1.1

The policy covers reimbursement of Hospitalisation / Domiciliary Hospitalisation expenses for illness / diseases or injury sustained.

1.2

(N.B.: Insurance Company's Liability in respect of all claims admitted during the period of
insurance shall not exceed the Sum Insured per person mentioned in the schedule.)

2.1

HOSPITAL/NURSING HOME

Means any institution in India established for indoor care and treatment of sickness and injuries and which Either

(a) 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
(b) Should comply with minimum criteria as under.
 i) It should have at least 15 in-patient beds
 ii) Fully equipped operation theatre of its own wherever surgical operations are carried out.
 iii) Fully qualified Nursing Staff under its employment round the clock
 iv) Fully qualified Doctor(s) should be in-charge round the clock.
(N.B. * In Class 'C' town condition of number of beds be reduced to 10).

2.1.1

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 place for alcoholics, a hotel or a similar place.

2.2

Surgical Operation means manual and/or operative procedures for correction of deformities and defects, repair of injuries. Diagnosis and cure of diseases, relief of suffering and prolongation of life.

2.3

Expenses on Hospitalisation for minimum period of 24 hours are admissible. However, this time limit is not applied to specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Dental Surgery, Lithotripsy (Kidney stone removal), Tonsillectomy, D & C taken in the Hospital/Nursing Home and the Insured is discharged on the same day; the treatment will be considered to be taken under Hospitalisation Benefit.

2.4

DOMICILIARY HOSPITALISATION BENEFIT 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:
i) The condition of the patient is such that he/she cannot be removed to the Hospital/Nursing Home or
ii)The patient cannot be removed to Hospital/Nursing Home for lack of accommodation therein

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.

1. Asthma.                                               7. Hypertension
2. Bronchitis                                             8. Influenza Cough and Cold
3. Chronic Nephritis and Nephritic Syndrome   9. All Psychiatric or Psychosomatic Disorders
4. Diabetes Mellitus and Insipidus                10. Pyrexia of unknown Origin for less than 10 days.
5. Diarrhoea and all type of Dysenteries        11. Tonsillitis and Upper Respiratory Tract Infection including
                                                                  Gastro-enteritis including Laryngitis and Pharingitis
6. Epilepsy                                               12. Arthritis, Gout and Rheumatism

Note: When treatment such as Dialysis, Chemotherapy, Radiotherapy etc. is taken in the Hospital/Nursing Home and the Insured is discharged on the same day, the treatment will be considered to be taken under Hospitalisation Benefit section

Anyone illness will be deemed to mean continuous period of illness and it includes relapse within 45 days from the date of last consultation with the Hospital/Nursing Home where treatment may have been taken Occurrence of same illness after a lapse of 45 days as stated above will be considered as fresh illness for the purpose of this policy.

3.1

PRE-HOSPITALISATION: Relevant medical expenses incurred during period upto 30 days prior to hospitalisation on disease / illness
/injury sustained will be considered as pan of claim mentioned under item 1.2 above.

3.2

POST -HOSPITALISATION: Relevant medical expenses incurred during period upto 60 days after hospitalisation on disease / illness / injury sustained will be considered as pan of claim as mentioned under item 1 2 above

3.3

MEDICAL PRACTITIONER: Means a person who holds a degree/diploma of a recognised institution and is registered by Medical Council of respective State of India. The term Medical Practitioner would include Physician, Specialist and Surgeon

3.4

QUALIFIED NURSE: Means a person who holds a certificate of a recognised Nursing Council and who is employed on recommendation of the attending Medical Practitioner.

4.0

The Insurance Company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of :

4.1

All diseases/injuries, which are pre-existing when the cover incepts for the first time.

4.2

Any disease other than those stated in clause 4.3 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 Panel of Medical Practitioners constituted by the Insurance Company for the 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 4.2 shall not however apply in case of the insured person having been covered under this scheme or group insurance scheme with any of the Indian Insurance Companies for a continuous period of proceeding 12 months without any break

4.3

During the first year of the operation of insurance cover, the expenses on treatment of diseases such as Cataract, Benign Prostatic Hypenrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal diseases, Fistula in anus, Piles, Sinusitis and related disorders are not payable.

4.4

Injury or Disease directly or indirectly caused byor arising from or attributable to War, Invasion, Act of Foreign Enemy, War like operations (whether war be declared or not).

4.5

Circumcision unless necessary 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 pan of any illness.

4.6

Cost of spectacles, contact lenses and hearing aids.

4.7

Dental treatment or surgery of any kind unless requiring hospitalisation.

4.8

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

4.9

All expenses arising out of any condition directly or indirectly caused to or associated with Human T -Cell Lymphotroplc Virus type III (HTLB-III) or Lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome or condition of similar kind commonly referred to as AIDS.

4.10

Charges incurred at Hospital/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.

4.11

Expenses on vitamins. And tonics unless forming part of treatment for injury or disease as certified by the attending Physician

4.11.1

Injury or Disease directly or indirectly caused by or contributed to by nuclear weapons/materials.

4.12

Treatment arising from or traceable to pregnancy, childbirth including caesarean section.

4.13

Naturopathy treatment.

This insurance is available to persons between the age of 5 years and 60 years only.

6.1

Preliminary notice of claim with particulars relating to Policy Numbers, Name of insured person in respect of whom claim is made, Nature of illness/Injury and Name and Address of the attending medical practitioner/Hospital/Nursing Home should be given to the Insurance Company within seven days from the date of Hospitalisation/injury/Death.

6.2.1

Final claim along with hospital receipted Bills/Cash memos, claim form and list of documents as listed in he claim form etc. should be submitted to the Insurance Company within 30 days of discharge from the Hospital.
Note: Waiver of this Condition may be considered in extreme cases of hardship where it is proved to the satisfaction of the Insurance Company that under the circumstances in which the insured was placed it was not possible for him or any other person to give such notice or file claim within the prescribed time limit.

All claims under this policy shall be payable in Indian currency. All medical treatments for the purpose of this insurance will have to be taken in India only.

Medi+Claim proposal form, wherever applicable, should be submitted with the membership application form. Risk Coverage shall commence after 60 days from the date of submission of the Medi+Claim proposal form. In the event of non-submission of Medi+Claim proposal form, coverage shall not be granted. Mere incorporation of Policy No. in the certificate shall not ensure coverage of Medi+Claim benefit

Medi+Claim coverage is provided under Group Insurance Policy with the New India Assurance Company Ltd. and coverage commencing from minimum membership fees of Rs.25,000/- a maximum limit of Rs. 3 Lacs. Medi+Claim Coverage shall be equivalent to the membership fee. Premium for e nsurance Coverage shall be paid by the Company and for the term of the PMWW-II scheme availed

The Policy provides for payment of certain amount for death. The amount payable depends on the capital Sum Insured and subject to acceptance and approval of The Life Insurance CorporationIndia Limited.

The sum assured is for Rs.1 Lac, Rs.4 Lacs & RS. 5 Lacs depending on the payment of offer price.
Offer price paid between Rs.1000 to Rs.9500, the SUM ASSURED is for Rs.1 Lac Offer price paid between Rs.9,501 to Rs.24,500, the SUM ASSURED is for Rs.4 Lacs Offer price paid between Rs.24,501 and above the SUM ASSURED is for Rs. 5 Lacs.

Age limit is 5years to 60years Members in the age bracket o 1 years to 70 years shall be extended Accidental Death Insurance Coverage upon payment of Rs.100 towards Age Relaxation Fees.

The Personal Accidental risks are divided into three groups as detailed below

 

RISK GROUP I: Accountants, Doctors, Lawyers, Architects, Consulting Engineers, Teachers, Bankers, Persons engaged in administrative functions, Persons primarily engaged in occupations of similar hazards.
RISK GROUP II: Builders, Contractors and Engineers engaged in superintending functions only, Veterinary Doctors, Paid drivers of motor cars and light motor vehicles and persons engaged in occupations of similar hazards and not engaged in manual labour. All persons engaged in manual labour (Except those falling under Group Ill), Cash carrying employees, Garage and motor mechanics, Machine operators, Drivers of Trucks or Lorries and other heavy vehicles, Professional athletes and sportsmen, Wood working machinists and persons engaged in occupations of similar hazards.
RISK GROP III: Persons working in underground mines, explosives magazines, workers involved in electrical installation with high tension supply, Jockeys, Circus personnel, Persons engaged in activities like racing on wheels or horseback, big game hunting, mountaineering, winter sports, skiing, icehockey, ballooning, hang gliding, river rafting, polo & persons engaged in occupations/activities of similar hazards.

Some of the major exclusions are as shown below: -
The policy does not cover death resulting from: -
(a) Service on duty with any armed force.
(b) Intentional self-injury, Suicide or attempted Suicide, Insanity, Venereal Diseases, AIDS or under the influence of intoxicating drink or drugs.
(c) Aviation other than as passenger (fare paying or otherwise) in any duly licenced standard typed of aircraft anywhere in the world.
(d) Nuclear radiation or nuclear weapons material.
(e) Any consequences of War, Invasion, Act of foreign enemy, Hostilities (whether war be declared or not), Civil War, Rebellion, Revolution, Insurrection, Mutiny, Military, or Usurped power, Seizure, Capture, Arrest, Restraint and Detainments of all Kings, Princes and People of whatever nation conditions or equality so ever.
(F) Child birth pregnancy or other physical causes peculiar to the female sex.
(g) Whilst committing any breach of law with criminal intent.
(h) Persons with mental or physical defect / infirmity.

It is necessary to provide details of Age and or Date of Birth. In the absence of this information Accidental Death Insurance Coverage shall not be extended

In the event of death due to Accident, claim should be submitted within' 60 days. The documents to be submitted are as given below:
i) Claim Form duly signed by the Nominee and Witness as mentioned in the Jabab.
ii) Death Certificate in original.
iii) Police Postmortem Report.
iv) Police Panchanama Report.
v) Jabab / Jaban.
vi) First Information Report/Police Report.
All the above documents duly attested by an appropriate authority and accompanied with the original copies should be submitted to the office. he original documents shall be returned after verification by The New India Assurance Co. Ltd.

Accidental Death Insurance Coverage is provided under Group Insurance Personal Accident Policies with the New India Assurance Company Ltd. Premium towards this Insurance Coverage shall be paid by the Company and for the term of the PMWW-II scheme availed.