The Group Mediclaim Insurance Policy is designed primarily for employers to provide health coverage for their employees. It is also ideal for institutions, societies, and clubs to cover registered members. This policy offers financial protection against hospitalisation expenses arising from illnesses or bodily injuries that require hospitalisation. It covers the costs of medical or surgical treatments at any qualified hospital or nursing home in India.

Definition of Family

  • Spouse
  • Dependent Children: Includes legitimate or legally adopted children up to the age of 21. If a child is employed above 18 years or a girl child gets married, they will no longer be covered under the policy. However, a male child can remain covered up to the age of 26 if he is a full-time student and fully dependent on the primary insured. An unmarried female child can be covered until marriage.
  • Dependent Parents/Parents-in-Law

Benefits

  • Lower Premiums: Generally more affordable than an individual Mediclaim policy.
  • Coverage for All Ages and Health Conditions: No age or health status restrictions.
  • Immediate Coverage: Coverage begins from the first day a member joins the group.
  • No Medical Exam: No requirement for a medical examination to avail coverage.
  • Maternity Benefit: Coverage for maternity-related expenses.
  • Inclusion of Pre-Existing Conditions: Pre-existing diseases are covered.
  • Family Floater Option: Coverage for the entire family under a single plan.
  • Waiver of Waiting Period: Certain waiting periods may be waived under specific conditions.
  • Premium Refund: If an employee resigns, the premium may be refunded on a prorated or short-period basis, as agreed between the insured and the insurer, provided no claims were made during the policy period.

Coverage

  • Hospitalisation Expenses: Costs incurred during hospitalisation.
  • Medicines, Consumables, and Diagnostic Expenses: Coverage for medication, medical supplies, and diagnostic tests.
  • Domiciliary Hospitalisation: Coverage for medical treatment received at home under specific conditions.
  • Day Care Treatment: Coverage for treatments that do not require overnight hospitalisation.
  • Pre- and Post-Hospitalisation Expenses: Costs incurred before and after hospitalisation.
  • Maternity Coverage: Option to include maternity benefits with no waiting period.
  • Baby Coverage: Coverage for the baby from day one.
  • Pre-Existing Illnesses: Coverage for pre-existing conditions.
  • Ambulance Charges: Coverage for emergency ambulance services.

Add-On Covers

  • Family Floater Coverage: Coverage for the entire family under a single policy.
  • Waiver of 30-Day Waiting Period: Waiver for the initial 30-day waiting period.
  • Waiver of First-Year Exclusions: Waiver of exclusions during the first year of the policy.
  • Room Rent Limit: Coverage for room rent based on a specified percentage of the sum insured, with separate limits for normal rooms and ICU.
  • Addition and Deletion of Family Members: Option to add or remove family members during the policy term.

Compensation Payable

  • Room Charges: Costs for hospital or nursing home room accommodation.
  • Nursing Expenses: Charges for nursing services during treatment.
  • Medical Practitioner Fees: Fees for doctors, including surgeons and specialists.
  • Treatment Costs: Expenses incurred for medical treatments.
  • Medicines and Diagnostic Costs: Costs for prescribed medications and diagnostic tests.
  • Blood and Oxygen: Expenses for blood transfusions and oxygen supply.
  • Cost of Medical Devices: Coverage for pacemakers, artificial limbs, and organ transplant costs.
  • Operation Theatre Charges: Expenses for the use of operation theatre facilities.
  • Surgical Appliances: Costs for any necessary surgical devices or equipment.
  • Dialysis, Chemotherapy, and Radiotherapy: Coverage for these critical treatments.
  • Pre- and Post-Hospitalisation Expenses: Costs incurred before and after hospitalisation.
  • Surgical Operation Expenses: Costs for surgeries, including associated procedures.

Exclusions

  • War and Related Perils: Any claims arising from war or war-related events.
  • Nuclear Risks: Claims related to nuclear incidents or hazards.
  • Cosmetic Surgery: Excludes plastic surgery, unless it’s medically necessary due to an accident or illness.
  • Eyewear and Hearing Aids: Costs for spectacles, contact lenses, or hearing aids.
  • Dental Treatment: Excludes dental procedures unless they result from an accident.
  • Recovery Beyond 60 Days: Expenses related to recovery after 60 days or for conditions like general debility.
  • Sterility, Sexually Transmitted Diseases, and Circumcision: Excludes coverage for these conditions.
  • Self-Inflicted Injuries: Claims arising from intentional self-harm.
  • Intoxication: Claims related to the use of drugs or alcohol.
  • Inconsistent Diagnostic Tests: Expenses for diagnostic or laboratory tests that do not align with the treatment provided.
  • Non-Therapeutic Supplements: Vitamins or tonics not deemed necessary for treatment.
  • Alternative Therapies: Excludes naturopathy treatments.
  • Substance Abuse and HIV/AIDS: No coverage for alcoholism, drug abuse, or AIDS-related conditions.

Claim Process

In the event of a medical need, you can use your insurance card through the following two methods:

  • Cashless
  • Reimbursement

For Cashless Treatment:

  • Present your health card at the hospital.
  • Planned Treatment: Obtain prior approval in advance.
  • Emergency Treatment: Approval must be sought within 24 hours.

For Reimbursement Treatment:

The following documents are required to process your reimbursement claim:

  • A fully completed claim form.
  • The final hospital bill with a detailed breakdown and proof of payment.
  • Medical documents, including original medical bills, prescriptions, and discharge summary.
  • Detailed bills for any miscellaneous charges, along with the treating doctor’s prescription