Training College
Bhopal region Office
● Health Insurance
● Type of Health Insurance Policy
● Structure of Mediclaim Policies
● New India Mediclaim Policies
● Portability & Migration
● U/W Mediclaim Policy
● IRDA Initiatives
Health Insurance
Health Insurance is a type of insurance that safeguards you and
your family against medical expenses that arise due to an
accident, illness or critical disease.
Most health insurance policies come with benefits like cashless
treatment, coverage for pre and post-hospitalisation expenses,
ambulance cover, etc.
Type of Health Insurance policies
● Individual health Insurance Policies
● Family Floater
● Senior Citizen Mediclaim Policy
● Critical Illness Cover
● Overseas Mediclaim Policy
● Tailer Made Group Mediclaim Policies
NEW INDIA ASSURANCE MEDICLAIM POLCIES
1. New India Mediclaim Policy
2. New India Floater Mediclaim
3. New India Top Up Mediclaim
4. New India Asha Kiran Policy
5. New India Cancer Guard Policy
6. New India Premier Mediclaim Policy
7. Senior Citizen Mediclaim
8. New India Sixty Plus Mediclaim Policy
9. Arogya Sanjeevani Policy
10.Corona Kavach Mediclaim
HEALTH INSURANCE POLICY STRUCTURE
01 SECTION I - WHAT WE COVER
02 SECTION II – DEFINITIONS
SECTION III - HOW MUCH WE WILL
03 REIMBURSE
04 SECTION IV - EXCLUSIONS
SECTION V -CONDITIONS
05
SEC-I :WHAT WE COVER
Hospitalisation Expenses which are Reasonable and
Customary, and Medically Necessary for treatment of any
Illness or Injury, We will reimburse such expense incurred by
You, through the Third Party Administrator, in the manner
stated herein.
MEDICLAIM POLICIES ARE INDEMNITY BASED POLICIES.
SECTION -II DEFINITIONS
2.14 CUMULATIVE BONUS means any increase or addition in
the Sum Insured granted by the insurer without an
associated increase in premium.
2.20 DOMICILIARY HOSPITALISATION means medical
treatment for an Illness/Injury which in the normal course
would require care and treatment at a Hospital but is actually
taken while confined at home .
2.22 GRACE PERIOD Grace Period is a specified time after
policy due date during which policy can be renewed without
losing continuity benefits, such as waiting period and
coverage of pre-existing diseases.
SECTION-III: HOW MUCH WE WILL
REIMBURSE
3.1 Our liability for all claims admitted during the Period of
Insurance will be only up to Sum Insured for which the
Insured Person is covered as mentioned in the Schedule.
Subject to this,
3.1 (a) Room rent, Boarding Charges, Nursing not exceeding 1% of the Sum Insured per day
3.1 (b) Intensive Care Unit (ICU)/ Intensive Cardiac Care Unit (ICCU), Intensivist charges, Monitor and
Pulse Oxymeter expenses not exceeding 2% of the Sum Insured per day.
3.1 (c) Associate Medical Expenses; such as Professional fees of Surgeon, Anaesthetist,
Consultant, Specialist; Anaesthesia, Blood, Oxygen, Operating Theatre Charges and
Procedure Charges such as Dialysis, Chemotherapy, Radiotherapy & similar medical
expenses related to the treatment.
3.1 (d) Cost of Pharmacy and Consumables, Cost of Implants and Medical Devices and Cost of
Diagnostics.
3.1 (e) Pre-Hospitalization Medical expenses
3.1 (f) Post-Hospitalization Medical expenses
3.2 PROPORTIONATE DEDUCTION
3.3 LIMIT ON PAYMENT FOR CATARACT:
3.4 TREATMENTS UNDER AYURVEDIC / HOMEOPATHIC /
UNANI SYSTEMS
3.5 HOSPITAL CASH : (0.1% of the Sum Insured, for each day
of Hospitalisation admissible under the Policy. The payment
under this Clause for Any One Illness shall not exceed 1% of
the Sum Insured.)
3.6 ADDITIONAL BENEFIT - HEALTH CHECK-UP (Rs. 5,000
or 1% of the average Sum Insured of the Insured Person in the
preceding three years, whichever is less)
3.7 PAYMENT OF AMBULANCE CHARGES
3.8 PAYMENTS ONLY IF INCLUDED IN HOSPITAL BILL (No
payment shall be made for any Hospitalisation expenses
3.13 OPTIONAL COVER I: NO PROPORTIONATE DEDUCTION
3.14 OPTIONAL COVER II: MATERNITY EXPENSES BENEFIT
3.15 OPTIONAL COVER III: REVISION IN LIMIT OF CATARACT
3.16 OPTIONAL COVER IV: VOLUNTARY CO-PAY
3.17 CUMULATIVE BONUS : The Sum Insured under Policy shall be increased
by 25% at each renewal in respect of each claim free year of insurance, subject
to maximum of 50%. If a claim is made in any particular year; the cumulative
bonus accrued may be reduced at the same rate at which it is accrued.
3.20 TREATMENT FOR CONGENITAL DISEASES
Congenital Internal Disease or Defects or anomalies shall be covered after
twenty-four months of Continuous Coverage.
Congenital External Disease or Defects or anomalies shall be covered after
thirty-six months of Continuous Coverage, but such cover for Congenital
External Disease or Defects or anomalies shall be limited to 10% of the
average Sum Insured in the preceding four years.
SECTION IV: EXCLUSIONS UNDER POLICY
4.1 PRE-EXISTING DISEASES
4.2 SPECIFIC WAITING PERIOD: Expenses related to the treatment of the following listed conditions, surgeries /
treatments shall be excluded until the expiry of Ninety Days / 24 / 48 months of continuous coverage.
4.3 FIRST THIRTY DAYS WAITING PERIOD (Code- Excl03)
1. Joint Replacement due to
4. Cataract and age related eye Degenerative Condition
ailments 2. Age-related Osteoarthritis &
7. Hernia of all types Osteoporosis
1. Diabetes Mellitus 8. Hydrocele 3. Treatment of mental illness,
2. Hypertension 10. Piles, Fissures and Fistula in stress or psychological disorders
3. Cardiac anus and neurodegenerative disorders.
Conditions 11. Pilonidal sinus, Sinusitis and 4. Age Related Macular
related disorders Degeneration (ARMD)
14. Stone in Gall Bladder 5. Genetic diseases or disorders
15. Stones in Urinary system
● (ii) 24 Months waiting
period
● (i) 90 Days Waiting
Period ● (iii) 48 Months waiting
period
4.4 EXCLUSIONS
4.4.1 INVESTIGATION & EVALUATION (Code- Excl04)
4.4.2 REST CURE, REHABILITATION AND RESPITE CARE
4.4.3 OBESITY/ WEIGHT CONTROL (Code- Excl06)
Expenses related to the surgical treatment of obesity that does
not fulfil all the below conditions:
a. Surgery to be conducted is upon the advice of the Doctor
b. The surgery/Procedure conducted should be
supported by clinical protocols
SECTION V : CONDITIONS :
It includes the conditions for Policy renewal ,Cancellation ,
Sum Insured Enhancement , claim Intimation , document
submission , Portability and Migration,CB , Free Look Up
Period etc for the policy.
NEW INDIA MEDICLAIM POLICY
ENTRY AGE : 18-65
SUM INSURED : Rs. 1/ 2/ 3/ 5/ 8/ 10/ 12/ 15 lakhs
ROM RENT : 1% & 2%
Pre & POST Hospitalisation : 30 & 60 DAYS
CB : MAXIMUM UPTO 50% OF SI
Free Health Check-up : AFTER EVERY 3 CLAIM FREE YEARS
Rs. 5000 or 1% of average sum insured, whichever is less.
AMBULACE CHARGES : 1% OF SUM INSURED
AYUSH TREATMENT : 25% OF SUM INSURED
HOSPITAL CASH : 0.1 % OF SUM INSURED /DAY MAXIMUM
New India Floater Mediclaim Policy
SALIENT FEATURES :
Critical Care Benefit - 10% of the Sum Insured.
FLOATER DISCOUNT : 2 MEMBER 5% , 3 MEMBER 10% & 4
AND ABOVE 15%
ENTRY AGE : 18-65
SUM INSURED : Rs. 1/ 2/ 3/ 5/ 8/ 10/ 12/ 15 lakhs
ROM RENT : 1% & 2%
Pre & Hospitalisation : 30 & 60 DAYS
New India TOP-UP Mediclaim Policy
Top up Mediclaim Policy provide Mediclaim coverage beyond a
predefined Threshold limit . This threshold limit can be met by a
health insurance Policy or by self-funding also. However, it is not
mandatory to have a base policy to buy a Top-Up Mediclaim
Policy
SALIENT FEATURES :
ENTRY AGE : 18-65
SUM INSURED OPTIONS: Rs 5/ 10/ 15 lakhs for threshold of Rs
5 lakhs (CAN BE TAKEN ON FLOATER BASIS )
Rs 7/ 12/ 17/ 22 lakhs for threshold of Rs 8 lakhs
New India TOP-UP Mediclaim Policy
1. Room rent charges, maximum of Rs. 5,000/- and Rs. 8,000/- for threshold of 5 & 8
Lakhs respectively.
2. ICU charges, maximum of Rs. 10,000/- and Rs. 16,000/- for threshold of 5 & 8 Lakhs
respectively.
3. Get well benefit of Rs. 5,000/- and Rs. 8,000/- for threshold of 5 & 8 Lakhs
respectively.
4. Cataract for each eye is up to Rs. 50,000/-
5. Hospital cash of Rs. 500/- and Rs. 800/- for threshold of 5 & 8 Lakhs respectively
maximum for 10 days.
6. Ayush Expenses are covered.
7. Pre Existing Diseases waiting period is 48 Months and for specified diseases waiting
period is 24 months.
8. Ambulance charges of up to Rs. 5,000/- and Rs. 8,000/- for threshold of 5 & 8 Lakhs
respectively.
New India Asha Kiran Policy
New India Asha Kiran Policy is designed to the parents with ONLY girl children, Maximum of TWO dependent daughters can be covered under this
policy.
SUM INSURED OPTIONS AVAILABKE : Rs 2/ 3/ 5/ 8 lakh
I .50% Discount on the premium for Girl Children.
ii. Critical Care Benefit - 10% of the Sum Insured.
iii. Personal Accident Cover up to 100% of Sum Insured.
iv. Room rent and ICU Charges at 1% and 2% of Sum Insured per day respectively.
v. Hospital Cash up to 1% of Sum Insured.
vi. Ambulance charges up to 1% of Sum Insured.
vii. Cataract claims, up to 10% of Sum Insured or Rs. 50,000 whichever less, for each eye.
viii. Ayurvedic / Homeopathic / Unani treatments are covered, up to 25% of the Sum Insured.
ix. Pre Existing Diseases has a Waiting period of 48 Months.
x. Specified diseases has a waiting period of 24 months.
xi. The Policy covers treatment only in India. Even within India, if premium is paid for lower zone and treatment taken in higher zone, our
liability towards any claim will be
a) 80% of admissible claim amount (or)
b) Sum Insured Whichever is less.
New India Sixty Plus Mediclaim Policy
1. Sum Insured: 2,3 & 5 Lakhs.
2. Entry age for the policy is 60-80 Years.
3. Attendant benefit of maximum of Rs. 800/day or actuals whichever is less, up to Rs. 5,000/-, Rs. 7,000/- & Rs. 10,000/- per
hospitalization for 2,3 & 5 Lakhs Sum Insured respectively.
4. Co-Pay of 10% is mandatory. For an additional co-pay of extra 10% i.e. for the total co-pay of 20% a discounted premium will
be charged.
5. If only single women senior citizen gets covered under the policy, then a discount of 5% will be given on the primary member’s
premium.
6. Children can take the Policy for their Parents for availing higher tax benefit under 80D for senior citizens.
7. At least one of the covered member should be a senior citizen i.e for example, If the Husband (Primary Member) is of 61
Years and Spouse is 55 Years, they both can be covered in this Policy.
8. Pre & Post Hospitalization expenses of 30 days, 60 days respectively subject to the maximum limit of 10% of the Sum
Insured
9. No accrual of fresh Cumulative Bonus(CB) under the New India Sixty Plus Mediclaim Policy, however the accrued CB, if
any, from the migrating policies can be carried over as CB Buffer.
10. In the event of unfortunate death of one of the insured, the other person can continue under the policy even if he/she is below
60years of age. In case the remaining person covered in the policy is female, she will become the primary member and will be
entitled for a discount of 5% as stated in point 5.
11. For fresh policies Health Checkup is Mandatory. If the proposal is accepted, then 50% of the cost of medical checkup will be
reimbursed.
Corona Kavach Policy
1. Sum insured from 50,000 to Rs. 5,00,000 in multiples of
Rs.50000.
2. Entry age – Day 1 to 65 years.
3. Policy can be taken on either individual or floater basis.
4. Policy triggers on positive diagnosis of COVID 19 as per Govt
mandates.
5. Minimum hospitalization of 24 hours mandatory.
6. Pre hospitalization – 15 days.
7. Post hospitalization – 30 days.
8. Ambulance charges – Rs.2000.
9. Room rent/ICU – No limit.
10. No proportionate deductions.
11. Policy period – 3 1/2 months (105 days), 6 1/2 ( 195 days), 9 1/2 months(285 days).
12. No free look period under the policy.
13. AYUSH – no sub limits.
14. Home Care Treatment– payable upto maximum of 14 days per incident.
15. Waiting period – 15 days.
16. Cover includes treatment for any co-morbid conditions also.
17. Lifelong renewal/Migration and portability clauses are
not applicable.
18. No instalment facility. Single premium.
19. Loading of 30% is applicable for persons suffering with any of the Co-Morbidities
20. Discount of 5% shall be given to Females.
21. Optional cover – Hospital cash of 0.5% maximum 15 days. – 15% loading on the premium.
Arogya Sanjeevani
1. Sum insured is from Rs 1 lac to Rs. 5 lacs in multiples of
Rs.50000.
2. The policy can be taken either on Individual or Floater Sum
Insured basis.
3. No Pre-Acceptance Medical Checkup.
4. Installment Facility : Monthly /QUARTERLY/HALF
YEARLY
5. Room rent is upto 2% of the sum insured subject to a
maximum of Rs.5000. ICU/ICCU will be upto 5% of the sum
insured subject to a maximum of Rs.10000.
6. Dependent spouse, children, parents and parents in law can
be covered under the policy.
7. Cataract surgeries will be paid upto 25% of sum insured
subject to a maximum or Rs.40000.
8. Ayush treatments will be paid upto the sum insured.
9. Treatments towards HIV, Mental Illness and Genetic
disorders are also payable under the policy.
10. Cumulative bonus is available @5% per every claim
free year upto a maximum of 50%.
11. A loading @ 5% per pre-existing life style diseases like
hypertension, diabetes and BMI >32.
12. Co-pay of 5% on each and every claim.
MIGRATION & PORTABILITY
IRDA/NEWINDIA GUIDELINE FOR MEDICLAIM
Thank You
