Salient Features of Group Mediclaim Policy in General Insurance

General Insurance Group Mediclaim Policy is an insurance policy that covers a group of people, usually who are the members of societies, employees of a common employer, or professionals in a common group, it is not issued to any individual, and the Group Mediclaim Policy have some salient features.

Group Mediclaim Policy gives to any Group, Association, Company, Firm, Institutions and the group mediclaim policy gives for more than 50 members /families, above 50 persons or above are covered under one group policy.

The different category members are not covered under one group policy and all members should cover only in the same category type of members, so the different category members are not covered under one group policy, this policy has not issued to unauthorized groups.

As per IRDA rules the group policy gives to group/ Association/ Institution/Company only which is authorized.  In the group policy the schedule of names of the insured persons including his/her eligible family members.

FAMILY Means

• Self(Insured  person
• Legal spouse
• Dependent children(own children or legally adopted children)
• Dependent parents

If the girl child after 18 years got married at that time she is not covered and the claim is not admissible. The male child covered the age of 26 years if he is a regular student of recognized university the claim is payable.  The girl child can be covered still she got married.

The group mediclaim policy means reimburses of hospital expenses and/or domiciliary hospitalization expenses for illness/injury/diseases.  The claim may be payable only up to the sum insured limit.

• The hospital room expenses, boarding, nursing expenses as provided by the hospital/ nursing home not exceeding 1% of the sum insured or Rs. 5000/- per day whichever is less.
• Intensive care unit expenses are payable not exceeding 2% of sum insured or Rs. 10000/- per day whichever is less.
• The claim may be payable for surgeon fees, Anaesthetist fees, Medical practitioner fees, Consultants, specialist fee.
• Anesthesia, oxygen, operation theatre charges, surgical appliances, medicines & drugs, dialysis, chemotheropy, radiotherapy, artificial limbs, cost of prosthetic devices implantation during surgical procedure like pacemaker, relevant laboratory/ diagnostic test, x-ray etc covered in mediclaim policy.
• Ambulance services also covered upto 1% of sum insured or Rs. 2000/- whichever is less.

Hospitalization benefit:

Hospitalization benefit means the insured person person taken a medical treatment in recognized hospital  above 3 three days as a in-patient called hospitalization. But the domiciliary hospitalization is not covered under this policy.  The insured have no home in the hospital area at that time the patient not removed in the hospital the claim is not covered and it is declared as domiciliary hospitalization. Expenses incurred for pre-hospitalization and post hospitalization.  The hospitalization expenses incurred for treatment for any of the following dieases

1. Asthma

2. Bronchitis

3. Chronic Nephritis and 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

Pre-Hospitalisation

The medical expenses can be paid during the period of 30 days prior to hospitalization on disease/illness/injury considered as part of the claim.

Post-Hospitalisation
 The post hospitalization means the medical expenses paid for the period of 60 days after the hospitalization  on disease/illness/injury was considered aas part of the claim.

Medical Practioner
The medical practitioner means a person who have a degree/ diploma from the recognised university and registered by the medical council of any state of India.  The medical practiotioner means physician or surgeon or specialist.

Qualified Nurse
 The qualified nurse means who have a original certificate of a recognized university or nursing council called qualified nurse.

Pre Existing Diseases

Pre existing diseases means any illness/disease/injury the insured person suffering from( he is already treated/or non-treated and declared or not declared in the proposal form of the insurance company) when taking a policy for first time. After the insurance any other complications arising from pre-existing disease/injury is not covered to the insured and it is considered as pre existing disease.

In-Patient

In-patient means the insured person whoi is admitted in the hospital at least 24 hours for the medicla treatment to illness/accident/injury/ disease during the policy period.

Reasonable and Customary Expenses
The reasonable and customary expenses means the surgical and medical expenses with in the scope of treatment when the insured person was hospitalized.

These are all group mediclaim salient features of Group Mediclaim Policy in General Insurance Sector. The  Policy Terms and Conditions are altered only by the insurance companies.