National Group Health Insurance

National Group Health Insurance provides financial protection to the employees of an organization/company. This group mediclaim policy is available to any Group/Association/ Institution/Corporate Body of more than 50 persons/families, provided the group has a central administration point. Each employee is an eligible insured member under this group policy. Keep reading this post and know more about the National Group Health Insurance coverage.

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National Group Health Insurance Base Cover

The insurer shall pay for the following medical expenses incurred during the policy term:

  1. Room, Boarding and Nursing Expenses covered up to 1 % of the sum insured or INR 5,000 per day, whichever is less.
  2. ICU charges up to 2% of the sum insured or INR 10,000 per day, whichever is less.
  3. Fees of Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists
  4. Cost of Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, Cost of Prosthetic devices implanted during surgical procedure like a pacemaker
  5. Relevant laboratory/diagnostic test, X-Ray, etc. prescribed by the attending medical practitioner
  6. Ambulance service charges up to 1% of the sum insured or INR 2,000, whichever is less.
  7. Domiciliary hospitalization
  8. Pre-hospitalization expenses up to 30 days
  9. Post-hospitalization expenses up to 60 days

The insured person can avail of the cashless facility at the Network Hospital through the appointed TPAs of the insurance company. At network hospitals, a discount of 5% will be given on the scheduled premium. Expenses on hospitalization are admissible only if the insured is hospitalized for a minimum of 24 hours, except in cases of specialized treatment as mentioned below:

  1. Hemodialysis
  2. Parenteral Chemotherapy
  3. Radiotherapy
  4. Eye Surgery
  5. Lithotripsy (kidney stone removal)
  6. Tonsillectomy
  7. D&C
  8. Dental surgery occurring due to an accident
  9. Hysterectomy
  10. Coronary Angioplasty
  11. Coronary Angiography
  12. Surgery of Gallbladder, Pancreas and bile duct
  13. Surgery of Hernia
  14. Surgery of Hydrocele
  15. Surgery of Prostate
  16. Gastrointestinal Surgery
  17. Genital Surgery
  18. Surgery of Nose.
  19. Surgery of throat.
  20. Surgery of Appendix.
  21. Surgery of Urinary System.
  22. Treatment of fractures/dislocation excluding hairline fracture, Contracture releases and minor reconstructive procedures of limbs which otherwise require hospitalization.
  23. Arthroscopic Knee surgery
  24. Laparoscopic therapeutic surgeries
  25. Any surgery under General Anaesthesia
  26. Any such disease/procedure agreed by TPA/Company before treatment

Maternity Expenses & Newborn Child Cover Benefit Extension

This optional coverage can be obtained by the employer under this policy on payment of 10% of the total basic premium. Maternity Expenses and Newborn Child Cover Benefit Extension can be added to this policy at the time of inception, and in case of cancellation, no refund is allowable under this optional cover. Insured persons who already have two or more living children are not eligible for this benefit. The maximum benefit allowable under this cover will be restricted to INR 50,000.

Conditions Applicable to Maternity Expenses & Newborn Child Cover Benefit Extension

  1. Maternity expenses are covered under this policy if the treatment is taken in a hospital/nursing home as an in-patient in India.
  2. A waiting period of 9 months shall apply to this cover. However, it may be relaxed in case of delivery, miscarriage or abortion due to an accident or other medical emergency.
  3. Voluntary medical termination of pregnancy during the first 12 weeks from the date of conception is not covered.
  4. Pre and post-natal expenses are not covered unless the insured is admitted to a Hospital/nursing home
  5. Pre and post-hospitalization benefits are not available under this cover.
  6. The newborn child shall be covered from Day 1 up to the age of 3 months
  7. Congenital diseases of newborn children shall be excluded under this cover.

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