Group Insurance 227 views May 12, 2021

HDFC ERGO Group Assurance Health Plan covers employees of an organization against medical expenses. The policy will cover hospitalization expenses, pre and post-hospitalization expenses, etc. Read this page further and learn more about the coverage and terms and conditions of the HDFC ERGO Group Assurance Health Plan.

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HDFC ERGO Group Assurance Health Plan Coverage

If you are hospitalized due to sickness or accidents, the policy will cover the following medical expenses –

  1. Room rent, boarding and nursing expenses
  2. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialist Fees
  3. Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines and Drugs, Diagnostic Materials and X-Ray, dialysis, Chemotherapy

The policy also covers –

  1. Pre and post-hospitalization medical expenses up to 30 days before the date of admission and up to 60 days post-discharge from the hospital.
  2. Ambulance charges up to INR 2,000 per hospitalization only on emergency hospitalization.
  3. Domiciliary hospitalization expenses
  4. Day Care treatments

Exclusions from HDFC ERGO Group Assurance Health Plan

The medical expenses are not admissible for the claim if they arise due to the following –

  1. War, invasion, an act of a foreign enemy, civil war and similar situations
  2. Breach of law
  3. Intentional self-injury or attempted suicide
  4. Participation in hazardous or adventure sports

The policy won’t cover the following medical expenses –

  1. Expenses incurred during admission for diagnostic and evaluation
  2. Any diagnostic expenses not related to your current diagnosis and treatment
  3. Rest Cure, rehabilitation and respite care
  4. Obesity treatment or other weight control programs
  5. Gender change treatments
  6. Cosmetic or plastic surgery unless it is part of the illness or injury treatment
  7. Treatment for alcoholism or drug abuse
  8. Treatment in any hospital or by any Medical Practitioner which has been specially excluded
  9. Treatments in health hydros, nature cure clinics, spas or similar establishments
  10. Unprescribed dietary supplements and substances
  11. Treatment for correction of eyesight due to refractive error < 7.5 dioptres
  12. Unproven treatments
  13. Sterility and infertility treatments
  14. Maternity treatments and related medical expenses
  15. Treatment of sleep-apnoea, general debility or exhaustion
  16. Congenital external diseases/defects/anomalies
  17. Stem cell harvesting
  18. Circumcision unless it is a part of the illness or injury treatment
  19. Sanatorium treatment
  20. Private duty nursing or long-term nursing care
  21. Preventive care and other nutritional and electrolyte supplements, unless certified necessary by the attending Medical Practitioner
  22. Vaccination, inoculation and immunizations (except post animal bite treatment)
  23. Non-Medical expenses such as food charges, laundry charges, etc.
  24. Outpatient treatment
  25. Cost of hearing aids, spectacles or contact lenses.
  26. Treatment and associated expenses for alopecia, baldness including corticosteroids and topical immunotherapy wigs, toupees, hairpieces, nonsurgical hair replacement methods, Optometric therapy.
  27. Expenses for artificial limbs and device used for diagnosis or treatment
  28. Non-allopathic treatments

Claim Process

You can claim the policy benefit by intimating the insurer/TPA about the hospitalization before 48 hours of a planned admission and within 24 hours in case of emergency admission. After that, provide the following documents to the insurer –

  1. Duly completed and signed claim form
  2. Original Bills
  3. All medical reports and records, including case histories, indoor case papers, investigation reports, treatment papers, discharge summaries
  4. A precise diagnosis of the treatment for which a claim is made
  5. A detailed list of individual medical services and treatments
  6. Prescriptions of drugs with the corresponding doctor’s invoice
  7. All pre and post-investigation, treatment and follow up consultation records related to the current ailment
  8. All investigation, treatment and follow up records of the previous ailment related to the claim
  9. Treating doctor’s certificate
  10. Stickers and invoice of implants (in case of surgery)
  11. Copy of Medico-legal case (MLC) and First information report (FIR), in case of an accident
  12. NEFT and KYC details
  13. Legal heir certificate

You need to undergo a medical examination by the insurer’s authorized Medical Practitioner if required for the claim processing. The insurer will bear the cost of such medical examinations.

Moratorium Period

There is a moratorium period of 8 years, and it would apply to the base sum insured and enhanced sum insured. After the expiry of the moratorium period, no health insurance claims are contestable except those which are proven fraud and come under permanent exclusions as specified above.

Note – The moratorium period shall apply to the enhanced limits in case of the enhanced sum insured.

Free Look Period

A free look period of fifteen days starts from the date of receipt of the policy document during which the policyholder can review the terms and conditions of the policy and return the same if not acceptable. The policyholder is entitled to a refund of the paid premiums less any expenses incurred on medical examination and the stamp duty charges. If the risk has already commenced, a deduction towards the proportionate risk premium for the period on the cover will be provided. Whereas if only a part of the insurance coverage has commenced, the company will refund such proportionate premium commensurate with the insurance coverage.

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