Insurance Plans November 3, 2020

United India Insurance Company Limited offers a group Health insurance product for employer-employee groups, known as the United Shramik Seva Policy. It will help take care of your most basic and essential health needs if you are an employee or worker in all industrial and commercial establishments, workplaces, offices, etc. In this post, you will know about the policy coverage, exclusion along with its terms and conditions. So, let’s read on!

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Coverage

During the policy period, if one or more insured requires hospitalization for treatment of an Illness or Injury as per the following advice of a duly qualified Medical Practitioner, the insurer will pay the medically necessary and reasonable customary expenses towards the below-mentioned coverage as in the United India Shramik Seva Policy schedule.

  1. Room Rent, Boarding, Nursing Expenses of the Hospital and Nursing Home (coverage up to 1% of the sum insured per day)
  2. Intensive Care Unit (ICU) or Intensive Cardiac Care Unit (ICCU) expenses (covered up to 2% of the sum insured per day)
  3. Surgeon, Anesthetist, Medical Practitioner, Consultants and the Specialist fees (Whether it is needed to be paid directly to the treating doctor/surgeon or the hospital)
  4. Anesthesia, blood, oxygen, operation theatre (OT) fees
  5. Surgical appliances, implants, medicines and drugs, costs for diagnostics (Diagnostic imaging modalities, and any such similar expenses)
  6. Actual expenses of cataract treatment including the lens cost (cover up to 15% of Sum Insured or INR 30,000, whichever is less), per eye during the Policy period.
  7. Dental treatment (if caused due to an injury)
  8. Plastic surgery (if it is the part of a disease or injury treatment)
  9. All daycare treatments
  10. Road Ambulance fee (covered upto INR 2000 per hospitalization)

Note: Expenses for hospitalization are valid for a minimum period of 24 consecutive hours only. However, the hospitalization time limit may not apply in Daycare Treatment.

In case of admission, room rates exceeding the aforesaid limits, and due to this the reimbursement/payment of all associated medical expenses incurred at the Hospital shall be given in the same proportion as the admissible rate per day bears to the actual rate per day of Room Rent.
And any proportionate deductions shall not apply in respect of those hospitals where differential billing is not followed or for those expenses where differential billing is not adopted in the room category.

  1. AYUSH Treatment – The insurer pays for the medical expenses incurred for inpatient care treatment under Ayurveda, Unani, Siddha, and Homeopathy systems of medicines each Policy Year. (cover up to INR. 15000 in any AYUSH Hospital)
  2. Pre-hospitalization medical expenses incurred and related to any admissible hospitalization requirement as inpatient care for 30 days before the admission to the hospital
  3. Post-hospitalisation medical expenses incurred and related to any admissible hospitalization requirement as inpatient care, up to 60 days from the date of hospital discharge
  4. Modern treatment methods and advancement in technologies for the following procedures (either as inpatient care or as part of daycare treatment in a hospital, coverage up to 50% of the Sum Insured, as specified in the policy schedule).
  5. Uterine Artery Embolization
  6. HIFU (High intensity focused ultrasound)
  7. Balloon Sinuplasty
  8. Deep Brain stimulation
  9. Oral Chemotherapy
  10. Immunotherapy (where Monoclonal Antibody is given as an injection)
  11. IntraVitreal Injections
  12. Robotic Surgeries
  13. Stereotactic radio surgeries
  14. Bronchial Thermoplasty
  15. The vaporization of the Prostate (Green laser treatment or holmium laser treatment)
  16. IONM – Intra Operative NeuroMonitoring
  17. Stem Cell Therapy (where hematopoietic stem cells are used for bone marrow transplant for hematological conditions)

United India Shramik Seva Policy Optional Covers

Apart from the above-mentioned coverage, the insurer will pay for some additional benefits. Have a look at them in the below pointers:-

  1. Out-patient Treatment Cover (within your Base Sum Insured) – Here, the company will cover the reasonable and customary fee incurred on an out-patient basis for medical consultation, doctor visit, diagnostic tests, and pharmacy expenses as per the standard medical protocol for an epidemic or pandemic (coverage up to INR. 5,000)

The purpose of this optional cover of outpatient is to provide a mean to the insured who is not hospitalized, but visits a hospital, clinic, or associated facility for diagnosis or treatment. And this very relevant part of the policy will stand deleted in the exclusion. All claims under the Out-patient Treatment benefit can be made without any hassle.

  1. Daily Cash Allowance of INR 500 on hospitalization will be paid to the insured, subject to a maximum of INR. 75,00 per policy period for every continuous and completed period of 24 hours of hospitalization. This benefit will not be payable for daycare procedures as the hospitalization is less than 24 hours in such cases. Your deductible equivalent to Daily Cash Allowance for the first 24 hours of hospitalization will be levied on each hospitalization per Policy Period. The payment of Daily Cash Allowance is over and above the Base Sum Insured.
  2. The first Diagnosis of Any Epidemic or Pandemic during the period of cover can be claimed. For this, the insurer pays INR 25,000 in a lump sum, provided that the Illness or disease was first diagnosed after 14 days from the Risk Inception Date. Once the claim is accepted, the cover under this benefit will terminate. The first Diagnosis of Any Epidemic or Pandemic is payable for the following:
  3. The Insured must have tested positive for the Epidemic/ Pandemic by a Government-authorized/ Government designated laboratory in India, appointed for the testing of the Epidemic/ Pandemic.
  4. The diagnosis must be confirmed by only those specific test(s) as defined by Government authorities or as per standard medical protocol.
  5. The lab diagnosis must have been performed after the completion of the initial waiting period of 14 days.

No benefit is payable if you are quarantined for any suspected epidemic, pandemic, or diagnosed with an epidemic or pandemic before the risk inception date or the initial waiting period (14 days). The initial waiting period may not apply to the first Diagnosis of Any Epidemic or Pandemic Cover if the optional cover for ‘Waiver of Initial Waiting Period of 30 days for any epidemic or pandemic has been opted for. The payment of this benefit is over and above the Base Sum Insured. The following are the claim documents required for this Benefit Cover:

  1. Duly filled claim form (physically or digitally by the Insured Person or Claimant)
  2. Lab report with duly signed and stamped, confirming the positive status for Epidemic or Pandemic.
  3. Certificate from the Government medical officer regarding the diagnosis or any medical practitioner authorized by the Government to issue such certificates.

If an epidemic or pandemic occurs to you in case, it may give rise to a claim under this benefit of the Policy. To claim it, you need to provide the above-mentioned necessary and mandatory information and documentation within 30 days of its occurrence.

Note: When you pay an additional premium, the insurer will agree and declare that the exclusion shall not apply to Epidemic or Pandemic benefit. The waiver of copayment on pre-existing comorbidities epidemic or pandemic is provided and declared by the insurer in a co-payment condition that does not apply to claims arising out of the hospitalization due to any Epidemic or Pandemic.

  1. Maternity Benefit is payable in a lump sum, it is an amount of INR 20,000 for the female Insured whose age is 18 years or above during the Policy Period for the delivery of a child in a Hospital (includes but not limited to cesarean section, vacuum birthing, water birthing, hypnobirthing, midwife birthing). This benefit is subject to the following condition.
  2. You can claim it after a waiting period of 9 months from the date of cover Inception under United India Shramik Seva Policy for the Female Insured member-only.
  3. Up to a maximum number of 2 deliveries are covered
  4. Payment under this cover is limited to a per event (cover for this is over and above the Base Sum Insured)

On the occurrence of this benefit, you can claim the policy by submitting the following necessary and mandatory information and documentation as specified about the benefit within 30 days of its occurrence:

  1. Duly filled claim form (physically or digitally by the Insured Person or Claimant)
  2. Birth Certificate issued by the local Government Body
  3. Delivery proof from the Hospital or Medical Centre equipped for conducting delivery

The payment of maternity benefit is over and above the Base Sum Insured as per the United India Shramik Seva Policy schedule.

Exclusions from the United India Shramik Seva Policy

The company is not liable to make any payment under United India Shramik Seva Policy, in respect of any of the following expenses:

  1. Expenses related to diagnostics and evaluation purposes (primarily)
  2. Any diagnostic expense not related or not incidental to your current diagnosis and treatment
  3. Admission fee where the insured is enforced to bed rest and no treatment is provided. Under this custodial care at home or in a nursing facility, personal care is also counted. Personal care such as help with activities of daily living such as bathing, dressing, moving around either by skilled nurses or assistants or a non-skilled person.
  4. Any expenses related to the surgical treatment of obesity that does not fulfill the below conditions:

Surgery upon the Doctor advice

Surgery/procedure conducted by clinical protocol

Age should be 18 years or older

Body Mass Index (BMI) must be greater than or equal to 40 or greater than or equal to 35 in conjunction with the following severe comorbidities (anyone) Obesity-related cardiomyopathy, Coronary heart disease, Severe Sleep Apnoea, or Uncontrolled Type 2 Diabetes.

  1. Surgical management treatment to change characteristics of the body to those of the opposite sex.
  2. Cosmetic or plastic surgery and any treatment that changes appearance unless it is required for reconstruction due to the following: an Accident, Burn(s), Cancer, or as part of the medically necessary to remove a direct or immediate health risk. To consider this as a medical necessity, it must be certified by the attending Medical Practitioner.
  3. Injury or Illness due to participation in hazardous or adventure sports, including but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing, scuba diving, hand gliding, skydiving, or deep-sea diving.
  4. Commit a breach of law with criminal intent
  5. Specifically excluded hospitals or medical practitioners by the insurer. However, in the case of life-threatening situations or an accident, expenses up to the stage of stabilization will be payable. (not incomplete)
  6. Alcoholism, drug, substance abuse, or any addictive condition and consequences treatment.
  7. Health hydros, nature cure clinics, spas, similar establishments, or private beds registered in a nursing home attached to such establishments where the admission is arranged wholly or partly for domestic reasons
  8. Dietary supplements and substances purchased without a prescription, including but not limited to Vitamins, minerals, and organic substances (unless prescribed by a medical practitioner
  9. Eyesight correction due to refractive error less than 7.5 dioptres
  10. Unproven treatment, services and supplies for or in connection with any treatment
  11. Any type of sterilization Assisted Reproduction services plus the artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI Gestational Surrogacy Reversal of Sterilization
  12. Childbirth treatment (including complicated deliveries and cesarean sections) except ectopic pregnancy
  13. Miscarriage (unless due to an accident) and any lawful medical termination of pregnancy in the policy period
    Complications arising from infertility treatment
  14. Injury or illness due to War, and warlike occurrence or invasion, acts of foreign enemies, hostilities, civil war, rebellion, revolutions, insurrections, mutiny, military, usurped power, seizure, capture, arrest, restraints, and detainment of all kinds (whether it is declared or not by the govt.)
  15. Illness or injury due to nuclear, chemical, or biological attack or weapons
  16. Biological attack or weapons means the emission, discharge, dispersal, release, or escape of any pathogenic (disease-producing) micro-organisms and/or biologically produced toxins causing any Illness, incapacitating disablement, or death to the insured.
  17. Any expenses incurred on Domiciliary Hospitalisation
  18. Treatment outside India
  19. Stem cell implantation, Surgery, therapy, harvesting, storage, or any kind of treatment in connection to stem cells (except for the above-mentioned cover)
  20. Growth Hormone Therapy
  21. Congenital External Diseases, Defects, or anomalies.
  22. Circumcision ( if not due to an Accident)
  23. Preventive health check-up and routine medical examination
  24. Hearing aids expenses including optometric therapy, cochlear implants (unless caused by an Accident)
  25. Intentional self-inflicted Injury (attempted suicide)
  26. Treatments are other than Allopathy, Ayurvedic, Homeopathic and Unani branches of medicine.
  27. OPD treatment unless used intra-operatively,
  28. Prosthesis expenses
  29. Corrective devices whether external or durable Medical and Non-medical equipment of any kind, such as instruments used in the treatment of sleep apnoea syndrome, Infusion
    pump, Oxygen concentrator, Ambulatory devices, subcutaneous insulin pump, and also any medical equipment, which are subsequently used at home.
  30. Change of treatment from one system of medicine to another (unless recommended by the consultant or hospital)
  31. Rotational Field Quantum Magnetic Resonance (RFQMR), External Counterpulsation (ECP), Enhanced External Counterpulsation (EECP), Hyperbaric Oxygen Therapy, chondrocyte, or osteocyte implantation. Also, the procedures using platelet-rich plasma, TransCutaneous Electrical Nerve Stimulation.
  32. Use of oral immunomodulatory or supplemental drugs
  33. Artificial life maintenance like a life support machine

Claim Procedure for United India Shramik Seva Policy

You can get your claim amount from the insurer via reimbursement or cashless claim facility. Let’s know about them in detail.

Key Points for United India Insurance Company Ltd. Cashless Claim:-

  1. For cashless facilities, treatment must be taken in a network provider, and this is subject to pre-authorization by the company or the authorized TPA
  2. Cashless request forms available at network providers and TPA must be completed and sent to the company or TPA (for authorization)
  3. Company or TPA if they get a cashless request form related to your medical information, will issue a pre-authorization letter to the hospital after verification.
  4. On discharge, you have to verify and sign the discharge papers, pay for the non-medical, and inadmissible expenses as well.
  5. Company or TPA has the right to deny the pre-authorization in case you are unable to provide the relevant medical details.
  6. In the case of denial, you may obtain the treatment as per your treating doctor’s advice and submit the claim documents to the company or TPA for treatment.

Key Points for United India Insurance Company Ltd. Reimbursement Claims-

For reimbursement, you may submit the necessary documents to the TPA or company within the prescribed time limit. The time limit of hospitalization, daycare, and pre-hospitalization expenses are thirty days since the date of discharge from the hospital. The reimbursement time limit for post-hospitalization expenses is fifteen days from the completion of post-hospitalization treatment.

Send Notification for Claims

Before you claim the amount, you need to send a notice with full particulars to the Company/TPA (if applicable) as under:

  1. Within 24 hours from the date of emergency hospitalization
  2. Or before you discharge from the Hospital (whichever is earlier)
  3. The notice must be sent within 48 hours before admission in Hospital (in a planned Hospitalization)

Documents

For the reimbursement claim, you need to submit the following documents within the above-mentioned prescribed time limit.

  1. Duly filled claim form
  2. Photo Identity (ID) proof
  3. Medical practitioner’s prescription (for admission)
  4. Original bills with itemized break up expenses
  5. Payment receipts
  6. Discharge summary (including your complete medical history along with other details)
  7. The investigation, diagnostic test reports with a prescription from your attending medical practitioner
  8. OT notes or surgeon’s certificate (Giving details of the operation for surgical cases)
  9. Sticker or Invoice of the Implants
  10. Medico-Legal Report (MLR) copy if carried out and First Information Report (FIR) if registered (wherever it is applicable)
  11. NEFT Details (for direct credit claim)
  12. Canceled Cheque
  13. KYC of the proposer, where the claim amount is above INR 1 Lakh (AML Guidelines)
  14. Legal heir or succession certificate (wherever applicable)
  15. Any relevant document required by the company or TPA for assessing the claim

Note: The insurer specifies the documents required in the original and waives off any of the above-required claim procedures. It only accepts bills, invoices, or medical treatment documents in the Insured Person’s name for whom the claim is submitted. In the event of a claim being lodged under the Policy and the original documents having been submitted to any other Insurer, the company will accept the copy of the documents and claim settlement advice, duly certified by the other Insurer subject to satisfaction of the company. Any delay in notification or submission where a delay is proved to be for reasons beyond the control of the Insured Person, a penalty is charged.

United India Shramik Seva Policy Claim Settlement with Penal Interest

  1. The insurer settles or rejects a claim, as per the case, within 30 days from the date of receipt of the last necessary document
  2. In case of delay beyond 45 days, the insurer is liable to pay penalty interest to the Insured Person at a rate 2% above the bank rate from the date of receipt of the last necessary document to the date of payment of your claim.
  3. However, where circumstances warrant an investigation for the claim in the opinion of the company, it will initiate and complete it at the earliest, in any case not later than 30 days from the date receipt of the last necessary document. In such cases, the insurer shall settle or reject the claim within 45 days from the date of receipt of the last necessary document.

Claim admissions and assessments, under this Policy by way of pre-authorization of cashless treatment or processing of claims other than cashless claims or both, are as per the underlying terms and conditions of the policy. The TPA provides services, except the following –

  1. Claim settlement and rejection
  2. Any services to the Insured Person or any other person unless such service is by the terms and conditions of the agreement.

All claims under United India Shramik Seva Policy shall be payable in Indian National Rupee (INR) currency only.

United India Shramik Seva Policy Terms & Conditions

Any amount that is payable under the policy is subject to the terms of United India Shramik Seva Policy coverage including the co-pay, sub-limits, exclusions, and conditions mentioned below. The liability of the company under all claims during each Policy Year shall be the Sum Insured opted by you as per the policy schedule.

  1. Any notice, direction, or instruction and any other communication should be made in writing
  2. Communication shall be sent to the company address or via any other electronic modes as specified in the Policy Schedule
  3. No insurance agent, brokers, another person, or entity is authorized to receive your notice unless it is explicitly stated in writing by the insurer
  4. The company communicates to you in writing, at the address as specified in the Policy Schedule, Certificate of Insurance, or through any other electronic mode.
  5. In case you have multiple policies from one or more Insurers to indemnify treatment costs, you will have the right to require a settlement of the claim in terms of any of your policies. In all such cases, the Insurer chosen by you shall be obliged to settle the claim as long as the claim is within the limits of the terms of the policy.

Having multiple policies also gives you the right to prefer claims under this policy for the amounts disallowed under any other policy/policies, even if the sum insured is not exhausted. Then, independently, the company shall settle the claim under the terms and conditions of the United India Shramik Seva Policy. If the amount to be claimed exceeds the sum insured under a single policy, you have the right to choose the Insurer from whom you want to claim the balance amount.

If you have policies from more than one Insurer to cover the same risk on an indemnity basis, you must indemnify the treatment costs by the terms and conditions of the chosen policy.

  1. If in respect of fraudulent claims, false statements, or declaration is made or used in support thereof, and any fraudulent means or devices are used to obtain any benefit under the policy, all benefits under this policy and the paid premium shall be forfeited. Any paid amount against such claims which are found fraudulent later shall be repaid by all recipient(s), Policyholder(s), who made that particular claim.

The suggestion, as a fact of that which is not true and which you do not believe to be true, is a fraudulent act. The active concealment of a fact by the insured having knowledge or belief of the fact, and any such act or omission as the law specially declares to be fraudulent.

The company may not repudiate the claim or forfeit the policy benefits on the ground of fraud if the insured or beneficiary can prove that the misstatement was true to the best of his/her knowledge.

  1. United India Shramik Seva policy is renewable except on grounds of fraud, misrepresentation, non-disclosure of material facts. The insurer endeavors to give notice for renewal. However, the insurer is not under obligation to give any notice for renewal. The renewal may not be denied on the ground that you had made a claim or claims in the preceding policy years. Requests for renewal along with requisite premium is received by the company before the end of the policy period. At the end of the policy period, the policy will terminate and it can be renewed within the 30 days of the Grace Period to maintain continuity of benefits without break in policy. Your coverage is not available under the policy during the grace period. No loading shall apply on renewals on individual claims experience.

Renewal Terms

  1. For alterations like increase or decrease in Sum Insured or change in optional cover can at the time of renewal, the insurer reserves the right to carry out an assessment of the group and provide the renewal quote in respect of the revised policy.
  2. The company makes adjustments to Premium Rates for renewals based on the experience of expiring policy. (for groups with at least 100 members in both expiring policy and upcoming policy period)
  3. At the company’s sole discretion, the revised premiums payable under the Policy or the terms of the cover are governed by the IRDAI rules and regulations

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