This document summarizes the key features of a health insurance policy, including: - It covers hospitalization expenses for injuries and illnesses requiring at least 24 hours of admission. It also covers some daycare treatments without a 24-hour stay requirement. - Expenses like room rent, ICU charges, surgery costs, medicines and diagnostics are covered up to the sum insured of Rs. 4 lacs. It also covers pre- and post-hospitalization expenses. - Common pre-existing conditions are covered from day 1, and it covers newborn babies and maternity delivery costs up to Rs. 50,000. - It provides a cashless claims process at networked hospitals, and reimbursement of expenses is also

1. Presented by

2. Why and when should I
need it?

3. Scope of cover
• Disease / Injury
– Treated medically / surgically
– By Hospitalization
– In India as in-patient
– For a minimum period of 24 hours or more
– Or for specific treatment in day-care (as per
list) which are covered even for less than 24
hours

4. Compensation payable
• Reasonable and necessarily
incurred
 Room expenses in hospital
 ICU Rent
 Operation Theatre Charges
 Nursing expenses
 Medical practitioner fee
 Surgeon Charges
Treatment cost
Medicines/ diagnostic cost
Surgical appliances
Dialysis, chemotherapy,
radiotherapy

5. • Max of Sum Insured 4 Lac
• Pre and post
hospitalisation expenses
• Surgical operation
• Manual operative
procedure for
– Medical Deformity
– Diagnosis cure
– Prolongation of life
Compensation payable

6. Hospitalization
• Min period of 24 hrs.
• Above time limit not applicable for specific
treatment (Day Care Treatments) as per list
•Dialysis
•Chemotherapy
•Tonsillectomy
•Fracture
•Cataract
•Incision of Prostrate
•Coronary Angiography
•Many More

7. Pre & Post hospitalization
• Pre hospitalization
– Relevant medical expenses 30 days prior to
hospitalization for the main illness
• Post hospitalization
– Relevant medical expenses 60 days after
hospitalization for the main illness
Includes Consultation, Medicines, Investigations etc.

8. Extensions (Group Privileges)
2 Years Exclusion
30 days Exclusions
Pre-Existing illness Cover
Covered
From
Day 1
Covered
From
Day 1
Covered
From
Day 1
All Conditions existing before taking the policy

9. Maternity (Child Birth) Upto
Rs. 50000
New Born Baby Cover
Extensions (Group Privileges)
Covered
From
Day 1
Covered
From
Day 1

10. Extensions - Two year exclusions Cover
Cataract
Benign Prostrate Hypertrophy
Removal of Cyst
Joint Replacement
Hernia/ hydrocele
Fistula in anus/ piles
Sinusitis & related disorder
Stone and many more…
Covered with us from Day 1!
Not covered in Retail Insurance till 24 months

11. Extensions – 30 days exclusions Cover
All Medical Treatments
Except Accidental
Emergencies are not
Covered in Retail Insurance
for first 30 days
Covered with us from Day 1!

12. My No Service Areas..
Ok.. Lot of things are
covered under GHI…Is
there anything left that we
don’t cover???

13. General exclusions
• War/ war group
• Nuclear perils
• Breach of Law
• Plastic surgery
• Spectacles/ contact lens/ hearing
aid
• Dental treatment (except
Accidental)
• Intentional self injury

14. General exclusions contd.…
• Use of intoxicating drugs/
alcohol
• Aids / HIV
• Diagnostic/ laboratory
expenses not consistent with
treatment
• Vitamins/ tonic inconsistent
with treatment
• Naturopathy
• Congenital

15. No Money
Emergencies can fall 24/7.
What if I don’t have money
for treatment?
Would your company help
me??

16. Cashless Mediclaim
• Most good hospitals have CASHLESS Tie-ups.
• Claim handled by both the Company and
Hospital.
• Planned treatment in notified hospital
– Inform Hospital TPA & get treatment post approval
– Cashless / Hassle free claims settlement
• Emergency – What to do???
– Give TPA membership no / Card
– Intimate TPA & approval
– Cashless / Hassle free claims settlement
It takes approx. 3-4 hours to get cashless approval

17. What if a nearby hospital
is not Cashless.
Process of getting my
expense back is always
tough.. I think I am sick..

18. Reimbursement – Mediclaim
• Planned / Emergency treatment in non-
notified hospital
– Intimate the company duly on Toll Free
– Submit in Original
• Duly completed claim form
• Prescriptions, Bills, receipts and
discharge certificate/card from the
Hospital
• Bills from Chemists supported by
proper prescription.
• Test reports and payment receipts
including X-ray, CT films
– Settlement within a 20-30 days after
complete submission

20. Thank you