Download Pre Hospitalisation

INSURER : ICICI LOMBARD INSURANCE COMPANY LIMITED
Group Health Insurance.
Covering the Members only.
This policy covers expenses arising out of Illness or accidental bodily
Injury or Maternity.
Policy Coverage
• Hospitalisation Expenses
• Pre-Hospitalisation Expenses - upto 30 days.
• Post Hospitalisation Expenses - upto 60 days
Add-on covers available under this Policy
•
30 days waiting period waived.
•
1/2/4 Years waiting period waived.
•
Pre Existing Diseases covered.
•
9 months waiting Period for Maternity waived.
Compensation Platform
• Room, Boarding Expenses as provided by the Hospitalisation/Nursing
Home- 1% of
Sum Insured subject to maximum Rs.5000/- (Normal) and 2% of Sum Insured subject to
maximum Rs.8000/-(ICU). In the event of Insured getting admitted in the category
higher than above, the insured will bear difference of all medical expenses in the final
hospital bills in the same proportions.
• Fees paid to Medical Practitioner, Surgeon, Anaesthetics, consultants and Specialist.
• Nursing Expenses.
• Surgical fees ,operation theatre, Anaesthetist, Anaesthesia, Blood, Oxygen and Surgical
Appliances, Drugs and medicines, X-ray, Lab
Compensation Platform…cont.
• 20% Co-Payment is applicable on each and every claim.
• 50% co- Payment shall be applicable for Cyberknife treatment and Stem cell
transplantation.
• Cochlear Implant treatment shall be restricted to 50% of
Sum Insured.
• Psychiatrist ailments is restricted to Rs.50,000/- only.
Compensation Platform…cont.
Sub Limits for the following disease subject to maximum of Sum Insured
Diseases
sub limits
Appendicetomy
25,000
Cataract/Glaucoma
20,000
Gall Bladder
31,250
Hernia
25,000
Hydrocele
15,000
Hysterectomy
Joint Replacement
including Vertebral joints
31,000
150,000
Kidney Stone
40,000
Piles
18,750
Heart Related
225,000
Maternity Benefit :
• Expenses incurred towards treatment taken in Hospital/Nursing home arising from or
traceable to pregnancy, child birth including normal caesarean section.
• Claim in respect of delivery for only first 2 children.
• Normal Delivery - Limited to Rs. 15,000.
• Caesarian - Limited to Rs. 25,000.
Major Exclusions :
• Treatment on trial/experimental basis.
• Treatment on account of Holter Monitoring /Prosthesis/ external medical
devices/Lasik Surgery/ Septoplasty etc.
• Infertility & Related ailments including male sterility.
• Administration, Services Charges and Miscellaneous
Charges are not Covered
• Domiciliary hospitalization expenses
Important Definitions..
Injury : Caused by External, Violent & Visible cause.
Disease : As Certified by a Medical Practitioner or Surgeon.
Hospital/Nursing Home:
• Registered with the Local Authorities
• Should have minimum 15 in-patient Beds
Contd…
Hospitalisation : Treatment as in-patient in a hospital/ Nursing Home for min 24
Hrs. The Condition is waived under:
Specific Treatments like Dialysis, Chemotherapy, Radiotherapy, Eye Surgery,
Lithotripsy (Kidney stone removal), Tonsillectomy, D&C, undertaken by Insured
Person in the Hospital/Nursing Home
Due to technological advances, the
than 24 hours as per our daycare list.
period
of
Hospitalisation
is
less
Day care expenses means the medical treatment costs necessary and reasonable
in scope for a Day Care Procedure preauthorized by the Administrator and done in
a network Hospital to the extent that such Cost does not exceed the reasonable
and customary charges in the locality for the same Day Care Procedure.
Important Definitions..
•
Any One illness: Continuous period of illness including relapse within 45
days from the last consultation date.
•
Pre Hospitalisation: Relevant Expenses for 30 days.
•
Post Hospitalisation: Relevant Expenses for 60 days.
•
Medical Practitioner: It means a person holding a degree/diploma of a
recognized institution and registered by Medical Council of respective State of
India. The term Medical Practitioner would include Physician, Surgeon and
Specialist.
Exclusions
• Attributable to War, Invasion, Act of Foreign Enemy, War like operation.
• Cost of Spectacles and contact lens, hearing aids.
• Dental treatment or Surgery of any Kind unless requiring hospitalization.
• 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/alcohols.
• HIV/AIDS related.
Claim Submission incase of reimbursement : • Incase the member undergoes treatment in a hospital that is not covered under
the network of ICICI Lombard, the member can claim reimbursement of the
expenses based on their eligibility.
• All original documents along with a set of photocopy.
• Bills & receipts.
• Reports.
• Duly filled in Claim Form (is available on HR Mantra)
• Print out of the E – Card.
Please note that all the above mentioned documents should be submitted within
10 -15 days of discharge from the hospital. Any delay in the same might result
in rejection of the claim by the insurance company. The claim for Post
Hospitalization expenses (upto 60 days) can be claimed seperately.
Thank You