Benefits of Care Group Health Insurance
There are several benefits of Care group health insurance policy. Care group health insurance offers two plans and their benefits are mentioned in the table below.
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Benefits
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Plan 1
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Plan 2
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In-patient Care (Medical Expenses Cover)
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Covered up to SI
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Covered up to SI
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Day-care treatment
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Covered up to SI
|
Covered up to SI
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|
Room rent Limit and ICU limit (respectively)
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One percent & two percent of SI
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Two percent & four percent of SI
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|
Waiting period
· 30 days, Second-year exclusion
· Pre-existing diseases
|
Waived off
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Waived off
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Pre-hospitalization & Post Hospitalization medical expenses
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30 days and 60 days respectively
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30 days and 60 days respectively
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Domestic road ambulance
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Rs. 1000
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Rs. 2500
|
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Maternity expenses delivery
(9 month waiting period in respect of maternity claims waived off)
|
25000 for normal and 35000 for LSCS first two living children only
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35000 for normal and 50000 for LSCS first two living children only
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|
Pre Natal and Post Natat
(for a period of 30 days)
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Rs. 2500 part of maternity limit
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Rs. 5000 part of maternity limit
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Inclusions of Care Group Health Insurance
If the policyholder is diagnosed with illness or suffers an injury during the policy tenure. The policy will provide cover for the following:
- In-patient Care: The medical charges incurred during the hospitalization of the insured on the written advice of a medical practitioner are indemnified.
- Day Care Treatment: The medical expenses incurred during the daycare treatment at a daycare centre or hospital on the written advice of a medical practitioner are indemnified.
The maximum, total and cumulative liability for the insured person while raising any claim incurred under the policy tenure will not exceed the sum insured amount.
- Sum-limit on Room Rent: If the room rent incurred is higher than the 1% of the SI per day then the insured person will have to bear the extra charges of the medical expenses.
- Sub-Limit on ICU charges: If the charges incurred are higher than than the ICU charges limit of 2% of SI per day then the insured member will have to bear the extra charges of the medical expenses.
Exclusions of Care Group Health Insurance
Care group health insurance policy does not provide cover for the following:
- Waiting period: Claim raised for any Medical Expenses incurred for treatment of any kind of illness in the starting 30 days of the cover tenure will not be admissible. The medical expenses incurred due to an injury will be covered.
- Specified Waiting period: For the starting 24 months, no claims raised by the insured will be admissible for the following illnesses or surgical procedures.
- The policy does not cover for Non infective Arthiritis, Osteoarthritis and Osteoporosis.
- The policy does not cover for Gout and Rheumatism
- Spinal disorders are not covered.
- The policy does not cover for Joint replacement Surgery.
- ENT disorders and surgeries are not covered.
- The policy does not provide cover for nasal septum deviation.
- Sinusitis and related disorders are not covered.
- The policy does not provide cover for Benign Prostatic Hypertrophy.
- Cataract, Dilatation and Curettage are not covered under this policy.
- The policy does not provide cover for Fissure/Fistula in anus.
- The policy does not provide cover for Hemorrhoids/Piles.
- The policy does not provide cover for Pilonidal Sinus.
- Gastric and Duodenal Ulcers are not covered.
- Genito urinary system surgery is not covered.
- The policy does not cover any kind of Hernia or Hydrocele.
- The policy does not cover for Hysterectomy for menorrhagia, fibromyoma.
- The policy does not provide cover for any Internal tumors and skin tumours.
- The policy does not provide cover for cysts and nodules.
- Polyps and Breast lumps (each of any kind) unless malignant are not covered under the policy.
- Kidney Stone and Ureteric Stone are not covered under the policy.
- The policy does not cover for Gall bladder Stone and Lithotripsy
- Varicose veins and varicose ulcers are not covered under this policy.
- Pre-existing diseases:If the policyholder suffers from any of the illnesses mentioned above, he will not be provided coverage under the policy.
Care Group Health Insurance Claim Procedure
To avail of the cashless claim, the insured has to follow the procedure mentioned below:
- Cashless Claim: The policy will provide cashless facility only at the network providers. The insured will have to provide a valid photo identification document (like: Voter ID card / Driving License /Passport / PAN Card / any other identification documentation as approved by insurance company).
- Reimbursement:
- At least 48 hours before the commencement of a planned hospitalization, the insured will have to tell the insurance company about it or within 24 hours of admission to Hospital if the Hospitalization is required in an Emergency.
- All the documents and information should be submitted to the insurance company immediately an in any event within 15 days of insured person discharges from the hospital after the treatment is done.
Documents Required During Claim
The policyholder will have to provide following document and informations to the insurance company while raising the claim.
- The form should be filled properly
- Written letter by the doctor that advised for hospitalization
- Doctor’s prescription that advised medicines, test.
- Bill provided by the hospital, discharge card from the doctor.
- Bill from the medical store.
- Original test reports and payment receipts.
- Case papers and documents.
- FIR/ final police report, if required
- Post mortem report, if conducted
- Any other document as required by the insurance company or TPA to assess the Claim.
- The insurance company will accept properly verified photocopies of the documents attested by insurance company or reimbursement provider submitted along with original payment certificate.
- The insurane company is liable to accept the bills/invoice that are made in the policyholder’s name.
- The insurenace company will entertain the delay only when the reason of delay is beyond control of the policyholder.
