Group Insurance 518 views May 28, 2021

National Group Mediclaim Policy

National Group Mediclaim Policy will cover the medical expenses of the insured members (employees). The policyholder (employer) can opt for additional coverage under this policy as per their choice. Read this page further and learn more about the coverage of the National Group Mediclaim Policy.

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National Group Mediclaim Policy Base Cover

Under this policy, the following medical expenses shall be covered –

  1. Room rent, boarding and nursing expenses
  2. Intensive care Unit (ICU) expenses
  3. Fees of surgeons and assistant surgeon, anesthetist, medical practitioner consultants, specialists
  4. Charges for administration, nebulization, RMO
  5. Cost of Oxygen, Blood, Operation Theatre Charges, surgical appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, Prosthetic devices implanted during surgical procedure l
  6. Organ transplant expenses excluding the cost of organ
  7. Pre and post-hospitalization medical expenses incurred 30 days before hospitalization and 90 days after the date of discharge from the hospital

National Group Mediclaim Policy Additional Cover

The policyholder can choose an additional cover from the following options

  1. Domiciliary Treatment Cover: If the insured requires a domiciliary treatment for an illness/injury as per the attending medical practitioner’s advice, 100% of the sum insured will be reimbursed.
  2. Domiciliary Hospitalization Cover: If the domiciliary medical treatment runs for at least 3 days for an illness/injury due to the poor condition of the patient or non-availability of room in a hospital, the insurer will cover such medical expenses.
  3. Alternative Treatment Cover: Under this, the insured will get coverage against Ayurveda, Unani, Siddha, Naturopathy and Homeopathy treatment for an illness/injury in a government hospital or any government-recognized institute.
  4. Maternity Expenses Cover: The insurer will cover the delivery of a child and medically necessary treatment and lawful medical termination of pregnancy during the policy year. The maximum coverage is INR 50,000 (Normal Delivery) and INR 75,000 (Caesarean Section)
  5. Baby Cover: Newborn baby cover starts from day one and all medical expenses that are incurred on the newborn baby during maternity will be covered up to INR 20,000 per child in addition to the maternity benefit.
  6. Ambulance Cover: The insurer will cover up to INR 2,500 per hospitalization, including transfer from one hospital to another or transfer from hospital to home if medically advised by the doctor. Under this cover, taxi and auto expenses shall be covered in actual, subject to a maximum of INR 750 per hospitalization.

Note: Ambulance charges incurred on transfer from one center to another due to non-availability of medical service shall be payable in full.

  1. Pre-existing Diseases Cover: If this additional cover is chosen by the policyholder, the pre-existing diseases/conditions shall be covered under this policy from day one.
  2. Congenital Anomalies Cover: Coverage for the treatment of congenital internal/external diseases, defects or anomalies will be provided to the insured.
  3. Psychiatric Diseases Cover: Treatment of psychiatric and psychosomatic diseases will be covered up to the sum insured.
  4. Advanced Medical Treatment Cover: All the approved medical procedures such as laser surgery, stem cell therapy shall be covered for an illness/injury both for in-patient hospitalization and daycare surgery.
  5. OPD Treatments Cover: Any medical treatment taken on an OPD basis shall be covered up to the sum insured for accidental hospitalization.
  6. Taxes & Other Charges Cover: All taxes, surcharges, service charges, registration charges, admission charges shall be covered under this additional cover. This cover includes charges for diapers and sanitary pads, if necessary during the treatment, nurse/attendant charges during hospitalization if recommended by the treating doctor.
  7. Treatment for Genetic Disorder & Stem Cell Therapy Cover: The insurer shall provide coverage for genetic disorder & stem cell therapy under this policy.
  8. Treatment for Age-related Macular Degeneration (ARMD) Cover: Rotational Field Quantum Magnetic Resonance (RFQMR), Enhanced External Counterpulsation (EECP) and related treatments are covered under this additional cover. scheme. The policy also covers treatments of all neurological/macular degenerative disorders.
  9. Rental Charges for External Medical Equipment: Any medical equipment used for diagnosis and treatment including CPAP, CAPD, Bi-PAP, Infusion pump and related equipment will be covered under this policy. However, the coverage under this benefit shall be provided on medical advice only.
  10. Ambulatory Devices: Under this, the insured will get coverage for walkers, crutches, belts, collars, caps, splints, braces, stockings, elastocrepe bandages, external orthopaedic pads, subcutaneous insulin pump, Diabetic footwear, Glucometer (including glucose test strips), Nebulizer, Prosthetic device, Thermometer, Alpha or water bed and such similar items.
  11. Physiotherapy Charges: The insurer shall cover physiotherapy charges if these are specified by the medical practitioner.

Note: All claims admitted in respect of any insured person shall not exceed the sum insured as stated in the policy schedule.

Exclusions from National Group Mediclaim Policy

The insurer is not liable to make any payment under this policy in respect of any of the following:

  1. Expenses related to any admission primarily for diagnostics and evaluation
  2. Rest Cure, Rehabilitation and Respite Care
  3. Change-of-Gender treatments
  4. Hospital stay if it is not medically necessary
  5. Self-inflicted injury or suicide.
  6. Birth control, Sterility and Infertility treatments
  7. Correction of eyesight due to refractive error < 7.5 dioptres
  8. Unproven treatments
  9. Drug/Alcohol abuse
  10. Non-Prescribed Drug
  11. Home Visit Charges
  12. Breach of Law
  13. War, invasion and similar operations
  14. Nuclear radiation/weapons/materials
  15. Circumcision unless necessary for treatment
  16. Vaccination or Inoculation
  17. Plastic surgery
  18. Cost of spectacles and contact lenses, hearing aids, other than Intraocular Lenses and Cochlear Implant
  19. Dental treatment
  20. Medical expenses arising out of Human T Cell Lymphotropic Virus Type III (HTLV – III) or Lymphadenopathy Associated Virus (LAV) or the Mutants Derivative or Variation Deficiency Syndrome or any syndrome of a similar kind commonly referred to as AIDS.
  21. All non-medical expenses including convenience items for personal comfort
  22. Critical illnesses diagnosed before the commencement of the policy
  23. Invalid bills/receipts/cash memos

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