300000)
Current Policy period :16/06/2013 to 15/06/2014
Major exclusions applicable for standard policies are
waived in this policy. Hence the policy has wider
cover as follows:
All pre existing diseases are covered from day one
First 30 days waiting period not applicable.
1 year, 2 years & 4 years exclusions for specific
ailments/treatments not applicable
Family definition: Self, Spouse , 2 dependent children and 2
dependent parents
New born baby covered from day one
Internal Congenital disease covered under life threatening
circumstance

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Hospital / Nursing
Home

Any institution in India established for Indoor care and

treatment of sickness and injuries and which either:

has been registered as a hospital or nursing home

with the local authorities and is under the
supervision of a registered and qualified medical
practitioner
OR
Should comply with minimum criteria as under:
At least 15 in-patient beds (for class C cities 10)
Fully Equipped operation Theatre of its own
wherever surgical Operations are carried out.
Fully Qualified Nursing staff under its employment
round the clock

The term Hospital/Nursing home shall not include an

establishment ,which is a place of rest, a place for
the aged , a place for drug addicts or for alcoholics ,
a hotel or a similar
place
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What are the expenses

The below given medical Reimbursable?
Expenses are payable If any insured
person suffers an illness or accident during the policy
period which requires the hospitalization as an inpatient
Room Rent, Boarding Expenses & Nursing: 1% of S.I + Rs.2000 *
Intensive care Unit:2% of S.I + Rs.4000 *
A Medical practitioner,
Anesthesia, Blood , Oxygen, Operation theatre charges , surgical
appliances
Medicines, drugs and consumables
Diagnostics procedures
The cost of prosthetic and other devices or equipment if implanted
internally during a surgical procedures
Disease wise Capping: Cataract Rs.24000 Per eye and No
Capping for other diseases
Hospitalization: Admission into hospital for medically necessary
treatment as an inpatient for continuous period of at least
24 hours
* Proportionate clause applicable if room rent exceeds eligibility
limit
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Maternity
Benefit
Maternity expenses are covered for
2 children. The insured
person who are already
having two or more living
children will not be eligible
for this benefit
Normal Delivery Expenses Capped
To : Rs.25000
Cesarean (C-section) Delivery
Expenses Capped
To:Rs.50000
9 months waiting period waived
Pre-natal and post-natal expenses
are not covered unless
admitted in Hospital/Nursing
Home and treatment is taken
there
New Born Baby covered from day
one
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Pre and Post

Hospitalization
Pre-Hospitalization:
The Medical Expenses incurred due to an Illness in the 30
days immediately before the Insured Person was
Hospitalized, provided that:
Such Medical Expenses were in fact incurred for the same
condition for which the Insured Persons
subsequent Hospitalization was required
Post-Hospitalization:
The Medical Expenses incurred in the 60 days
immediately after the Insured Person was
discharged post Hospitalization provided that:
Such costs are incurred in respect of the same condition
for which the Insured Persons earlier
Hospitalization was required
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Day care
procedure
Treatment undertaken in a hospital/Nursing Home on the
recommendation of medical Practitioner for the
following diseases, Illness or injury which requires
hospitalization for less than 24 hours:
Dialysis
Chemotherapy
Radiotherapy
Eye Surgery
Lithotripsy (Kidney stone removal)
Tonsillectomy
Dilatation & Curettage
Hydrocele Surgery
Hernia Repair Surgery
Sinusitis
Coronary Angiography

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Policy Exclusion

LASIK surgery for correction of eyesight, Contact lens,

Spectacles, Hearing aids including Cochlear implants
Dental treatment unless arising due to accident
Medical termination of pregnancy / abortion within 12 weeks
Sterilization procedures, treatment of infertility/sub-fertility/
Assisted conception procedures
Plastic and cosmetic surgery, vaccination, inoculation,
circumcision
External congenital disease, anomalies, defects
Intentional self injury / suicide attempt, psychiatric and
psychosomatic disorders
Direct / indirect effects of use of alcohol / intoxicating drugs
AIDS and related syndromes
Technical admission Admission for diagnostic/evaluation
without active line of treatment
Expenses on vitamins or general tonics
Naturopathy treatment

Policy Exclusion

Pre and post expenses related to maternity claim

Unproven procedure/ treatment, experimental or alternative
medicine/treatment including acupuncture, acupressure,
magneto-therapy, RFQMR, etc.
Genetic disorders/stem cell implantation/surgery
External equipments like CPAP, CAPD, infusion Pump etc.,
ambulatory devices like walker/ crutches/ belts/
collars/caps/ splints/ slings/ braces/ stockings/ diabetic footwear/ glucometer/ thermometer & similar related items &
any medical equipment which could be used at home
subsequently
Treatment for obesity or condition arising therefrom
(including morbid obesity) and any other weight control
program/ services/ supplies.
Massages/ Steambath/ Surodhara & alike Ayurvedic
treatment.
Any kind of service charges/surcharges, admission
fees/registration charges etc. levied by the hospital.

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Cashless Facility
Planned Admission
(48 hrs in advance) Emergency Admission

Insurance Help Desk

at the Hospital

Hospital
Admission

Insurance Help Desk

Pre-Authorization Process

Process of
Reimbursement

Please submit the following documents in

original along with completed claim
form within 15 days from the date
of discharge
Discharge Summary
Final Hospital Bill (with detailed break-up)
& Receipts
Medicine Bills along with Doctors
Prescriptions
Investigations & Test Reports with Doctors
prescriptions. If original is required
for future treatment, please submit
photocopies duly attested by the
treating doctor with his signature &
seal
In case of non-availability of
prescriptions, kindly ask your

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Please send all the

documents to

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Escalation Matrix

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Thank you
Wish You & Your Family
A Healthy &
Happy Future !!!
-Team & Medi Assist

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