Insurance Plans August 25, 2020

A health insurance policy that covers all your in-hospitalization expenses is New India Top Up Mediclaim. The insurance policy can be claimed when one or more policy members are hospitalized. It doesn’t cover your Pre and Post-hospitalization expenses. Read the page below to know how much the policy covers, what expenses it covers and what it does not.

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Medical Expenses Covered in New India Top Up Mediclaim

Accident: When you and any of the insured person meet with a sudden, unforeseen and involuntary event that is caused by external visible means, the treatment or surgery expenses will be paid by the insurance company.

Illness: When you get hospitalized after a continuous illness of 45 days or more.

Congenital Anomaly: A physical condition where the person’s body structure is different from normal by birth.

Congenital Internal Anomaly: A condition where the disability can’t be seen.

Continuous Coverage: An uninterrupted coverage for the Insured Person with New India from the date of inception to the date of commencement of this Policy. If there is a break in insurance for a period not exceeding 30 days, it may not be reckoned as an interruption in the policy. In case the Sum Insured is changed during the break, the lowest Sum Insured would be reckoned for the continuous coverage.

Cumulative Hospitalization Expense: Medical expenses incurred owing to the treatment of illness or injury are covered under the policy. Expenses include the cost of medicines, doctor fees, surgery, etc. The patient should be admitted to the Hospital during the Period of Insurance. It shall not cover expenses of pre and post hospitalization that are incurred due to the illness or injury.

Day Care Centre: An institution which is authorized by the local government or present within a hospital which complies with the following criteria for treatment of illness or injury.

  1. Should have qualified nursing staff and Medical Practitioner
  2. The Day Care Centre should have a fully equipped operation theatre (OT)
  3. Maintains a daily record of the patients
  4. And the records should be accessible to an insurance company or Third Party Administrators (TPA)

Treatment at Day Care Centre

Dental Treatment: It is a treatment that is carried out by a dental practitioner. This process may include the patient examinations, fillings if required, crowns, extractions, and surgery excluding cosmetic surgery or implants.

Domiciliary Hospitalization: A medical treatment for an Illness or Injury but performed at home under due to the following circumstances:

  1. The condition of the patient is not such that he/she cannot go to a hospital
  2. Takes treatment at home due to the non-availability of room in a hospital.

Maternity Expenses:

  1. Medical Treatment Expenses to childbirth (including cesarean during Hospitalisation),
  2. Expenses towards lawful medical termination of pregnancy

Medical Advice: Consultation Fees of your doctor that includes the issue of any prescription or repeat prescription.

Medical Necessity: Treatment, Tests, Medication, or Stay in Hospital expenses

Network Hospital: The Hospitals, Day Care Centres, or other options which the insurance company or TPA have mutually agreed on to provide treatment to the insured person.

Pre Existing Disease or Condition: Any condition, ailment, or Injury which you have signs or symptoms, within 48 months before the date of policy inception.

Room Rent: The amount charged by a Hospital for the occupancy of a bed per day.

Expenses Which are Excluded from New India Top Up Mediclaim Policy

While purchasing a health insurance policy, you must look at what it covers and what it does not. Because if the deal isn’t satisfying for you as per your health issue then it’s of no use. Check out the list of expenses that the New India Top Up Mediclaim policy does not cover for the insured person.

  1. Treatment of any Pre-existing Condition or Disease
  2. Any Illness that is contracted by the Insured person during the first 30 days of the policy commencement.
  3. All internal and external benign tumours
  4. Cysts
  5. Polyps of any kind
  6. Breast lumps
  7. Ear, Nose and Throat disorders
  8. Prostate Hypertrophy
  9. Cataract and age-related eye ailment
  10. Congenital Internal Disease
  11. Diabetes Mellitus
  12. Gastric or Duodenal Ulcer
  13. Gout
  14. Rheumatism
  15. Hernia of all types
  16. Hydrocele
  17. Hypertension
  18. Non-infective Arthritis
  19. Piles
  20. Fissures and Fistula in anus
  21. Pilonidal sinus or sinusitis related disorder
  22. Prolapsed intervertebral Disc or Spinal Diseases unless it is a result of an accident
  23. Skin Disorders
  24. Stone in Gallbladder, Bile duct and Urinary system.
  25. Treatment for Menorrhagia
  26. Fibromyoma
  27. Myom
  28. Prolapsed uterus
  29. Varicose Veins
  30. Varicose Ulcers
  31. And joint Replacement due to Degenerative Condition
  32. Age-related Osteoarthritis and Osteoporosis.

Note: The above-mentioned Illnesses will not be covered if they arise from a Pre-existing Condition.

  1. Pre and Post HospitalisationMedical Expenses: It includes Naturopathy Treatment, acupressure, acupuncture, magnetic, and other such therapies.
  2. Injury or Illness caused by a War, invasion, Act of Foreign enemy, War like operations, nuclear weapon, ionizing radiation, contamination by Radioactive material, nuclear fuel or nuclear waste or from the combustion of nuclear fuel.
  3. Circumcision: Unless treatment is required
  4. Change of life: Insured person sex-change surgery
  5. Cosmetic Treatment: Beauty treatments such as Breast augmentations, Buttock augmentations, Buttock implants, Nose reshaping, etc.
  6. Aesthetic Treatment: Chemical Peels, Collagen induction therapy and laser treatment for skincare.
  7. Plastic Surgery: Unless it is advised by a doctor to cure the accident scars or if it is a part of any Illness treatment.
  8. Vaccination or inoculation
  9. Cost of braces
  10. Equipment or external prosthetic devices
  11. non-durable implants
  12. Eyeglasses
  13. Cost of spectacles
  14. Contact lenses
  15. Hearing aids including cochlear implants
  16. Durable medical equipment.
  17. Dental treatment or Surgery: Unless it is necessitated by an accident
  18. Convalescence
  19. general debility
  20. ‘Run-down’ condition or rest cure
  21. Obesity treatment and its complications
  22. Treatment relating to all psychiatric and psychosomatic disorders
  23. Infertility
  24. Sterility
  25. Congenital External Disease
  26. Venereal disease
  27. Intentional self-injury and Illness or Injury caused by the use of intoxicating drugs and alcohol.
  28. Bodily injury or sickness due to willful or deliberate exposure to danger (except if you save human life)
  29. Intentional self-inflicted Injury from suicide or non-adherence to medical advice.
  30. Treatment of any Injury or Illness that is a result of active participation in any hazardous sport.
  31. Treatment of Injury or Illness sustained whilst or as a result of participating in any criminal act.
  32. Sexually transmitted diseases, any condition directly or indirectly caused due to or associated with Human T-Cell Lymphotropic Virus Type III (HTLV-III), lymphadenopathy Associated Virus (LAV), Mutants Derivative, Variation Deficiency syndrome, or any syndrome and condition of a similar kind commonly AIDS.
  33. Hospital charges for diagnosis of disease or injury such as, x-ray, Laboratory examinations, or other diagnostic studies that are not consistent.
  34. Vitamins and tonics unless prescribed by the doctor
  35. Maternity Expenses, such as treatment arising from pregnancy, miscarriage, abortion, or complications, except abdominal operation for extra uterine pregnancy that is offered by submission of Ultrasonography Report and Certification by Gynaecologist.
  36. Genetic disorders and stem cell Surgery.
  37. External durable Medical or Non-medical equipment for diagnosis and treatment including:
  38. CPAP (Continuous Positive Airway Pressure)
  39. Sleep Apnoea Syndrome
  40. CPAD(Continuous Peritoneal Ambulatory Dialysis
  41. Oxygen Concentrator for Bronchial Asthmatic condition, Infusion pump, etc.
  42. Ambulatory devices
  43. Domiciliary Hospitalisation
  44. Unproven or Experimental Treatment
  45. Change of treatment from one system to another unless recommended by the Consultant or Hospital under which the treatment is taken.
  46. Any kind of Service charges, Surcharges, Admission Fees or Registration Charges levied by the Hospital
  47. Any expenses relating to the cost of items detailed in covered expenses.
  48. Treatment for Age-related Macular Degeneration (ARMD), drugs such as Avastin or Lucentis or Macugen and other related drugs, treatments such as Rotational Field Quantum Magnetic Resonance (RFQMR), External Counterpulsation (ECP), Enhanced External Counterpulsation (EECP), Hyperbaric Oxygen Therapy
  49. Treatment or Investigation taken outside India

New India Top Up Mediclaim Reimbursement

You can claim the amount up to Sum Insured above which the insurance company can’t pay your medical expenses. Following is the list of expenses that the policy covers.

  1. Room Rent, boarding and nursing expenses up to INR 5,000 per day for Sum Insured INR 5,00,000 Threshold and INR 8,000 per day for INR 8,00,000 Threshold
  2. Intensive Care Unit (ICU) and Intensive Cardiac Care Unit (ICCU) expenses are capped at INR 10,000 per day for INR 5,00,000 Threshold and INR 16,000 per day for INR 8,00,000 Threshold.
  3. This includes Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialist fees
  4. Things that are required during the surgery such as Anaesthesia, Blood, Oxygen, Surgical Appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, Cost of Prosthetic devices implanted during surgical procedure like a pacemaker, Relevant Laboratory/Diagnostic test, XRay and other medical expenses.
  5. Get Well Benefit of INR. 5,000 for INR 5,00,000 Threshold and INR 8,000 for INR 8,00,000 Threshold, for any illness. Payable only for the first four admissible claims under the Policy which will reduce the Sum Insured.
  6. Treatment for Cataract for each eye shall not exceed INR 50,000.
  7. Hospital cash will be paid at the rate of INR. 500 per day for the INR 5,00,000 threshold and INR 800 per day for the INR 8,00,000 threshold for a maximum of 10 days for any covered illness.
  8. The payment under this policy is applicable only where the period of Hospitalization exceeds 24 hours.
  9. Ambulance service expenses are covered subject to a cap of INR 5000 for INR 5,00,000 threshold and INR 8,000 for INR 8,00,000 threshold. These expenses are payable only if there is a reasonable emergency.

The Process to Claim the New India Top Up Mediclaim

If you want to make any claim under this New India Top Up Mediclaim Policy, you need to inform TPA in writing of any illness or injury you have been suffering from. You can inform the TPA immediately or 48 hours before the hospitalization takes place. After that, you need to submit the following documents to TPA within seven days from the date of discharge:

  1. Bill Receipt
  2. Discharge certificate or card from the Hospital
  3. Cash Memos from the Hospitals or Chemists, with proper prescriptions.
  4. Receipt and Pathological test reports from Pathologist by the attending Medical Practitioner or Surgeon
  5. Surgeon’s certificate stating the nature of the operation
  6. Surgeons’ bill and receipt
  7. Attending Doctor, Consultant, Specialist, Anesthetist bill and receipt for the diagnosis

The Insured must submit to the TPA all original bills, receipts and other documents upon which a claim is settled.

NoteNew India Assurance can let a medical practitioner authorized by the TPA or itself to examine the insured person if the insurer feels it necessary regarding any claim.

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