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GROUP MEDICLAIM
INSURANCE
Group Mediclaim
Insurance
• Group Personal Accident
policy takes care of an event
which relates to an external
peril.
• What if there is an action of
internal peril? The human
life is exposed to a peril
acting from within.
• These are in the nature of
action of a bacteria or a
virus affecting the normal
functions of living.
• We call them action of
disease crippling the normal
life.
• When this leads to a
necessity of hospitalisation
there is a policy to take care
of the bills of
hospitalisation.
• Apart from the action of
internal perils there are also
possibilities of a severe
accident leading to
hospitalisation for correcting
the affected limb.

Group Mediclaim
Insurance
• Scope of cover:
• Policy covers reimbursement
of hospitalization expenses
incurred for diseases
contracted or injuries
sustained in India.
• Medical expenses upto 30
days for Pre – hospital-
ization and upto 60 days for
post – hospitalization are
also admissible

Group Mediclaim
Insurance
• Main Exclusions
• Pre Existing Diseases
• Diseases Contracted During
first 30 Days
• Cost Of Spectacles / Contact
Lenses
• Dental Treatment
• AIDS
• Pregnancy
• Certain specified diseases
during first year of the
policy.

Group Mediclaim
Insurance
• Sum Insured

• Minimum Rs. 15,000/- and


Maximum Rs. 5,00,000/-

Group Mediclaim
Insurance
• Premium
• Premium chargeable
depends upon age of the
person and the Sum Insured
selected
• Age limit is 5 to 80 years
• Children above 3 months can
be covered provided one or
both parents are covered
concurrently

Group Mediclaim
Insurance
• Group Discount
• Policy can be given to
Corporate Body
• Institution & Association
• Slab wise group discount is
admissible on standard
premium if the group size
exceeds 100
• Larger the group size higher
is the discount.

Group Mediclaim
Insurance
• Bonus / Malus
Clause
• As always good features
provides eligibility for
discounts and bad features
attracts loading in the
premium. The loading
applied is termed as Malus.

Group Mediclaim
Insurance
• Extension

• Policy can be extended to


cover maternity benefits on
payment of additional
premium
Group Mediclaim
Insurance
• More details:
• During the policy period, if
any Insured Person shall
contract any disease or
suffer from Any One Illness
or sustain any bodily injury
through accident, and if
such disease, illness,
accident or injury shall
require any such Insured
Person, upon the advice of a
Medical Practitioner to incur
Hospitalisation or
Domiciliary Hospitalisation
expenses, the Company will
pay to the Insured Person,
the amount of such
expenses as are reasonably
and necessarily incurred
thereof, by or on behalf of
such Insured Person but not
exceeding the sum insured
for the person as specified.

Group Mediclaim
Insurance
• Domiciliary Hospitalisation:
• The term “Domiciliary
Hospitalisation” 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 the
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 can not be
removed to Hospital/
Nursing Home for lack of
accommodation therein

Group Mediclaim
Insurance
• Domiciliary Hospitalisation
does not cover:
• 1. Asthma
• 2. Bronchitis
• 3. Chronic Nephritis and Chronic
Nephritic Syndrome
• 4. Diarrhoea and all types of
Dysenteries including Gastro-enteritis
• 5. Diabetes Mellitus and Insipidus
• 6. Epilepsy
• 7. Hypertension
• 8. Influenza, Cough and Cold
• 9. All Psychiatric or Psychosomatic
Disorders
• 10. Pyrexia of unknown origin for less
than 10 days
• 11. Tonsillitis and Upper Respiratory
Tract Infection including Laryngitis
and Pharingitis
12. Arthritis, Gout and Rheumatism

Group Mediclaim
Insurance
• Exclusions
• Pre existing diseases
• Disease contracted during
the first 30 days of
insurance.
• Certain disease like cataract
hernia etc excluded during
the first year of the policy
• Cosmetic and aesthetic
treatment plastic surgery
etc not covered unless
essentially associated with a
treatment.
• Cost of spectacles
• Dental treatment
• General debility, run down
condition, intentional self
injury, sterility etc
• AIDS, expenses on tonics,
expenses only for
diagnostics etc

Group Mediclaim
Insurance
• Basis of assessment:
• a) Room, and Boarding
Expenses as incurred at the
Hospital/Nursing Home;
• b) Nursing Expenses;
• c) Fee paid to Medical
Practitioner, Surgeon,
Anaesthetics, Consultants,
and Specialists
• d) Anaesthesia, Blood,
Oxygen, Operation Theatre
Charges, Surgical
Appliances, Medicines &
drugs, Diagnostic Materials
and X – Ray, Dialysis,
Chemotherapy,
Radiotherapy, Cost of
Pacemaker, Artificial Limbs
& Cost of Organs and similar
expenses; and /or
e) Pre Hospitalisation and
Post Hospitalisation expenses,
wherever applicable

Group Mediclaim
Insurance
• Claim documents
a) Duly completed claim form
b) Bills, receipts and
discharge certificate/card from
the Hospital
c) Bills from Chemists
supported by proper
prescription.
• d) Test reports and
payment receipts

Group Mediclaim
Insurance
• INTIMATING THE CLAIM:

• CONTACT THIRD PARTY


ADMINISTRATOR M/S
PARAMOUNT HEALTH
SERVICES ON NUMBERS TO
BE PROVIDED TO YOU.
Group Mediclaim
Insurance
• Definitions
• Policy lays down definitions
of following terms
• • Any One illness
• • Domiciliary Hospitalization
• • Hospital/Nursing Home
• • Hospitalization
• • Specified Treatment
• • Medical Practitioner
• • Maternity Expenses Benefit
• • Post Hospitalization
• • Pre Hospitalization
• • Qualified Nurse
• Surgical Operation

Group Mediclaim
Insurance