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Ôapid population growth, contamination of food, Water and Air etc.
which leads to hospitalization are more frequent. To cater to the
varying and increasing needs, different forms are available. Health
insurance is a safeguard against rising medical costs. A health insurance
policy is a contract between an insurer and an individual or group, in
which the insurer agrees to provide specified health insurance at an
agreed upon price (premium).
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However, the introduction of famous ͚MEDICLAIM͛ policy has made a
huge difference to an ordinary citizen͛s usage of insurance for medical
cover purpose. There are many health cancers including the following
which accentuate the demand for health insurance:-
3.cA person may face serious monetary problems for the medical
treatment and hospitalization during life.
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like other forms of insurance is a form of
collectivism by means of which people collectively pool their risk, in this
case the risk of incurring medical expenses. It is sometimes used more
broadly to include insurance covering disability or long-term nursing or
custodial care needs. It may be provided through a government-
sponsored social insurance program, or from private insurance
companies. It may be purchased on a group basis (e.g., by a firm to
cover its employees) or purchased by individual consumers. In each
case, the covered groups or individuals pay premiums or taxes to help
protect themselves from high or unexpected healthcare expenses.
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cThese facilities are officially available to the entire population either
free or for nominal charges.
cMuch of the facilities for health insurance originates from the Union
Ministry of Health and family welfare and is channeled to the state
governments, which retain considerable authority for the spending
decisions.
cÝver the years, the central government has been the main source of
funds for the primary health care facilities, whereas the states bear
the major responsibility of recurrent costs, especially the costs of
running hospitals.
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cÝver the years coverage has grown substantially with provision for
the non-allopathic system of medicines as well as for allopathic. In
addition, the CGHS reimburses patients for part of then out of
pocket costs on treatment at the government hospitals and some
other facilities.
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cHowever since 1989 the scheme has been expanded and it now
includes all such factories which are not using power and employing
20 or more persons.
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d) Ýperation theatre charges, surgical appliances, medicines and drugs,
diagnostic reports, dialysis, chemotherapy charges etc.
cThe total liability covered under such a policy does not exceed the
total sum assured for each such disease as mentioned in the
schedule by the insurer at the time of buying the policy.
cIn order to recover the claims under this policy, the claimant
should be hospitalized for a minimum period of 24 hours.
Expenses incurred for a period upto 30 days prior to
hospitalization and 60 days after hospitalization could be
considered as a part of the claim. In case of certain specific
treatment such as chemotherapy, eye surgery, kidney stone
removal, dialysis etc. the 24 hours, limit could be waived if the
insured is discharged before 24 hours by the doctor.
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cThis is a life time policy where the medical benefits are made
available after retirement of the insured.Ýne has to pay the
premiums during the earning period and make provisons for
medical benefits after retirement.Persons in the age group of 22
to 55 years of age are eligible. for this policy.
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cThe policy provides hospitalization benefits for a lifetime after
retirement age of the insured. The minimum sum to be insured is
Rs.50, 000 and can be increased in multiples of Rs. 10,000 as a
unit. The maximum sum insured is Rs.2 lacs In case of death of
insured before retirement, refund of premium will be at a pre-
determined scale and it is payable to the nominee or the
assignee.
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cThis policy is meant for the people with limited means of paying
the premium. The sum assured is limited to Rs 5,000 and the
premium is very low as compared to the regular policy.
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cThere are two types of cancer policies offered in India, one is the
group policy issued by the Indian Cancer Society and the other is a
group policy offered to the members of the Cancer Patients Aid
Association. The cover is limited to Rs. 5 lacs in the case of ICS
policy and can go upto Rs 20 lacs in case of CPAA policy.
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c Such Medical Expenses were in fact incurred for the same condition for
which the Insured Person͛s subsequent Hospitalisation was required, and
c We will pay the Medical Expenses incurred within the 60 days prior to the
date of Hospitalisation, if we are provided with the following at least 5
days before the Hospitalisation:
Medical documents with all details about the Illness; and the that
And the place of the Proposed Hospitalisation.
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cThe Medical Expenses incurred in the 60 days immediately after the Insured
Person was discharged post Hospitalisation provided that:
cSuch costs are incurred in respect of the same condition for which the
Insured Person͛s earlier Hospitalisation was required, and
cWe will pay the Medical Expenses in the 90 days immediately after the
Insured Person was discharged if We were provided with the following at
least 5 days before the Hospitalisation:
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The Medical Expenses for a day care procedure or surgery mentioned in the
list of Day Care Procedures in this Policy where the procedure or surgery is
taken by the Insured Person as an inpatient for less than 24 hours in a
Hospital (but not the outpatient department of a Hospital).
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c The condition for which the medical treatment is required continues for at
least 3 days, in which case We will pay the reasonable cost of any necessary
medical treatment for the entire period, and
c If We accept a claim under this Benefit We will not make any payment for
Post-Hospitalisation expenses but We will pay Pre-hospitalisation expenses
for up to 60 days in accordance with b) above, and
c No payment will be made if the condition for which the Insured Person
requires medical treatment is:
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Claims made in respect of any of the benefits below will be subject to the Sum
Insured and will affect both the entitlement to a Cumulative bonus and a
health check-up.
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A daily cash amount will be payable per day if the Insured Person is Hospitalised
in Shared Accommodation in a Network Hospital for each continuous and
completed period of 24 hours if the Hospitalisation exceeds 48 hours, provided
that:
c This benefit shall not apply to time spent by the Insured Person in an
intensive care unit, and
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The Medical Expenses for an organ donor͛s treatment for the harvesting of
the organ donated, provided that:
i)c The organ donor is the Insured Person͛s blood relative and the organ
donated is for the use of the Insured Person, and
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ii)c We will not pay the donor͛s pre- and post-hospitalisation expenses or
any other medical treatment for the donor consequent on the
harvesting, and
iii)cWe have accepted an inpatient Hospitalisation claim under Benefit 1a).
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c Note: This benefit is optional and effective only if noted as such in the
Schedule of Benefits:c
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c Note: This benefit is optional and effective only if noted as such in the
Schedule of Benefits:
c You have submitted a proposal for the insurance of the newborn baby
within 30 working days after the birth, and We have in Ýur sole and
absolute discretion accepted the same and received the premium sought.
c Newborn Baby means those babies born to You and Your spouse during the
Policy Period Aged between 1 day and 90 days.
c Claims made in respect of any of the benefits below will not be subject to
the Sum Insured and will not affect either the entitlement to a Cumulative
bonus or a health check-up.
c The benefits below are optional and each is only effective if shown in the
Schedule to be effectiveJ
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cÝur maximum liability per delivery or termination shall be limited to the
amount specified in the Schedule of Benefits, and
cWe will pay the Medical Expenses of pre-natal and post-natal expenses per
delivery or termination upto the amount stated in the Schedule of
Benefits, and
cWe will cover the Medical Expenses incurred for the medically necessary
treatment of the new born baby upto the amount stated in the Schedule
of Benefits unless the new born baby is covered under 2e), and
c We will not pay for any dental treatment that comprises cosmetic
surgery, dentures, dental prosthesis, dental implants, orthodontics,
orthographic surgery, jaw alignment or treatment for the
temporomandibular (jaw) joint, or upper and lower jaw bone surgery
and surgery related to the temporomandibular (jaw) unless
necessitated by an acute traumatic injury or cancer.
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c Claims made in respect of any of the benefits below will not be subject to
the Sum Insured and will not affect either the entitlement to a Cumulative
bonus or a health check-up.
c If the Schedule shows that the Critical Illness benefit is effective, then We
will pay the Critical Illness Sum Insured as a lump sum in addition to Ýur
payment under 1)a), provided that:
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