Health Insurance 1677 views August 31, 2020

New India Janata Mediclaim Policy

Health is important to everyone and what if an unknown illness strikes you when the financial situation isn’t good for you? Don’t worry, with the help of the New India Janata Mediclaim Policy, you can get coverage for illness or injury. The policy will cover the hospitalization expenses of the insured person. All you need to do is to inform the insurance company or the Third Party Administrator (TPA) before the hospitalization. So they can track the network hospital for your treatment. To claim your New India Janata Mediclaim Policy, you just need to submit the detailed list of bills. Read this page below to know the policy features and coverage range for your hospitalization.

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Expenses Covered Under the New India Janata Mediclaim Policy

  1. The policy covers the cost of treatment taken in the General Ward of a Hospital or Day-Care Centre for a maximum of INR 450 per day.
  2. Intensive Care Unit (ICU) and Intensive Cardiac Care Unit (ICCU) expenses if the insured has undergone a surgery
  3. Surgeon, Anaesthetist, Medical Practitioner, Consultant, or Specialist fees.

Expenses of Items or Equipment Used During Hospitalization

  1. Anesthesia
  2. Blood
  3. Oxygen
  4. Operation Theatre (OT) Charges
  5. Surgical Appliances
  6. Medicines & Drugs
  7. Dialysis
  8. Chemotherapy
  9. Radiotherapy
  10. Artificial Limbs
  11. Cost of Prosthetic devices implanted during surgical procedures

Pre-Hospitalisation Medical Expenses 

Before you get admitted to the hospital, the insurance company will pay the expenses of the doctor consultant fee, tests and prescribed medications for up to 30 days. This is the pre-hospitalization period.

Hospitalisation Medical Expenses

When the pre-hospitalization period ends, you get admitted to the hospital on the advice of the doctor. The date on which you get admitted and the date on which you get discharged is the hospitalization period. The insurance company will cover the expenses for up to 60 days, subject to a maximum of 10% of the hospital bill as mentioned in the receipt.

AYUSH Treatment

The expenses incurred from an Ayurvedic, Homeopathic, or Unani Treatment are covered up to 25% of the Sum Insured. But the claim is valid if the treatment for illness or injury is performed in a government hospital or an institute recognized by the government.

Ambulance Services on New India Janata Mediclaim Policy

Actual expenses of patient transportation are insured up to INR 1000 if a patient has to be shifted from his home to Hospital or from one Hospital to another Hospital in an equipped ambulance for better medical facilities.

List of Specified Illness Covered Under the New India Janata Mediclaim Policy

  1. Cataract with an imported foldable lens for which the insurance company offers coverage up to INR 10,800 including all the expenses – room rent, doctor fee, treatment expense, etc.
  2. Hysterectomy surgery within the limit of INR 22,500
  3. Appendicectomy coverage of INR 16,200
  4. Cholecystectomy capped at INR 18,000
  5. Transurethral Resection of the Prostate (TURP) surgery up to INR 18,000
  6. Hernia-Inguinal for upto INR 16,200
  7. Hernia- Ventral or Incisional for upto INR 19,800
  8. Septoplasty at a maximum of INR 9,000
  9. Haemorrhoidectomy surgery capped at INR 8,100
  10. Fissurectomy surgery for INR 9,000
  11. Fistulectomy for INR 10,800
  12. Angiography surgery is capped for INR 12,000
  13. Angioplasty (imported stent single) is covered up to its actual expenses or up to the Sum Insured, whichever is less
  14. Coronary Artery Bypass Grafting (CABG) is covered up to its actual expenses or up to the Sum Insured, whichever is less
  15. Total Knee replacement is covered up to its actual expenses or up to the Sum Insured, whichever is less
  16. Total hip replacement is covered up to its actual expenses or up to the Sum Insured, whichever is less
  17. Tonsillectomy surgery covered up to INR 7,200/-
  18. Tympanoplasty cover capped upto INR 13,500
  19. Kidney stone or lithotripsy surgery covered up to INR 13,500
  20. Arthroscopy covered up to INR 10,800
  21. PID-Discectomy covered upto INR 31,500
  22. Mastectomy(Radical) surgery covered upto INR 36,000
  23. Exploratory Laparotomy surgery between INR 13,500 to 27,000

Pre-Existing Illness Benefits on New India Janata Mediclaim Policy

As per the terms and conditions of the policy, the cover won’t be available for pre-existing illnesses for up to 48 months since the date of inception. The exclusion of pre-existing diseases will be removed after 4 consecutive claim-free policy years. On the payment of your additional premium, which is compulsory for an insured person suffering from pre-existing diseases such as Diabetes and Hypertension gets covered in the following manner.

  1. No claim in the 1st year of the policy
  2. No claim in the anniversary year
  3. 50% of an admissible claim or the sum insured, whichever is less from the 3rd year onward
  4. 75% of an admissible claim or the sum insured, whichever is less from the 4th year onward
  5. And 100% admissible claim or sum insured from the 5th year onward

Diseases, Ailments, or Surgeries Not Covered under the New India Janata Mediclaim Policy

  1. Any skin disorder
  2. All internal & external benign tumors, cysts, polyps of any kind, including benign breast lumps
  3. Benign Ear, Nose and Throat disorders
  4. Benign Prostate Hypertrophy surgery
  5. Cataract & age-related eye ailments
  6. Diabetes Mellitus
  7. Gastric or Duodenal Ulcer
  8. Gout & Rheumatism
  9. Hernia of all types
  10. Hydrocele
  11. Hypertension
  12. Hysterectomy for Menorrhagia/Fibromyoma, Myomectomy, and Prolapse of the uterus
  13. Non-Infective Arthritis
  14. Piles, Fissure and Fistula in Anus
  15. Pilonidal Sinus, Sinusitis and related disorders
  16. Prolapsed Intervertebral Disc unless arising from Accident
  17. Stone in Gall Bladder & Bile duct
  18. Stones in Urinary Systems
  19. Unknown Congenital internal disease/defects
  20. Varicose Veins and Varicose Ulcers
  21. Age-related Osteoarthritis & Osteoporosis
  22. Joint Replacements due to Degenerative Condition

Note: These exclusions are for the duration of 2 to 4 years, only after that, the cover will be given.

Permanent Exclusions from the New India Janata Mediclaim Policy

There are a few treatments, illnesses, or surgery that are not covered in this policy permanently. Have a look at them below.

  1. War invasion illness or injury
  2. Circumcision
  3. cosmetic or aesthetic treatment
  4. plastic surgery unless required to treat the injury or illness
  5. Vaccination & Inoculation
  6. Cost of braces
  7. Equipment or external prosthetic devices
  8. Non-durable implants
  9. Eyeglasses
  10. Cost of spectacles and contact lenses
  11. Hearing aids including cochlear implants
  12. Durable medical equipment.
  13. All types of dental treatments except it is due to an accident
  14. Convalescence
  15. General debility
  16. ‘Run-down’ condition or rest cure
  17. Obesity treatment and its complications
  18. Congenital external disease, defects, or anomalies
  19. Treatment relating to all psychiatric and psychosomatic disorders
  20. Infertility
  21. Sterility
  22. Use of intoxicating drugs or alcohol
  23. Use of tobacco leading to cancer
  24. Bodily injury or sickness due to willful or deliberate exposure to danger
  25. An intentionally self-inflicted injury like suicide
  26. Treatment of any bodily injury sustained due to involvement in any criminal act or hazardous sport
  27. Sexually transmitted diseases
  28. Diagnosis, X-Ray, or Laboratory examination not consistent with the diagnosis and treatment of illness or injury
  29. Vitamins and tonics unless prescribed by a doctor
  30. Maternity expenses, except abdominal operation for extrauterine pregnancy
  31. Naturopathy Treatment
  32. Cost of instruments used in the treatment of Sleep Apnoea Syndrome (C.P.A.P.), Continuous Peritoneal Ambulatory dialysis (C.P.A.D.) and Oxygen Concentrator for Bronchial Asthmatic condition.
  33. Genetic disorders and stem cell implantation
  34. Domiciliary treatment
  35. Treatment – taken outside India
  36. Experimental and unproven treatment
  37. Change of treatment from one hospital to another without doctor consult
  38. Service charges levied by the hospital
  39. Except for registration or admission charges
  40. Treatment for Age-related Macular Degeneration (ARMD)
  41. Treatments such as Rotational Field Quantum Magnetic Resonance (RFQMR), External Counterpulsation ECP), Enhanced External Counterpulsation (EECP), Hyperbaric Oxygen Therapy

Claim for New India Janata Mediclaim Policy

A preliminary notice of New India Janata Mediclaim Policy claim with particulars such as the name of the insured person in respect of whom claim is to be made, nature of his/her illness/injury name and address of the attending medical practitioner, Hospital, or Nursing Home should be given to the Insurance Company or Third Party Administrator (TPA) within 7 days from the date of hospitalization if you want to reimburse the claim.

For the final claim along with the hospital original bills and cash memos, you may require the listed documents.

  1. Bill
  2. Receipt
  3. Discharge certificate or card from the Hospital.
  4. Cash Memos from the Hospitals (s) and Chemists (s), with proper prescriptions.
  5. Receipt and Pathological test reports from the attending Medical Practitioner, Surgeon, or Pathologist.
  6. Surgeon’s certificate stating the nature of the operation
  7. Surgeons’ bill and receipt
  8. Attending Doctor, Consultant, Specialist and Anesthetist bill and receipt
  9. And a certificate regarding diagnosis from the attending Medical Practitioner or Surgeon that the insured person is fully cured

Note: You should submit the documents to the policy issuing Office or TPA not later than 30 days of discharge from the hospital.

Cashless Claim

To use the cashless facility on your New India Janata Mediclaim Policy, you need to submit a pre-authorization letter to the TPA in which you have to state all your medical details. From the agreed list of network hospitals and nursing homes for pre-admission authorization, the TPA books it for the insured person. The TPA reserves the right to deny pre-authorization in case the insured person is unable to provide the relevant medical details. In that case, the insured can seek reimbursement.

Repudiation of New India Janata Mediclaim Policy

A claim, which is not covered under the Policy conditions, can be rejected. New India will collect the documents submitted to the TPA electronically for settlement of claims. In case you have violated the terms and conditions of the policy, the claim can be rejected by the respective authority. The repudiation communication shall be sent to the insured person on getting prior approval from the insurer. The communication explicitly mentions the grounds for repudiation, through the TPA. The insurance company shall settle the claim, including rejection, within 30 days of getting the last necessary document.  On receiving the completed documents either from the insured or hospital, the insurance company shall settle the claim if it meets the terms and conditions as stated in the policy. The insurer or the TPA shall transfer the funds within 7 working days of accepting the settlement claim made by the insured. If there remains an unusual delay, New India or its TPA will pay the penal interest rate, which is 2% above the bank rate at the beginning of the financial year in which the claim review takes place. The claims will be settled in Indian currency.

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