National Insurance Company Limited

Regd. Office 3, Middleton Street, Post Box 9229, Kolkata 700 071
CIN - U10200WB1906GOI001713 IRDA Regn. No. - 58

VARISTHA Mediclaim for Senior Citizens

Prospectus
1.1 Product
This policy has been designed to cater to the needs of Senior Citizens.
The policy covers –
Section I -Hospitalisation and Domiciliary Hospitalisation Expenses
Section II - Critical Illnesses (optional cover)

1.2 Scope of Cover:

Coverage:
Section I- Hospitalisation and Domiciliary Hospitalisation Cover

Hospitalisation Benefits Limits

1A Room charges subject to 1% of sum insured per day and Intensive care unit Maximum limit under Section 1 A -
(ICU) charges subject to 2% of sum insured per day (including nursing care, 25% of the sum insured per illness
RMO charges, IV fluids / blood transfusion / injection administration charges). / injury
1B Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees Maximum limit under Section 1 B -
25% of sum insured per illness /
Injury
1C Anesthesia, Blood, Oxygen, OT charges, Surgical appliances (any disposable Maximum limit under Section 1 C -
surgical consumables), Medicines, drugs, Diagnostic material & X-Ray, 50% of sum insured per illness /
Dialysis, Chemotherapy, Radiotherapy, cost of pacemaker, artificial limbs, Injury
Cost of Stent & Implants

Sublimit
i. Company’s liability in respect of claims arising due to Cataract is up to `10000/- (ten thousand) and that of Benign prostatic
hyperplasia is up to `20,000/- (twenty thousand) only.
ii. Company’s liability under Domiciliary Hospitalisation is limited to 20% of the sum insured under Section I.
iii. Hospitalisation expenses of person donating an organ during the course of organ transplant will also be payable subject to the sub
limits under 1.C above applicable to the insured person within the sum insured of the insured person.
iv. Ambulance charges up to a maximum limit of `1000/- (one thousand) in a policy period shall be reimbursed, subject to the sub
limits under 1.C above.
v. Sublimit mentioned in 1A, 1B and 1C shall not apply in case of Hospitalisation in a preferred provider network (PPN) for certain
procedure/treatment.

Co-payment
Co-payment of 10% shall apply to all the admissible claims other than claims arising due to Cataract and Benign prostatic hyperplasia.
Co-payment of 20% shall be considered wherever the insured person has opted.
Co-payment of 10% shall apply to all the admissible claims arising out of pre-existing diseases for which the insured person opted cover
and paid additional premium. This copayment is in addition to the copayment stated herein above and applicable only for claims arising
out of Pre-existing Diseases.

1.3 Good health incentives

1.3.1 Cumulative bonus (CB)
At the time of renewal, cumulative bonus allowed shall be an amount equal to 5% (five percent) of sum insured (excluding CB) of
the expiring policy in respect of an insured person, provided no claims were reported under the expiring policy.
In the event of a claim being reported under the expiring policy the cumulative bonus with respect to the insured person shall be
reduced by an amount equal to 5% (five percent) of sum insured (excluding CB) of the expiring policy.

Varistha Mediclaim for Senior Citizens UIN: IRDA/NL-HLT/NI/P-H/V.I/294/13-14

Cumulative bonus shall be aggregated over the years and available, subject to maximum of 50% (fifty percent) of the sum insured
(excluding CB) of the expiring policy.

Insured person has the option either to avail cumulative bonus or claim 5% discount in renewal premium in respect of each claim free
year of insurance subject to maximum of 10 (ten) claim free years of insurance.

1.4.2 Health checkup

Expenses of health checkup will be reimbursed once at the end of a block of three continuous policy periods provided no claims are
reported during the block and the policy has been continuously renewed with the company without a break. Expenses payable is a
maximum of 2% of the average sum insured (excluding CB) of the block. Claim for health checkup benefits may be lodged at least 45
(forty five) days before the expiry of the fourth policy period.

2.1 Other benefits

Tax rebate
The insured person can avail tax benefits for the premium paid for hospitalisation cover (section I of policy); under Section 80D of
Income Tax Act 1961.

2.2 Eligibility
Policy can be availed by persons between the age of 60 (sixty) years and 80 (eighty) years.

2.3 Sum insured (SI)

Sum Insured is fixed per person.
Section I - Hospitalisation & Domiciliary Hospitalisation Cover - Sum Insured is `1,00,000/- (one lac).
Section II (Optional benefit) - Critical Illness cover - Sum Insured is `2,00,000/- (two lacs).

2.4 Policy period

The policy is issued for a period of one year.
2.5 Buying the Policy
The policy can be bought
i. from our offices
ii. from our agents
2.6 Completion of proposal form
i. The proposal form is to be completed in all respects (including personal details, medical history of insured person) and to be
submitted to the office or to the agent.
ii. If a person is insured under health insurance policy of any other non life insurance company and wants to port (switch) to
Varistha Mediclaim for Senior Citizens Policy, the portability and proposal form will have to be completed and submitted to
the office or to the agent.
2.7 Pre policy checkup
i. No Medical Checkup is required if the insured was covered under any Health Insurance Policy of National Insurance
Company or other Insurance companies uninterruptedly for preceding three years.
ii. Other persons have to undergo medical checkup at their own cost for Blood / Urine Sugar, Blood Pressure, Echo-
cardiography and eye check up including retinoscopy.
iii. The Company will reimburse 50% of the expenses incurred for pre policy checkup, if the proposal is accepted.
iv. The date of medical reports should not exceed 30 (thirty) days prior to the date of proposal.
2.8 Payment of premium
i. Premium is based on age and sum insured.
ii. Premium as per the premium table attached is to be paid in full before the commencement of the policy.
2.9 Renewal of policy
i. The policy can be renewed annually throughout the lifetime of the insured person.
ii. The premium of 76-80 age band will be loaded by 10% for up to 85 (eighty five) years and by 20% for up to above 85 (eighty
five) years of age
iii. The policy may be renewed by mutual consent before the expiry of the policy.
iv. The company is not bound to send renewal notice.
v. Renewal of policy can be denied on grounds of fraud, moral hazard, misrepresentation or noncooperation.

Varistha Mediclaim for Senior Citizens UIN: IRDA/NL-HLT/NI/P-H/V.I/294/13-14

 vi. In the event of break in the policy a grace period of 30 (thirty) days is allowed. Coverage is not available during the grace
period. Coverage is not available during the grace period.

3. Definitions

3.1 Any one illness means continuous period of illness and it includes relapse within 45 (forty five) days from the date of last
consultation with the Hospital where treatment may have been taken.

3.2 Break in policy occurs at the end of the existing policy period when the premium due on a given policy is not paid on or before
the renewal date or within the grace period.

3.3 Cashless facility means a facility extended by the company to the insured person where the payment of the cost of treatment
undergone by the insured person in accordance with the policy terms and conditions, is directly made to the network provider by the
company to the extent of pre-authorization approval.

3.4 Domiciliary hospitalisation means medical treatment for an illness/disease/injury which in the normal course would require care
and treatment at a hospital but is actually taken while confined at home under any of the following circumstances:
i. the condition of the patient is such that he/she is not in a condition to be removed to a hospital, or
ii. the patient takes treatment at home on account of non availability of room in a hospital.

Domiciliary hospitalisation shall not cover:

i. Treatment of less than 3 (three) days
ii. Expenses incurred for pre and post hospitalisation and
iii. Expenses incurred for any of the following diseases;
a) Asthma
b) Bronchitis
c) Chronic Nephritis and Nephritic Syndrome
d) Diarrhoea and all type of dysenteries including Gastroenteritis
e) Diabetes Mellitus and Insipidus
f) Epilepsy
g) Hypertension
h) Influenza, Cough and Cold
i) All Psychiatric or Psychosomatic Disorders
j) Pyrexia of unknown origin for less than 10 (ten) days
k) Tonsillitis and Upper Respiratory Tract Infection including Laryngitis and Pharingitis
l) Arthritis, Gout and Rheumatism

3.5 Grace period means 30 (thirty) days immediately following the premium due date during which a payment can be made to
renew or continue the policy in force without loss of continuity benefits such as waiting period and coverage of pre-existing disease.
Coverage is not available for the period for which no premium is received.

3.6 Hospitalisation means admission in a hospital as an in-patient for a minimum period of 24 (twenty four) consecutive hours.
However, this time limit is not applied to specific treatments i.e. day care treatment for stitching of wound/s, close reduction/s and
application of POP casts, dialysis, chemotherapy, radiotherapy, arthroscopy, eye surgery, ENT surgery, laparoscopic surgery,
angiography, endoscopy, lithotripsy (kidney stone removal), dilatation and curettage (D&C), tonsillectomy taken in the hospital and
the insured person is discharged on the same day. The treatment will be considered to be taken under hospitalisation benefit. This
condition will also not apply in case of stay in hospital of less than 24 (twenty four) hours provided –
i. the treatment is such that it necessitates hospitalisation and the procedure involves specialized infra structural facilities
available in hospitals.
And
ii. due to technological advances hospitalisation is required for less than 24 (twenty four) hours only.

3.7 In-patient means an insured person who is admitted in hospital upon the written advice of a duly qualified medical practitioner for
more than 24 (twenty four) continuous hours, for the treatment of covered disease/ injury during the policy period.

Varistha Mediclaim for Senior Citizens UIN: IRDA/NL-HLT/NI/P-H/V.I/294/13-14

3.8 Medical practitioner means a person who holds a valid registration from the Medical Council of any State or Medical Council of
India or Council for Indian Medicine or for Homeopathy set up by the Government of India or a State Government and is thereby
entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of licence.

3.9 Network provider means hospitals or health care providers enlisted by an insurer or by a TPA and insurer together to provide
medical services to an insured person on payment by a cashless facility.

3.10 Policy period means period of one year as mentioned in the schedule for which the policy is issued.

3.11 Pre hospitalisation means medical expenses incurred 30 (thirty) days immediately before the insured person is hospitalised,
provided that:
i. such medical expenses are incurred for the same condition for which the insured person’s hospitalisation was required, and
ii. the in-patient hospitalisation claim for such hospitalisation is admissible by the company
Pre hospitalisation will be considered as part of hospitalisation claim.

3.12 Post hospitalisation means medical expenses incurred 60 (sixty) days immediately after the insured person is discharged from
hospital, provided that:
i. such medical expenses are incurred for the same condition for which the insured person person’s hospitalisation was
required, and
ii. the in-patient hospitalisation claim for such hospitalisation is admissible by the company
Post hospitalisation will be considered as part of hospitalisation claim.

3.13 Pre-existing diseases means any condition, ailment or injury or related condition(s) for which the insured person had signs or
symptoms and/or was diagnosed and/or received medical advice/ treatment within 48 (forty eight) months prior to the first policy
issued by the company.

3.14 Preferred provider network (PPN) means a network of hospitals which have agreed to a cashless packaged pricing for certain
procedures for the insured person. The list is available with the company/TPA and subject to amendment from time to time.
Reimbursement of expenses incurred in PPN for the procedures (as listed under PPN package) shall be subject to the rates applicable
to PPN package pricing.

3.15 Reasonable and customary charges means the charges for services or supplies, which are the standard charges for the specific
provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the
nature of the illness / injury involved.

3.16 TPA means any entity, licenced under the IRDA (Third Party Administrators - Health Services) Regulations, 2001 by the
Authority, and is engaged, for a fee by the company for the purpose of providing health services.

3.17 Waiting period means a period from the inception of the first policy during which specified diseases/treatment is not covered.
On completion of the period, diseases/treatment will be covered provided the policy has been continuously renewed without any
break.

4 Exclusions (Applicable to Section I)

The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any
person in connection with or in respect of:

4.1 Pre existing disease

All pre-existing diseases. Such diseases shall be covered after the policy has been continuously in force for 12 months. Any
complication arising from pre-existing disease shall be considered as a part of the pre existing disease.
Diabetes and/or Hypertension, if preexisting shall be covered from the inception of the policy, subject to exclusion 4.2 stated herein
under, by charging additional premium. However, any ailment already manifested or being treated and attributable to diabetes and/or
hypertension or consequences thereof at the time of inception of insurance will not be covered.

Cost of treatment towards dialysis, chemotherapy & radiotherapy for preexisting diseases is not payable even after 12 months.

4.2 First 30 days waiting period

Varistha Mediclaim for Senior Citizens UIN: IRDA/NL-HLT/NI/P-H/V.I/294/13-14

Any disease contracted by the insured person during the first 30 (thirty) days of continuous coverage from the inception of the policy.
This shall not apply in case the insured person is hospitalised for injuries, suffered in an accident which occurred after inception of the
policy.

4.3 One year waiting period

a. Cataract i. CSOM (Chronic Suppurative Otitis Media)

b. Benign prostatic hypertrophy j. Pilonidal sinus
c. Hernia k. Calculus diseases
d. Hydrocele l. Benign lumps/growths in any part of the body
e. Congenital internal disease m. Surgical treatment of tonsils, adenoids and deviated nasal
septum and related disorders
f. Fissure/Fistula in anus n. Hysterectomy for menorrhagia or fibromyoma
g. Piles (Haemorrhoids) o. Joints replacements of any kind unless arising out of accident
h. Sinusitis

If these diseases are pre-existing at the time of proposal, they will be covered only after one claim free year as mentioned in exclusion
4.1 above.

4.4 HIV, AIDS

Expenses arising out of any condition directly or indirectly caused to or associated with Human T-Cell Lymphotrophic Virus Type III
(HTLV-III) or Lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or variations Deficiency Syndrome or any
syndrome or condition of a similar kind commonly referred to as AIDS.

4.5 Convalescence, general debility ‘Run Down’ condition or rest cure.

4.6 Sterility, venereal disease.

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

4.8 Intentional self-injury, drug/alcohol abuse

Intentional self-injury and use of intoxicating drugs / alcohol, rehabilitation therapy in any form.

4.9 Congenital external disease or defects or anomalies.

4.10 Vaccination or inoculation.

4.11 Cosmetic, plastic surgery, change of life

Change of life or cosmetic or aesthetic treatment of any description, plastic surgery other than as may be necessitated due to as
accident or as part of any illness.

4.12 Naturopathy treatment.

4.13 Dental treatment

Dental treatment unless arising due to an accident.

4.14 Vitamins and tonics

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

4.15 Hospitalisation for the purpose of diagnosis and evaluation

Expenses incurred at Hospital primarily for diagnostic, X-Ray or laboratory examinations or other diagnostic studies not consistent
with nor incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury for which
confinement is required at a Hospital.

4.16 Spectacles and contact lenses, hearing aids.

Varistha Mediclaim for Senior Citizens UIN: IRDA/NL-HLT/NI/P-H/V.I/294/13-14

4.17 Nuclear weapons/materials
Injury or disease directly or indirectly caused by or contributed to by nuclear weapons/materials.

4.18 War group perils

Injury or disease directly or indirectly caused by or arising from or attributable to War Invasion Act of Foreign Enemy Warlike
operations (whether war be declared or not).

5. Conditions (Applicable to section I)

5.1 Territorial Limit

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

5.2 Physical examination

Any medical practitioner authorised by the company shall be allowed to examine the insured person in case of any alleged injury or
disease requiring hospitalisation when and as often as the same may reasonably be required on behalf of the company.

5.3 Contribution
In the case of a claim arising under the policy, there is in existence any other policy (other than cancer insurance policy in
collaboration with Indian Cancer Society) effected by the insured person or on behalf of insured person which covers any claim in
whole or in part made under the policy then the insured person has the option to select the policy under which the claim is to be
settled. If the claimed amount, after considering the applicable co payment, exceeds the sum insured under any one policy then the
company shall pay or contribute not more than its rateable proportion of the claim.

5.4 Claims Procedure

Section I - Hospitalisation and Domiciliary Hospitalisation Cover
Claims will be settled by the Third Party Administrators (TPA).

5.4.1 Notification of claim

In case of a claim, the insured person/insured person’s representative shall notify the TPA in writing by letter, e-mail, fax providing all
relevant information relating to claim including plan of treatment, policy number etc. within the prescribed time limit.
Claim notification in case of Cashless facility TPA must be informed:
In case of planned hospitalisation At least 72 (seventy two) hours prior to the insured person’s
admission to network provider/PPN
In case of emergency hospitalisation Within 24 (twenty four) hours of the insured person’s admission to
network provider/PPN

Claim notification in case of Reimbursement TPA must be informed:

In case of planned hospitalisation At least 72 (seventy two) hours prior to the insured person’s
admission to hospital
In case of emergency hospitalisation Within 24 (twenty four)hours of the insured person’s admission to
hospital

5.4.2 Procedure for Cashless claims

i. Treatment may be taken in a network provider/PPN and is subject to pre authorization by the TPA.
ii. Cashless request form available with the network provider/PPN and TPA shall be completed and sent to the TPA for
authorization.
iii. The TPA upon getting cashless request form and related medical information from the insured person/ network provider/PPN will
issue pre-authorization letter to the hospital after verification.
iv. At the time of discharge, the insured person has to verify and sign the discharge papers, pay for non-medical and inadmissible
expenses.
v. The TPA reserves the right to deny pre-authorization in case the insured person is unable to provide the relevant medical details.
vi. In case of denial of cashless access, the insured person may obtain the treatment as per treating doctor’s advice and submit the
claim documents to the TPA for reimbursement.

5.4.3 Procedure for reimbursement of claims

Varistha Mediclaim for Senior Citizens UIN: IRDA/NL-HLT/NI/P-H/V.I/294/13-14

For reimbursement of claims the insured person may submit the necessary documents to TPA/company within the prescribed time
limit.

5.4.4 Documents
The claim is to be supported with the following documents and submitted within the prescribed time limit.
i. Completed claim form
ii. Original bills, payment receipts, medical history of the patient recorded, discharge certificate/ summary from the hospital etc.
iii. Original cash-memo from the hospital (s)/chemist (s) supported by proper prescription
iv. Original payment receipt, investigation test reports etc. supported by the prescription from attending medical practitioner
v. Attending medical practitioner’s certificate regarding diagnosis and bill receipts etc.
vi. Surgeon’s original certificate stating diagnosis and nature of operation performed along with bills/receipts etc.
vii. Any other document required by company/TPA

Type of claim Time limit for submission of documents to

TPA
Reimbursement of hospitalisation and pre Within 15 (fifteen) days of date of discharge from hospital
hospitalisation expenses
Reimbursement of post hospitalisation expenses Within 15 (fifteen) days from completion of post hospitalisation
treatment
Reimbursement of health checkup expenses (as per At least 45 (forty five) days before the expiry of the fourth policy
clause 2.2 of the policy) period.
Note
In the event of a claim lodged as per clause 5.3 of the policy and the original documents having been submitted to the other insurer,
the company may accept the documents listed under clause 5.4.4 of the policy and claim settlement advice duly certified by the other
insurer subject to satisfaction of the company.

5.4.5 Services offered by a TPA

The TPA shall render health care services covered under the policy like issuance of ID cards & guide book, hospitalization & pre-
authorization services, call centre, acceptance of claim related documents, claim processing and other related services
The services offered by a TPA shall not include
i. Claim settlements and rejections with respect to the health insurance policies; However, TPA may handle claims admissions and
recommend to the insurer for the payment of the claim settlement, provided a detailed guideline is prescribed by the insurer to the
TPA for claims assessments & admissions in terms of capacity requirements, internal control requirements, claim assessment &
admissions procedure requirements etc under the agreement
ii. Any services directly to the policyholder or insured person or to any other person unless such service is in accordance with the
terms and conditions of the Agreement entered into with the insurer.

Waiver
Time limit for claim notification and submission of documents may be waived in cases where it is proved to the satisfaction of the
company, that the circumstances under which insured person was placed, it was not possible to intimate the claim/submit the
documents within the prescribed time limit.

5.5 Portability
In the event of the insured person porting to any other insurer, insured person must apply with details of the policy and claims to the
company where the insured person wants to port, at least 45 (forty five) days before the date of expiry of the policy.
Portability shall be allowed in the following cases:
i. All individual health insurance policies issued by non-life insurance companies including family floater policies.
ii. Individual members, including the family members covered under any group health insurance policy of a non-life insurance
company shall have the right to migrate from such a group policy to an individual health insurance policy or a family floater
policy with the same insurer. One year thereafter, the insured person shall be accorded the right to port to another non-life
insurance company.

Section II: Critical Illness Cover

The Company shall pay to the insured person, the sum insured as mentioned in the schedule, should an insured person be diagnosed,
during the period of insurance set in the schedule, as suffering from a critical illness, symptoms (and/or the treatment) which were not
present in such insured person at any time prior to inception of this policy.
Varistha Mediclaim for Senior Citizens UIN: IRDA/NL-HLT/NI/P-H/V.I/294/13-14
1. Definitions

1.1 Critical illness means stroke resulting in permanent symptoms, cancer of specified severity, kidney failure requiring regular
dialysis, major organ/ bone marrow transplant, multiple sclerosis with persisting symptoms and open chest CABG (Coronary Artery
Bypass Graf) as mentioned in the policy.

Critical illness also includes permanent paralysis of limbs and blindness if mentioned in the schedule.

1.1.1 Stroke resulting in permanent symptoms

Any cerebrovascular incident producing permanent neurological sequelae.This includes infarction of brain tissue, thrombosis in an
intracranial vessel, haemorrhage and embolisation from an extracranial source. Diagnosis has to be confirmed by a specialist medical
practitioner and evidenced by typical clinical symptoms as well as typical findings in CT Scan or MRI of the brain. Evidence of
permanent neurological deficit lasting for at least 3 (three) months has to be produced.
The following are not covered
i. Transient ischemic attacks (TIA)
ii. Traumatic injury of the brain
iii. Vascular disease affecting only the eye or optic nerve or vestibular functions.

1.1.2 Cancer of specified severity

A malignant tumour characterised by the uncontrolled growth & spread of malignant cells with invasion & destruction of normal
tissues. This diagnosis must be supported by histological evidence of malignancy & confirmed by a pathologist. The term cancer
includes leukemia, lymphoma and sarcoma.
The following are not covered
i. Tumours showing the malignant changes of carcinoma in situ & tumours which are histologically described as premalignant or non
invasive, including but not limited to: Carcinoma in situ of breasts, Cervical dysplasia CIN-1, CIN -2 & CIN-3.
ii. Any skin cancer other than invasive malignant melanoma
iii. All tumours of the prostate unless histologically classified as having a Gleason score greater than 6 (six) or having progressed to at
least clinical TNM classification T2N0M0.
iv. Papillary micro - carcinoma of the thyroid less than 1 (one) cm in diameter.
v. Chronic lymphocyctic leukaemia less than RAI stage 3 (three).
vi. Microcarcinoma of the bladder.
vii. All tumours in the presence of HIV infection.

1.1.3 Kidney failure requiring regular dialysis

End stage renal disease presenting as chronic irreversible failure of both kidneys to function, as a result of which either regular renal
dialysis (hemodialysis or peritoneal dialysis) is instituted or renal transplantation is carried out. Diagnosis has to be confirmed by a
specialist medical practitioner.

1.1.4 Major organ/ Bone marrow transplant

The actual undergoing of a transplant of:
i. One of the following human organs: heart, lung, liver, kidney, pancreas, that resulted from irreversible end-stage failure of the
relevant organ, or
ii. Human bone marrow using haematopoietic stem cells. The undergoing of a transplant has to be confirmed by a specialist medical
practitioner.
The following are not covered
i. Other stem-cell transplants
ii. Where only islets of langerhans are transplanted

1.1.5 Multiple Sclerosis with persisting symptoms

The definite occurrence of multiple sclerosis. The diagnosis must be supported by all of the following:
i. investigations including typical MRI and CSF findings, which unequivocally confirm the diagnosis to be multiple sclerosis;
ii. there must be current clinical impairment of motor or sensory function, which must have persisted for a continuous period of at
least 6 (six) months, and
iii. well documented clinical history of exacerbations and remissions of said symptoms or neurological deficits with at least two
clinically documented episodes at least one month apart.
Varistha Mediclaim for Senior Citizens UIN: IRDA/NL-HLT/NI/P-H/V.I/294/13-14
The following are not covered
Other causes of neurological damage such as SLE (Systemic Lupus Erythematosus) and HIV (Human Immunodeficiency Virus)

1.1.6 Open chest CABG

The actual undergoing of open chest surgery for the correction of one or more coronary arteries, which is/are narrowed or blocked, by
coronary artery bypass graft (CABG). The diagnosis must be supported by a coronary angiography and the realization of surgery has
to be confirmed by a specialist medical practitioner.
The following are not covered
i. Angioplasty and/or any other intra-arterial procedures
ii. Any key-hole or laser surgery.

1.1.7 Permanent paralysis of limbs

Total and irreversible loss of use of two or more limbs as a result of injury or disease of the brain or spinal cord. A specialist medical
practitioner must be of the opinion that the paralysis will be permanent with no hope of recovery and must be present for more than 3
(three) months.

1.1.8 Blindness
The total and permanent loss of all sight in both eyes.

1.2 Diagnosis means diagnosis by a registered medical practitioner, supported by clinical, radiological, histological and laboratory
evidence, acceptable to the Company.

2 Exclusions (Applicable to section II)

2.1 Waiting period

No claim will be payable, if a critical illness as specified in the policy incepts or manifests during the first 90 (ninety) days of the
inception of the policy.

Varistha Mediclaim for Senior Citizens UIN: IRDA/NL-HLT/NI/P-H/V.I/294/13-14

2.2. Pre existing condition
The company will not be liable for a critical illness and/or its symptoms (and/or the treatment) of which were present in the insured
person at any time before inception of the policy or the date on which cover was granted to such insured person, or which manifest
themselves within a period of 90 (ninety) days from such date, whether or not the insured person had knowledge that the symptoms
or treatment were related to such critical illness. In the event of any interruption in cover, the terms of this exclusion will apply as
new from recommencement of cover.

2.4 The company shall not pay any benefit to any insured person who suffers a critical illness which arises or is caused by or
associated with

2.4.1 Non Prescribed drug

The ingestion of drugs other than those prescribed by a practicing and duly qualified member of the medical profession.

2.4.2 Drug addiction

The ingestion of medicines, prescribed or not, for treatment of drug addiction and any treatment relating to drug addiction.

2.4.3 Suicide
Any attempt by the insured person at suicide or any, injury, which is self inflicted or in any manner willfully caused by or on
behalf of the insured person.

2.4.4 AIDS, HIV

AIDS (Acquired Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus) . AIDS and HIV will be interpreted
as broadly as possible so as to include all or any mutants, derivatives or variations thereof. The onus will always be on the
insured person to show that any event was not caused by or did not arise through AIDS or HIV.

2.4.5 Radioactivity
Any illness or injury directly or indirectly caused by or contributed to by nuclear weapons/materials or contributed to by or
arising from ionising radiation or contamination by radioactivity by any nuclear fuel or from any nuclear waste or from the
combustion of nuclear fuel.

2.4.6 War group perils

War, invasion, act of foreign enemy, hostilities, civil war, rebellion, revolution, insurrection, mutiny, military, or usurped
power, seizure, capture, arrest, restraints and detainment of all kings, princes and people of whatever nation condition or
quality whatsoever.

2.3 Smoking
No claim will be payable if the insured person smokes 40 (forty) or more cigarettes / cigars or equivalent tobacco intake in a day.

3 Special Conditions (Applicable to section II)

3.1 Restricted cover

The amount payable for Open chest CABG shall be limited to 20% of the sum insured.

3.2 Medical examination

Each of the above illnesses mentioned in the policy, must be confirmed by a medical practitioner appointed by the company and must
be supported by clinical, radiological, histological and laboratory evidence acceptable to the company and to be reconfirmed by a
medical practitioner appointed by the company.

3.3 No. of claims in a policy period

The company shall pay to the insured on behalf of the insured person only once in respect of any particular critical illness.

3.4 Cession of cover

The cover under the policy will cease upon payment of the sum insured on the happening of a critical illness and no further payment
will be made for any consequent disease or any dependent disease or any critical illness.

3.5 Survival period

The insured person needs to survive for 30 (thirty) days after the diagnosis of the critical illness in order to make a claim.

Varistha Mediclaim for Senior Citizens UIN: IRDA/NL-HLT/NI/P-H/V.I/294/13-14

3.6 Multiple policies
3.6.1 An insured person shall not be covered under more than one Critical Illness Insurance policy issued by the company. In the
event that an insured person is covered under more than one such insurance policy, the company will only pay under one
insurance and will refund any duplicated premium, which may have been paid by or on behalf of the insured.
3.6.2 The insured person must give at least 30 (thirty) days’ notice to the company of his intention to effect another policy (by any
other name) covering the Critical Illness to be issued by another insurer before effecting such cover. Failure to give such
notice shall render the policy liable to be cancelled or the benefits under the policy shall be forfeited.

3.7 Claims Procedure

Section II - Critical Illness Cover

3.7.1 Notification of claim

Upon detection of any critical illness, which may give rise to a claim under this section, notice with full particulars shall be sent to the
company within 15 (fifteen) days from the date of diagnosis of the disease.

3.7.2 Documents
Claim documents as mentioned hereunder must be submitted to the company after 30 (thirty) days from the date of diagnosis of the
disease.
a. Discharge summary, Doctor’s certificate confirming diagnosis of the critical illness along with date of diagnosis.
b. Pathological/ Radiological/other diagnostic test reports confirming the diagnosis of the critical illness.
c. Any other documents required by the company

Conditions applicable to both Sections I & II

1 Disclosure of information
The policy shall be void and all premium paid hereon shall be forfeited to the company, in the event of misrepresentation, mis-
description or non-disclosure of any material fact.

2 Condition precedent to admission of liability

The due observance and fulfillment of the terms and conditions of the policy, by the insured person, shall be a condition precedent to
any liability of the company to make any payment under the policy.

3 Communication
i. All communication should be in writing.
ii. For claim serviced by TPA, ID card, PPN/network provider related issues to be communicated to the TPA at the address
mentioned in the schedule. For claim serviced by the company, the policy related issues, change in address to be
communicated to the policy issuing office at the address mentioned in the schedule.
iii. The company or TPA will communicate to the insured person at the address mentioned in the schedule.

4 Claim documents
The insured person shall obtain and furnish the Company with all original bills, receipts and other documents upon which a claim is
based and shall also give the Company such additional information and assistance as the Company may require in dealing with the
Claim.

5 Claim Settlement
i. On receipt of the final document(s) or investigation report (if any), as the case may be, the company shall within a period of 30
(thirty) days offer a settlement of the claim to the insured.
ii. If the company, for any reasons, decides to reject a claim under the policy, shall communicate to the insured person in writing and
within a period of 30 (thirty) days from the receipt of the final document(s) or investigation report (if any), as the case may be.
iii. Upon acceptance of an offer of settlement as stated above by the insured, the payment of the amount due shall be made within 7
(seven) days from the date of acceptance of the offer by the company.
iv. In the cases of delay in the payment, the company shall pay interest at a rate which is 2% above the bank rate prevalent at the
beginning of the financial year in which the claim is paid.

6 Payment of claim
All claims under the policy shall be payable in Indian currency through NEFT/ RTGS only.
Varistha Mediclaim for Senior Citizens UIN: IRDA/NL-HLT/NI/P-H/V.I/294/13-14
7 Fraud
The company shall not be liable to make any payment under the policy in respect of any claim if such claim be in any manner
fraudulent or supported by any fraudulent means or device whether by the insured person or by any other person acting on his behalf.

8 Cancellation
The company may at any time cancel the policy (on grounds of fraud, moral hazard, misrepresentation or noncooperation) by sending
the insured person 30 (thirty) days notice by registered letter at insured person person's last known address and in such event the
company will not allow any refund.
The insured person may at any time cancel the policy and in such an event the company shall allow refund of premium after
charging premium at company’s short period rate mentioned below provided no claim occurred up to the date of cancellation.

Period of risk Rate of premium to be charged

Up to 1 month ¼ of the annual rate
Up to 3 months ½ of the annual rate
Up to 6 months ¾ of the annual rate
Exceeding 6 months Full annual rate

9 Territorial jurisdiction
All disputes or differences under or in relation to the policy shall be determined by the Indian court and according to Indian law.

10 Arbitration
i. If any dispute or difference shall arise as to the quantum to be paid under the policy, (liability being otherwise admitted) such
difference shall independently of all other questions, be referred to the decision of a sole arbitrator to be appointed in writing by
the parties here to or if they cannot agree upon a single arbitrator within 30 (thirty) days of any party invoking arbitration, the
same shall be referred to a panel of three arbitrators, comprising of two arbitrators, one to be appointed by each of the parties to
the dispute/difference and the third arbitrator to be appointed by such two arbitrators and arbitration shall be conducted under and
in accordance with the provisions of the Arbitration and Conciliation Act, 1996.
ii. It is clearly agreed and understood that no difference or dispute shall be referable to arbitration as herein before provided, if the
company has disputed or not accepted liability under or in respect of the policy.
iii. It is hereby expressly stipulated and declared that it shall be a condition precedent to any right of action or suit upon the policy
that award by such arbitrator/arbitrators of the amount of expenses shall be first obtained.

11 Renewal of policy
The policy may be renewed by mutual consent. The company is not bound to give notice that it is due for renewal. Renewal of the
policy cannot be denied other than on grounds of fraud, moral hazard, misrepresentation or noncooperation. In the event of break in
the policy a grace period of 30 (thirty) days is allowed. Coverage is not available during the grace period.

12 Revision of terms of the policy including the premium rates

The company, in future, may revise or modify the terms of the policy including the premium rates based on experience. The insured
person shall be notified three months before the changes are effected.

13 Withdrawal of product
In case the policy is withdrawn in future, the company will provide the option to the insured person to switch over to a similar policy
at terms and premium applicable to the new policy.

14 Free look period

The insured person is allowed a period of 15 (fifteen) days from date of receipt of policy to review the terms and conditions of the
policy, and to return the same if not acceptable.
If the insured person has exercised the option of free look period and has not made any claim during the free look period, the insured
person shall be entitled to-
i. a refund of the premium paid less any expenses incurred by the company on medical examination of the insured person and the
stamp duty charges; or
ii. where the risk has already commenced and the option of return of the policy is exercised by the insured person, a deduction
towards the proportionate risk premium for period on cover
The free look provision is not applicable to renewal of the policy.

Varistha Mediclaim for Senior Citizens UIN: IRDA/NL-HLT/NI/P-H/V.I/294/13-14

15 Redressal of grievance
In case of any grievance relating to servicing the policy, the insured person may submit in writing to the policy issuing office or
regional office for redressal. If the grievance remains unaddressed, insured person may contact Customer Relationship Management
Dept., National Insurance Company Limited, Chhabildas towers, 6A, Middleton Street, Kolkata - 700071.
If the insured person is not satisfied, the grievance may be referred to “Health Insurance Management Dept.”, National Insurance
Company Limited, 3 Middleton Street, Kolkata - 700071.

The insured person can also approach the office of Insurance Ombudsman of the respective area/region for redressal of grievance.

Premium:

Sum Insured Premium

60-65 years 66-70 years 71-75 years 76-80 years
Mediclaim 1,00,000 4180 5196 5568 6890
Critical Illness 2,00,000 2007 2130 2200 2288
TOTAL 6187 7326 7768 9178
Service Tax extra
Loading
The premium of 76-80 age band will be loaded by 10% for up to 85 (eighty five) years and by 20% for up to above 85 (eighty five)
years of age

i. For fresh entrants to National Insurance above premium will be loaded by 10%.

ii. Under Mediclaim Section (Section I), if the insured intends to cover pre-existing diseases of Hypertension and / or Diabetes
from the inception of the policy he / she has to pay additional premium @10% for either hypertension or diabetes & 20% for
hypertension & diabetes for first year of the policy. However, if a fresh entrant suffers from blood pressure / hypertension
and/or diabetes and opts for Critical Illness cover, the same may be covered at additional premium @10% for either
hypertension or diabetes & 20% for hypertension & diabetes provided no organ of the proposer is affected in consequence of
blood pressure and / or diabetes. If the medical report indicates occurrence of any such consequential complication, those
proposals will be declined.
Loading for preexisting Diabetes and / or Hypertension to be applied on Total Premium for first year and on Critical Illness
Premium only from 2nd year onwards.

iii. At the time of taking this policy, if a person suffers from any of the terminal diseases referred under Critical Illness cover
mentioned below, that particular disease will never be covered under Section II of this policy even on payment of additional
premium.

iv. Cover for Permanent paralysis of limbs and Blindness under Critical Illness:
Permanent paralysis of limbs and Blindness may be covered under Critical Illness by loading the Critical Illness premium
by 15% in each case or 25% in case of both covers together.

v. Under Group Policy, if the incurred claim ratio of the group exceeds 70% then the renewal premium will be loaded on 70%
as if basis i.e. if the incurred claim ratio of any policy year exceeds 70% renewal premium will be loaded in such a way that
the incurred claim ratio of expiring policy becomes 70%.

Varistha Mediclaim for Senior Citizens UIN: IRDA/NL-HLT/NI/P-H/V.I/294/13-14