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    MEDICLAIM INSURANCE

    INDEX

    SR

    NO

    PARTICULARS PAGE

    NO1 DESIGN OF STUDY 2

    2 METHODOLOGY 3

    3 INTRODUCTION 4

    4 DEFINITION 5

    5 TYPES OF INSURANCE 6

    6 PRINCIPLES OF INSURANCE 13

    7 TYPES OF MEDICLAIM POLICIES 16

    8 BENEFITS OF MEDICLAIM 31

    9 NEED FOR MEDICLAIM INSURANCE 42

    10 PRECAUTIONARY MEASURES TO BE

    TAKEN

    44

    11 FREQUENTLY ASKED QUESTIONS 53

    12 CASE STUDIES 57

    CONCLUSIONBIBLIOGRAPHY

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    CHAPTER 1

    INTRODUCTION

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    INSURANCE: AN INTRODUCTION

    Insurance may be described as a social device to reduce or eliminate risks of loss to

    life and properly. It is a provision which a prudent man makes against inevitablecontingencies, loss or misfortune.

    Once Frank H. Knight said "Risk is uncertainty and uncertainty is one of the

    fundamental facts of life." Insurance is the modern method by which men make the

    uncertain certain and the unequal; equal. It is the means by which success is almost

    guaranteed. Through its operation- the strong contribute to the support of the

    weak and weak secure, not by favor sent by right duly purchased and paid for, the

    support of the strong (Calvin Coolidge.)

    Under the plan of insurance, a large number of people associate themselves by

    sharing risks attached to individuals. As in private life, in business also there are

    dangers and risks of different kinds. The aim of all types of insurance is to

    make provision against such dangers. The risks which can be insured against

    include fire, the perils of sea (marine insurance), death (life insurance) and,

    accidents and burglary. Any risk contingent upon these, may be insured against at a

    premium commensurate with the risk involved. Thus, collective bearing of risks is

    insurance.

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    Definition

    Insurance in its basic form is defined as A contract between two parties whereby

    one party called insurer undertakes in exchange for a fixed sum called premiums,

    to pay the other party called insured a fixed amount of money on the happening of

    a certain event."

    In simple terms it is a contract between the person who buys Insurance and an

    Insurance company who sold the Policy. By entering into contract the Insurance

    Company agrees to pay the Policy holder or his family members a predetermined

    sum of money in case of any unfortunate event for a predetermined fixed

    sum payable which is in normal term called Insurance Premiums.

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    DESIGN OF STUDY

    SCOPE

    Human resources management starts the moment an employee joints an

    organization and continues till he leaves the organization either on account

    of retirement, registration and death or otherwise. It covers every aspects of

    employee training, manpower planning etc

    OBJECTIVES:

    Human resource management is a fascinating and important subject. The

    fascinating lies in fact that it involves people and decision involving people

    artwork. It is human resources that determine the fact of an organization. I have

    selected the topic of job satisfaction and communication management because the

    quality of human resources is a critical factor in the success of any organization

    and more in service organization like banks.

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    METHODOLOGY

    In order to conduct the research an appropriate methodology became necessary. Inthis direction both primary and secondary data were required to be collected. Themethodology for collecting secondary data was taken from the different

    published books, article, journals and relevant websites. The different libraries ofthe college, institution were of much great help.

    Questionnaire was prepared for the collection of primary data from different banks.These forms i.e. questionnaire was given to different banks for getting theinformation of their report on working of job satisfaction and communicationmanagement along with different other questionnaires. It was prepared to get detail

    information of an individual topic so we can get proper information and also theknowledge of the banks.

    After finalization of the questionnaire it was decided to approach different banks inthe nearby areas. These questions were presented to the employees. The primarydata collection was restricted only to banks. Thus the methodology became a

    preplanned strategy in collecting, editing, tabulating and interpreting the requiredinformation for the research.

    Hence, the methodology relied on both primary and secondary data with the helpof questionnaire, discussions observations as well as published work andunpublished work.

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    CHAPTER 2

    TYPES OF INSURANCE

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    TYPES OF INSURANCE

    Life insurance

    Life insurance is an insurance coverage that pays out a certain amount of money to

    the insured pr their specified beneficiaries upon a certain event such as death of the

    individual who is insured. This protection is also offered in a family tactful plan, a

    Shariahbased approach to protecting you and your family. The coverage period

    for a life insurance is usually more than a year. So this requires a periodic premium

    payment, either monthly, quarterly or annually. The risks that are covered by life

    insurance are:

    Premature death

    Income during retirement

    Illness

    The main products of life insurance include:

    1. Whole life

    2. Endowment

    3. Term

    4. Investment-linked

    5. Life annuity plan

    6. Medical and health

    General insurance

    General insurance is basically an insurance policy that protects u against looses

    and damages other than those covered by life insurance. For more comprehensive

    coverage, it is vital for you to know about the risks covered to ensure that you and

    your family are protected from unforeseen losses.

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    The coverage period for most general insurance policies and plans is usually one

    year, whereby premiums are normally paid on a one-time basis.

    The risks that are covered by general insurance are:

    Propertyloss, for example, stolen car or burnt house

    Liabilityarising from damage caused by yourself to a third party

    Accidentaldeath or injury

    The main products of general insurance include:

    Motorinsurance

    Fireinsurance

    Personalaccident insurance

    Medicaland health insurance

    Travelinsurance

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    CHAPTER 3

    HEALTH INSURANCE IN INDIA

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    HEALTH INSURANCE IN INDIA

    The guiding principle enunciated in the Bhore committee of 1946, which states that

    `no individual should fall to secure adequate medical care because of inability to

    pay for it', looks unreachable even after 50 years of Indian Independence. Someform of health insurance, either social or private, covers hardly 3% of the

    Indian population. The total expenditure on health in India is 6% of the GDP and

    the government spending is less than 25% against the average spending of 30-40%

    another developing countries.

    In India, health insurance mainly exists in the form of Mediclaim policy offered to

    the individuals or group, association or corporate bodies. State owned insurance

    companies; covering only about 2.5 mn people of the countrys population, do the

    penetration of Mediclaim policy. Social insurance like Employee State InsuranceScheme is available but they have restricted the coverage to a very small segment

    of the population that is round 3%.

    The government has taken serious interest in the potential of insurance companies

    to provide and popularize health insurance coverage at modest rate of premium. To

    achieve this goal the government has allowed income tax rebates for premium paid

    for health insurance policies.

    GIC made some headway under its various health care plans for different segmentsof policyholders, by covering more than 2 mn people. LIC and Tails made attempt

    to offer some type of health insurance covers. However, health insurance could not

    pick momentum in India due to the following reasons:

    1. Service costs are out of reach of many people.

    2. Lack of good and efficient physician and less number of hospitals.

    3. High illiteracy rate

    4. Poor medical equipment and

    5. Poor budget allocation towards healthcare.

    We shall now discuss in detail about the health insurance policies available in

    India.

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    CHAPTER 4

    HISTORY OF MEDICLIAM

    INSURANCE

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    DECADES OF MEDICLAIM

    The concept of health insurance was proposed in 1694 by Hugh the

    Elder Chamberlin from the Chamberlin family. In the late 19th century, "accident

    insurance" began to be available, which operated much like modern disability

    insurance. This payment model continued until the start of the 20th century in

    some jurisdictions (like California), where all laws regulating health insurance

    actually referred to disability insurance.

    Before the development of medical expense insurance, patients were expected

    to pay all other health care costs out of their own pockets, under what is known as

    the fee business model. During the middle to late 20th century, traditional

    disability insurance evolved into modern health insurance programs. Today, mostcomprehensive private health insurance programs cover the cost of

    routine, preventive, and emergency health care procedures, and also most

    prescription drugs, but this was not always the case.

    Hospital and medical expense policies were introduced during the first half of

    the20th century. During the 1920s, individual hospitals began offering services to

    individuals on a pre-paid basis, eventually leading to the development of

    BlueCross organizations. The predecessors of today's Health Maintenance

    Organizations (HMOs) originated beginning in 1929, through the 1930s and onduring World War II.

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    MEDICLAIM IN INDIA

    In mid 80s most of the hospitals in India were governments owned and treatment

    was free of cost. With the advent of Private Medical Care the need for Health

    Insurance was felt and various Insurance Companies (New IndiaAssurance, National Insurance Company, Oriental Insurance & United Insurance

    Company) introduced Mediclaim Insurance as a product.

    According to recent news report Health insurance continues to be the fastest

    growing segment with annual growth rate of 55%. Health Premium has risen to

    Rs.3300 cores in 2006-2007. As per the recent reports from various agencies the

    Health sector has the potential to become a Rs. 25000-crore industry by 2010.

    On August 15, 2007 Prime Minister has announced Rs 2000 Cores for HealthInsurance for poor citizens. We foresee that this amount will be partly in form

    of subsidy therefore during calendar year 2008 we can expect Health

    Insurance premium to touch figure in the range of Rs 10,000 Cores.

    In 2001 with entry of various private Insurance companies now the customers

    have choice of buying this insurance from 14 Insurance companies.

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    The Companies, which offer Health or Mediclaim Insurance,

    are;

    Bajaj Allianz General Insurance Company Limited

    Future Generali India Insurance Company Limited

    HDFC General Insurance Company Ltd.

    ICICI Lombard General Insurance Limited.

    National Insurance Company Limited

    New India Assurance Company Limited

    Oriental Insurance Company Limited

    Reliance General Insurance Company Limited

    Royal Sundram Alliance Insurance Company Limited

    Star health and Allied Insurance Company Limited

    TATA AIG General Insurance Company Limited. (Overseas Health Insurance

    only)

    United India Insurance Company Limited

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    India is the only country where hospitalization insurance policy was being

    soldas Mediclaim Insurance Policies. The very name gives a feeling to the insured

    that claim has to be lodged. If motor insurance policy is not sold as motor

    insurance claim policy and household insurance policy is not sold as householdclaim policy then why this is named as Mediclaim?

    In the recent years the trend has emerged that some Insurance companies have

    started calling this product as Health Insurance.

    Health Insurance and Mediclaim are two different names for the same product. The

    change has started coming and now we have started calling it Health

    Insurance.ICICI Lombard has even named it as Health Insurance Policy.

    Calling is as Health Insurance is a positive way of looking at this Insurance. It also

    giving us a feeling that we as a society have started moving from curative medical

    care to preventive medical care.

    According to sources in Oriental insurance it is being felt that mindset has started

    changing over the last couple of years The new middle- class of India aspires

    of quality healthcare service and doesnt mind going to expensive hospitals like

    Apollo or Escorts. There is no reason why healthcare insurance should not be

    successful with this class.

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    Principles of insurance

    1.IndemnityA contract of insurance contained in a fire, marine, burglary or any other policy(except life assurance and personal accident and sickness insurance) is a contractof indemnity. This means that the insured, in case of loss against which the policyhas been issued, shall be paid the actual amount of loss not exceeding the amountof the policy, i.e. he shall be fully indemnified. The object of every contractof insurance is to place the insured in the same financial position, as nearlyas possible, after the loss, as if he loses had not taken place at all. It would beagainst public policy to allow an insured to make a profit out of his loss or damage.

    2.Utmost Good FaithSince insurance shifts risk from one party to another, it is essential that there must

    be utmost good faith and mutual confidence between the insured and the insurer. Ina contract of insurance the insured knows

    More about the subject matter of the contract than the insurer. Consequently, heisduty bound to disclose accurately all material facts and nothing should be withheldor concealed. Any fact is material, which goes to the root of the contractor

    insurance and has a bearing on the risk involved. It is only when the insurer knowsthe whole truth that he is in a position to judge

    (a)Whether he should accept the risk and

    b) What premium he should charge.

    If that were so, the insured might be tempted to bring about the event insuredagainst in order to get money.

    3. Insurable InterestA contract of insurance affected without insurable interest is void. It means that theinsured must have an actual pecuniary interest and not a mere anxietyor sentimental interest in the subject matter of the insurance. The insured must beso situated with regard to the thing insured that he would have benefit by its

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    existence and loss from its destruction. The owner of a ship run a risk of losing hisship, the charterer of the ship runs a risk of losing his freight and the owner of thecargo incurs the risk of losing his goods and profit. So, all these persons havesomething at stake and all of them have insurable interest. It is the existence ofinsurable interest in a contract of insurance, which distinguishes it from a merewatering agreement.

    4.Causa ProximaThe rule of causa proxima means that the cause of the loss must be proximate

    or immediate and not remote. If the proximate cause of the loss is a peril insured

    against, the insured can recover. When a loss has been brought about by two

    or more causes, the question arises as to which is the causa proxima, although the

    result could not have happened without the remote cause. But if the loss is broughtabout by any cause attributable to the misconduct of the insured, the insurer is not

    liable.

    5.RiskIn a contract of insurance the insurer undertakes to protect the insured fromspecified loss and the insurer receive a premium for running the risk of such loss.Thus, risk must attach to a policy.

    6.Mitigation of LossIn the event of some mishap to the insured property, the insured must take allnecessary steps to mitigate or minimize the loss, just as any prudent person woulddo in those circumstances. If he does not do so, the insurer can avoid the paymentof loss attributable to his negligence. But it must be remembered that though theinsured is bound to do his best for his insurer, he is, not bound to do so at the

    risk of his life.

    7.SubrogationThe doctrine of subrogation is a corollary to the principle of indemnity and appliesonly to fire and marine insurance. According to it, when an insured has receivedfull indemnity in respect of his loss, all rights and remedies which he has against

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    third person will pass on to the insurer and will be exercised for his benefit until he

    (the insurer) recoups the amount he has paid under the policy. Itmust be clarifiedhere that the insurer's right of subrogation arises only when he has paid for the lossfor which he is liable under the policy and this right extend only to the rights and

    remedies available to the insured in respect of the thing to which the contract ofinsurance relates.

    8.ContributionWhere there are two or more insurance on one risk, the principle of contribution

    comes into play. The aim of contribution is to distribute the actual amount of loss

    among the different insurers who are liable for the same risk under

    different policies in respect of the same subject matter. Any one insurer may pay to

    the insured the full amount of the loss covered by the policy and then becomeentitled to contribution from his co-insurers in proportion to the amount which

    each has undertaken to pay in case of loss of the same subject-matter.

    In other words, the right of contribution arises when

    (I)There are different policies which relate to the same subject-matter

    (II) The policies cover the same peril which caused the loss, and

    (III) All the policies are in force at the time of the loss, and

    (IV) One of the insurers has paid to the insured more than his share of the loss.

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    CHAPTER 5

    TYPES OF MEDICLAIM POLICIES

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    TYPES OF MEDICLAIM POLICIES

    MEANING:

    Policies under this insurance, the insurer undertakes to indemnity the assured in

    consideration of certain payment, up to certain specified amount insured against

    for loss arising in respect of hospitalization or injury sustained by the insured

    person.

    Due to rapid population growth and more and more use of contamination of fond,

    water, and air etc., which leads to hospitalization are more frequent. To cater to the

    varying and increasing needs, different forms of cover are available.

    Types of policies:

    The following types of policies are issued by the insurance corporation in order to

    meet the public at large:

    I. Mediclaim policy (Individual):Coverage: the policy provides for the hospitalization/domiciliary hospitalization

    expenses for illness/diseases or injuries sustained.

    Expenses on hospitalization is payable when the insured is admitted in the hospital

    for a minimum period of 24 hours. An individual can opt for the sum insured

    ranging from Rs.15, 000 to Rs.5, 00,000 in multiples of Rs.5, 000.

    Eligibility: People in the between age group of 5 and 80 years are eligible for the

    policy. Children between the ages of 3 months to 5 years can be covered provided

    one or both parents opt mediclaim over.

    Benefits:Reimbursement of hospitalization/domiciliary hospitalization expenses as

    mentioned above. Family discount- a discount of 10% in the total premium is

    available if the policyholder is opting cover under the policy for anyone of the

    following: spouse, dependent children, and dependent parents. Cost of health

    checkups- this cost is payable to the insured at the end of every four year block

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    provided there is no claim reported during the block. The cost reimburse will be

    the amount equal to 1% of the averages suminsured during the block. Premium ofRs.15, 000 is exempted under income tax section 80D, if paid bycheque.

    Conditions:

    Any event giving rise to claim under the policy should be informed

    or communicated to the insurance company in writing within 7 days from the date

    of injury, hospitalization/ domiciliary hospitalization.

    Claim must be filed within 30 days from the date of discharge from the hospital.

    The company will not be liable for any payment for claim, which are fraudulent

    or supported by any fraudulent device.

    II. Group medical policy:

    The group medical policy will be available to pay or association, institution

    or corporate body of more than 50 persons provided it has central administration

    point. Each insurer should cover all eligible candidates under one group policy

    only which means that different categories of eligible members are not allowed to

    be covered under different group Medicalim policies.

    The group discount is permissible depending upon the total number of insured

    person covered under the group mediclaim policy at the inception of the policy. It

    is to be noted that no discount is offered to a group with less than 101 members.

    III. Overseas Mediclaim policy:

    Overseas Mediclaim policy was originally introduced in 1984 to provide payment

    of medical expenses incurred in respect of illness suffered or sustained by Indian

    resident during their overseas trips. The insurance scheme, since 1984 has been

    modified several times to provide for additional benefits like in-fight personal

    accident, loss of passport etc. in the year 1991, employment of study policy was

    introduced for Indian citizens temporarily living abroad.

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    There are two type of plan under overseas mediclaim policy:

    Standard cover.

    Videsh yatra mitra.

    Eligibility:

    The policy is available to the following person: Indian residents traveling abroad

    for the following purposes:

    Business

    Official

    Holiday tour

    Professional Training

    Accompanying spouse and children of the person going aboard will be treated as

    going under holiday travel.

    Age limit:

    Adults: the age limit is 70 years. Adults between the age of 70 and 80 years can be

    covered at the discretion of the insurer by loading the premium and persons above80, years can also be covered provided the insurance company's head office

    accepts the proposal.

    Benefits:

    The following are the important benefits of overseas medical policy:

    Reimbursements of medical expenses of the insured during his/her stay abroad.

    Automatic extension of insurance period.

    In the event of claim, services will be provided by M/s. Mercury internationalassistance and claims limited, whose services are available all over the world.

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    If the insured is required to be sent back, to the home country on account of

    sickness suffered or injury sustained, the expenses incurred therewith are also paid.

    An amount up to $225 for immediate relief of dental plan is alsopayable with the

    approval of M/s. Mercury.

    All the expenses are reimbursed in the local currency of the country

    IV.Jan Arogya Bima Policy:

    The coverage under this policy can be considered, to a certain extent, along the

    lines of individual mediclaim policy expect that cumulative bonus and mediclaim

    check up benefits are not included. The above plan covers the risks orreimbursement in respect of hospitalization and domiciliary hospitalization up to

    Rs.5000 per person per annum. The salient feature of the scheme is granted only

    for the benefits of the lower income of society and common masses.

    V. Cancer policy:

    This policy is designed to meet the risks or coverage for the members of the

    cancer patient aid association. There are two schemes available for cancer policy:

    a. Indian cancer society

    b. Cancer Patients Aid Association.

    This policy is introduced in collaboration with Indian Cancer Society can

    avail of the benefits of this scheme. The policy lapses immediately if the insured

    ceases to be a member of the Cancer society for any reason whatsoever. On

    payment of the prescribed membership fees, which is included in insurance

    premium during the currency of the policy suffers from cancer; the policy will pay

    up toRs. 50, 000 to meet the cost of diagnosis, biopsy, chemotherapy,hospitalization and rehabilitation.

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    VI. Bhavishya Arogya Policy:

    This scheme had been designed so as to enable a person to provide himself

    for medical needs during an old age security. Under this policy the medical

    expenses to be incurred over the balance life span after a predetermined age ofretirement will be reimbursed up to the amount of the sum insured with a limit of

    an amount per any one illness or injury. The amount of maximum total benefits

    available under the basic policy is Rs. 50, 000 during the lifetime of the insured

    commencing from the policy retirement age and is not to exceed Rs. 20, 000.

    VII. Videsh Yatra Mitra Policy:

    Videsh yatra policy is another overseas mediclaim scheme introduced

    by general Insurance Corporation with effect from1998. This policy provides the

    widest cover of personal accident, loss of checked baggage, loss of passport,

    medical expenses and repatriation, delay of checked baggage, personal liability etc.

    insured person is that person named in the overseas policy schedule, for which the

    appropriate premium had been paid. The policy is valued only from the first day of

    insurance and expires on the last day of the number of days specified in the policy

    schedule or on return to India whichever is

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    MAJOR MEDICAL INSURANCEA NEW TYPE OF

    INDIVIDUAL HEALTH INSURANCE

    Major medical insurance is designed to pay a high proportion of the covered

    expenses of a catastrophic illness or injury. This type of plans is often sold in

    conjunction with a hospitalization and surgical plan, and is aimed at covering costs

    that a normal hospitalization plan does not cover. Most such plans include the

    following characteristics:

    1. Extensive coverage:Usually the major medical insurance coverage is wide and includes all the

    reasonable and essential medical expenses and other related expenses from a

    covered illness or injury.

    2. Generous Maximum Limits:Many of such plans offered overseas have generous lifetime limits ranging

    from$300,000 to a million or even more. Locally, the limits offered are often less,

    but still considered high relative to the cost of major illness treatments. A high

    limit is necessary because the purpose of having such plans is to cover catastrophic

    losses that a normal hospitalization plan does not cover.

    3. Benefit Period:A benefit period is the length of time that the plans benefits will be paid after

    the deductible is satisfied. At the end of the benefit period, the insured has to

    satisfy afresh deductible in order to establish a new benefit period. The purpose of

    the benefit period is to grant a definite period within qualified medical expenses for

    a particular disease or injury must be incurred in order to reimburse under

    the policy.

    4. Deductible:Deductible are the stated amounts each claim has to satisfy before any

    payments of the benefits are made. The purpose od deductibles is to eliminate

    small claims that a pose a relatively high processing cost to insures. This will help

    insurers keep the premiums for major medical plans reasonable.

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    5. Co-Insurance:A co-insurance is a policy provision that requires the insured to pay a

    certain percentage of the eligible medical expenses in excess of the deductible.

    The purpose of this clause is to reduce premium and prevent over utilization ofpolicy benefits. Since the insured has to pay part of the bill, premiums can be

    offered at cheaper rates. Another purpose of the provision is to discourage the

    patients from simply choosing the most costly medical services while lower-

    cost versions are available and are just as good.

    6. Exclusions :Like all types of insurance policies, major medical plans contain exclusion

    clauses. Some of the common exclusions that are found in such plans are as

    follows:

    Expanses incurred as a result of war or military conflict.

    Optional cosmetic surgery.

    Normal dental care.

    Pregnancy and childbirth, except for complication that arises as a result

    of childbirth.

    Experimental surgery

    To further control cost, internal limits are sometimes imposed on the plan. There

    may be in the form of annual or lifetime limits on the amount paid for certain

    diseases.

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    Different policy offered by companies

    The New India Assurance Co Ltd

    Who can take this policy

    This insurance is available to persons between the age of 18 years to 60 years.Children between the ages of 3 months to 18 years can be covered provided

    parents are covered simultaneously. The persons beyond 60 years can continuetheir insurance provided they are insured under Mediclaim policy with ourCompany without any break.

    What does this policy cover?The policy covers hospitalization expenses for the treatment ofillness/injury provided hospitalizations is more than 24 hours. Pre-hospitalizationexpenses for 30 days and post hospitalization expenses for 60 days are also

    payable.

    Day-care treatment - The Medical expense towards specific technologicallyadvanced day-care treatments / surgeries where 24 hour hospitalization is notrequired.

    Ambulance Charges for shifting the insured from residence to hospital are coveredup to the limits specified in the policy.

    Ayurvedic / Homeopathic and Unani system of medicine are covered to the extent

    of 25% of Sum Insured provided the treatment is taken in the Government

    Hospital.

    Pre-existing diseases are covered only after 4 continuous and claim free renewalswith our Company.Pre-existing conditions like Hypertension, Diabetes, and their

    complications are covered after two years of continuous insurance on payment ofadditional premium.

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    Exclusions:

    Diseases contracted within 30 days of insurance

    Dental treatment except arising out of accident.

    Debility and General Run down Conditions.

    Sexually transmitted diseases and HIV (AIDS)

    Circumcision, Cosmetic surgery, Plastic surgery unless required to treat injury orillness

    Vaccination and Inoculation

    Pregnancy and child birth

    War, Act of foreign enemy, ionizing radiation and nuclear weapon.

    Treatment outside India

    Naturopathy

    Domiciliary Treatment

    Experimental or unproven treatment

    All external equipments such as contact lenses, cochlear implants etc

    Premium:

    Premium is based on age of the proposer and geographical area of treatment.

    Special features of the policy:

    Discount in premium for family cover

    Loyalty Discount

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    Good Health Discount

    Cumulative Bonus

    Cost of Health Check up

    Income Tax Benefit under Section 80D of IT Act.

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    National Insurance

    . Salient Feature

    Hospitalization for illness,

    Disease

    Accident, including surgery

    2. Scope of Cover

    Mediclaim insurance policy has been devised under the aegis of the Government

    of India.

    The policy provides the following benefits.

    1) Reimbursement of hospitalization expenses which are reasonably andnecessarily incurred,

    Under the following heads:

    a) Room, boarding expenses as provided by the hospital/nursing home.

    b) Nursing expenses.

    c) Fees of surgeon, anesthetist, medical practitioner, consultant and specialist.

    d) Expenses on account of anesthesia, blood, oxygen, operation theatre charges,

    surgical Appliances, medicines and drugs, diagnostic material, X-ray, dialysis,

    chemotherapy, Radiotherapy cost of pacemaker, artificial limbs and cost of organs

    and similar expenses.

    2) Introduction of Sub-Limits:

    The following provisions have been introduced:

    A. Room, Board and Nursing Expenses as provided by the Hospital /Nursing

    Home- Room Rent limit: 1 % of the Sum Insured per day subject to maximum

    of Rs.5000./-. I.C. Unit Expenses: 2 % of Sum Insured per day subject to

    maximum of Rs. 10,000/-. Over all limits under this head: 25% of S.I. per illness.

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    B. Surgeon, Anesthetist, Medical Practitioner, Consultants Special fees

    maximum limits per Illness25% of S.I.

    C.Anesthesia, Blood, Oxygen, OT charges, Surgical appliance, Medicines,

    drugs,Diagnostic Material & X-Ray, Dialysis, Chemotherapy, Radiotherapy, costof pacemaker, artificial limbs And cost of stint and implant. Maximum limit

    per illness50% of Sum Insured.

    D. Ambulance services - 1% of the sum insured subject to maximum of Rs 1000/-

    provided Registered ambulance is used for shifting patient from residence

    tohospital if admitted to ICU or emergency ward OR from one hospital to

    another subject to sub-limits under c above

    E. Hospitalization expenses of person donating an organ during the course of organtransplant Will also be payable subject to the sub-limits under c above.

    3) Premium paid for the policy towards self, spouse, dependent childrenanddependent parents are exempt from Income Tax under Sec. 80D of the l.T.Act.

    4) Cost of Health Check Up and Cumulative Bonus - Benefits will accrue onlyif the Policy is a renewal

    Of National.

    3. Additional Features

    1) Definition of Family:A)Self (Primary Insured).B) Spouse.C) Dependent Children (i.e. legitimate or legally adopted children). Children above18 years, if employed, can not be covered. Male children, if not employed, but a

    bonafide student can be covered up toage of 25 years. Female children, if notemployed, can be covered until the time she is married.

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    D) Dependent parents. All members of the family must be covered under onepolicy.

    2) Entry Age:This insurance is available to a person between the age of 18 to 59 years.

    However, the Policy can be renewed upto the age of 80 years as stipulated in

    the premium chart above.

    a) Children above the age of 3 months can be covered provided parents are covered

    concurrently and suitable premium is paid. If the child above 18 years is employed

    or if the Girl child is married, he or she shall cease to be covered under the policy.

    However male child can be covered up to the age of 25 years if he is a bonafide

    regular student and fully dependent on primary insured. Female child can becovered up to the time, she is unmarried.

    b) If the insured has taken continuous Mediclaim insurance policy with us for at

    least 5 years prior to attaining the age of 80 years the policy can be

    renewed beyond the age of 80 up to the age of 90 years as a special case with the

    approval of Regional In charge on case to case basis. The premium chargeable

    shall be 10%of the premium for 75-80 years age slabs for proposers above 85 and

    20% of the premium for 75-80 age slabs for proposers above 90.

    c) No inclusion of family member during currency of policy is permissible except

    for a new born child between the age of 3 months to 6 months and newly married

    spouse within 60 days of marriage. Otherwise inclusion of family member shall be

    allowed only at the time of Renewal. Prorata premium shall be charged for such

    inclusion during the currency of the policy for the unexpired period.

    3) Sum Insured: Minimum sum insured shall be Rs 50,000/- and can be increasedin multiples of Rs25,000/-up to Rs 5 lacs. The sum insured must be identical for

    primary insured and the dependents. However, the children may be covered for50% Sum Insured as per item no. 2 above.

    4)TPA option: The premium includes cashless facility through TPA. If thepolicyholder does not require cashless facility then 6% discount on premium maybe given.

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    5) Pre -Acceptance Health Checkup:Pre acceptance health check-up is mandatorywhen age is 50 years and above and he/she is seeking insurance cover for the firsttime as an individual or as member of a family where there is break in Insuranceincrease in sum insured on renewal.

    Propose/Insured Person will be required to undergo the following Medical Check-up or any other medical test as required by the Company either on his/her ownor from its authorized Network Diagnostic Centre in prescribed format. The costshall be borne by the insured.

    If the insured was covered under any Health Insurance Policy of National

    uninterruptedly for

    Preceding 3 years, no pre-acceptance Medical check up is required.

    PHYSICAL EXAMINATION

    BLOOD

    URINE SUGAR

    BLOODPRESSURE

    ECHO CARDIOGRAPHY

    EYE CHECK UP

    MEDICAL TEST CHECKUP INCLUDING

    RETINOSCOPY

    Age(in years) 50 and above

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    4. Exclusions

    The most important exclusion relates to pre-existing illness. If the insuring personhad a health condition, existing prior to taking the policy, which required medical

    treatment, the same gets automatically excluded in the policy. To ensure that insubsequent renewals medical conditions.

    Incepting since the policy was taken do not get excluded, the insuring person mustrenew the policy without break. The other exclusions for illustrative purposes are:-

    a) Exclusion of certain named diseases in the first year of the policy.

    b) Congenital external disease, sterility, venereal disease, intentional self-injury,

    use of drugs, Alcohol, rest cure etc.

    c) AIDS

    d) Charges primarily for diagnostic, laboratory examinations, and not related toany treatment in hospital. So also for vitamins and tonics unless prescribedfor treatment.

    e) Dental treatment not requiring hospitalization.

    f) Treatment arising from or traceable to pregnancy, childbirth, includingcaesarean.

    g) Naturopathy treatment.

    EXCLUSION 4.a, 4.b & 4.c have been amended . Pre-existing diseases shall becovered after 4 continuous claims free Policy years with National. However,incase of exclusion 4.3, for renewals, Existing condition shall apply, i.e. the oneyear exclusion applicable earlier shall be valid

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    BENEFITS OF MEDICLAIM

    Benefits of a Mediclaim policy are many. Some of which arelisted below.

    1) First and foremost the Mediclaim policy offers you a chance to get yourmedical expenses covered under a policy. Thus it takes care of thehospitalization fees. Protects the person or family (in case of family plan) forhospitalization expenses as a result of any specific injury or illness which hastaken place during the period of insurance and on the advice of a doctorrequires hospitalization.

    2) Pre hospitalization expenses for the person or the insurer and also to go with itPost-Hospitalization Expenses:

    Post Hospitalization expenses are medical expensesincurred during a period up to aspecific number of days after hospitalization for the particular ailment disease orinjury is over but still needs expenditures in order to completely become normal.

    3) If you have a health insurance policy that supports cashless Mediclaim, it meansthat you can get medical treatment just by displaying your insurance card

    without paying any cash to the hospital. Most health insurance companies offer thisbenefit. Some times the benefits may be applicable only to a certain number ofhospitals or medical centers.

    4) Some of the insurance policies also provide tax benefits. These tax benefitsare provided to the person under the name of whom the insurance policy has beenassigned. Under the Section 80D, tax benefits are provided to people who get aMediclaim policy done in their n

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    WIDER HEALTH COVER FOR POOR

    New Delhi: With assembly elections in six states and general elections just months

    away , t h e g o v e r n m en t i s p l an n i n g t o ex p an d t h e s co p e o f i t s

    health insurance schemes for the poor. At a marginal premium, familiesabove poverty line (ALP)c o u l d a l s o g e t t h e b e n e f i t o f i n s u r a n c e

    c o v e r i f t h e p r o p o s a l g o e s t h r o u g h . The health ministry is planning

    to modify the scope of its yet-to take-off Rs 8,000-crore National Urban Health

    Mission (NUHM) for the urban poor to cover services like outpatient care, which

    are not covered by the Rashtriya Swasthya Bima Yojana(RSBY). Health secretary

    Naresh Dayal told ET that his ministry was exploring the op t i on o f

    m o d i f y i n g t h e p r o p o sed i n su r an ce sch em e u n d e r NUHM so t h a t

    t h e u r b an p o o r c an g e t ad d i t i o n a l b en e f i t s . Th e g o v e r n m en t i s

    a ls o e xa mi ni ng t he p o s s i b i l i t y o f r a i s i n g t h e c o v e r f r o m R s

    3 0 , 0 0 0 i n i t i a l l y p r o p o s e d . T h e s e suggestions came up at a

    meeting of senior government officials last week. APL families are not

    covered under RSBY. NUHM was announced in March this year by

    health minister Anbumani Ramadoss and was to be launched in four

    months. However, in April, the labour ministry operationalised RSBY

    announced last year for workers in the unorganized sector. Now, the health

    ministry, which was all set to kick start NUHM on the lines of the National

    Rural Health Mission, is thinking of re-designing the insurance component of

    this ambitious programmed.We are looking at a variety of options. We

    may either launch the programmed with better reach and coverage or

    wil l modify it and cover those areas that have been left out by the labor

    ministry. Once things get finalized, we will take it to the Cabinet for approval. All

    this may take 3-4 months, Mr Dayal told ET.

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    DATABASE OF MEDICLAIM INSURANCE

    General Insurance Corporation through its four subsidiaries: Oriental

    Insurance, Ne w In di a As su ra nc e, Na ti on al Insurance Company,

    Un i t ed I n d i a I n su r an ce .

    Age:

    Between 5 - 80 years. Children between 3 months and 5 years can be

    cov e re d pr ov id ed o ne o r b ot h parents are also covered.

    Coverage:

    Insures against any hospitalization expenses that may arise in future. The scheme

    r e i m b u r se s h o sp i t a l i z a t i o n ex p en se s f o r i l l n e s s , d i s ea se so r injurysustained, excludes any disease existing before taking the policy.

    Cost:

    Suminsuredcan be anywhere between Rs 15,000 - Rs 500,000. Rate of premium

    ranges between Rs 175 per year to Rs 2,500 per year depending on the

    age and capital sum insured.

    Amount:

    Compensationup to the extent of sum insured.

    http://www.medindia.net/patients/insurance/health_mediclaim.htmhttp://www.medindia.net/patients/insurance/health_mediclaim.htmhttp://www.medindia.net/patients/insurance/health_mediclaim.htmhttp://www.medindia.net/patients/insurance/health_mediclaim.htmhttp://www.medindia.net/patients/insurance/health_mediclaim.htmhttp://www.medindia.net/patients/insurance/health_mediclaim.htmhttp://www.medindia.net/patients/insurance/health_mediclaim.htmhttp://www.medindia.net/patients/insurance/health_mediclaim.htmhttp://www.medindia.net/patients/insurance/health_mediclaim.htmhttp://www.medindia.net/patients/insurance/health_mediclaim.htmhttp://www.medindia.net/patients/insurance/health_mediclaim.htm
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    DOCUMENTS REQUIRED

    Given below is a general list of documents that are required in case of a claim.

    1. Duly completed claim form (available with all network hospitals).

    2. Original bills, receipts and discharge certificate / card from the hospital.

    3. Bills from chemists supported by proper prescription

    4. Investigation test reports and payment receipts, supported by the note from

    attending medical practitioner / surgeon prescribing the test.

    5. Doctorsreferral letter advising hospitalization in non-accidental cases.

    6. Nature of operation performed and surgeons bill and receipt.

    7.Any other documentation / information as required by the Service

    Provider/TPA.

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    MEDICLAIM RENEWAL BY INSURERS MUST

    BEAUTOMATIC, RULES BY SUPREMECOURT

    The Supreme Court has ruled that insurance companies are obliged to renew the

    mediclaim policy automatically unless otherwise mutually agreed betweeninsurer and insured.

    A bench comprising Justice SB Sinha and Justice VS Sirpurkar also asked

    theregulator (Irda) to lay down guidelines to check the imposition of arbitrary

    clausesof mediclaim policy and its renewal. The court said, Renewal of a

    mediclaimpolicy subject to just exceptions should ordinarily be made.

    But where a renewal is based on mutual consent, there may be no automatic

    renewal. A mediclaim policy in which a senior citizen is involved would stand on adifferent footing. It will depend upon the contract entered into between the parties

    and the statutes operating in the field as also the constitutional scheme, court said.

    It rejected the plea of some public sector insurance companies, which had said that

    wherever renewal is subject to mutual consent of the parties, it might be at its

    whims and caprice to refuse the renewal of the policy.

    The insurance companies cannot, either in their prospectus or in the terms

    of policy, lay down any condition which would be derogatory to the terms and

    conditions approved by the regulatory authority. If the contract of insurance

    itself provides for renewal of an insurance policy the same may not mean that the

    assured has a legal right of automatic renewal, but the courts are required to strike

    A balance said Justice Sinha writing the verdict. The court asked the authorities

    concerned to lay down guidelines in this regard. We would like to observe that

    keeping in view the role played by the insurance companies, it is essential that the

    regulatory authority must lay down clear guidelines by way of regulations or

    otherwise. No doubt, the regulations would be applicable to all the players in thefield... the court said. The duties and functionsof the regulatory authority,

    however, are to see that the service provider mustrender their services keeping in

    view the nature thereof. It will be appropriate if thecentral government or the

    general insurance companies also issue requisitecirculars, the court said.It further

    said, We would request the IRDA to consider the matter indepth and undertake a

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    scrutiny of such claims so that in the event it is found that the insurance companies

    are taking recourse to arbitrary methodologies in the matter of entering into

    contracts of insurance or renewal thereof, appropriate steps on that behalf may be

    taken.

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    CASHLESS CLAIM PROCEDURE

    When should you claim?

    There are a host of benefits for having a claim-free policy, the most

    important being additional cover at the same premium, but the whole purpose of

    health insurance is to provide for your medical expenses. However, you must make

    your claims prudently. So, you should not make small claims. To choose which

    claims are worth making, get the numbers right! Check if by making a claim, the

    no-claim bonus you forfeit and the 10 per cent of cumulative bonus cover you lose

    will exceed the compensation you get. If it does, it makes sense not to make a

    claim but pay for the expenses you? Claim only if the amount is on the higher side

    and you it makes sense to forfeit the no claim bonus. Also keep in mind that in thelong term, it will reflect on your records and will the insurer will penalize you with

    an extra load on your premiums.

    How would you claim?

    1.Select a hospital from your service provider's network hospital tie-ups.Check the

    Network Hospitals booklet mailed to you or visits your service provider's website.

    However, do note that the hospital booklet might not be updated. Your provider

    may include or exclude hospitals without giving prior information. It is advisable

    to check the updated list from the website or contact them directly for information.

    2. Produce your cashless card in the chosen hospital

    Prior hospitalization.

    3.Fill in the Pre-authorization form with the insurance details. The hospital shallfill in information regarding the diagnosis, treatment plan, past history and the

    expected of the cost of treatment. The pre-authorization form can be availed at the

    hospital or downloaded from the service provider's website.

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    4. The hospital shall then fax the signed and stamped form to the service provider.

    5. The service provider then evaluates the documents and classifies the case as

    Approved, Queried or Rejected. Accordingly, the

    Authorization form would be faxed to the hospital.

    6. It is advisable to follow the above procedure and get the Authorization

    Letter before getting admitted to avoid any disappointments. However, in case

    of an Emergency Hospitalization, the authorization form can be obtained

    after admission.

    7. Note that the Cashless Authorization does not cover: Attendant/Visitor pass

    charges

    Ambulance chargesunless covered under the policy

    Special nursing charges not authorized by the attending doctor

    Charges for extra bed for attendant

    Purchase of Medicines not related to the treatment

    Claimssome important notes

    Telephone/Fax charges. Claims must be authorized by us before you go ahead

    with treatment. This can be done by calling Customer Support on0300 123 3200.

    By doing so you can go ahead with the treatment, safe in the knowledge that you

    are covered

    Emergency treatment is not covered. Once your condition has been stabilized and

    if your consultant agrees, you can be transferred (with our prior approval) to

    private facilities or become a private patient within the NHS

    Claims will not be paid if your premiums are not up to date

    All claims made in the first year of the policy will be referred toour Chief Medical

    Officer

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    Additional information may be required from your GP at the time of claim

    If a claim can be paid under another insurance policy or by anyone else, we will

    only pay the proper share.

    The main reasons for claim not being passed in full are

    Insured has preexisting disease and it was already mentioned in policy document

    as exclusion.

    The specific diseases are not covered under the policy

    Disease is a preexisting disease and it was not revealed by the insured at the timeof issue of policy.

    The main reasons for claim being passed in part are :

    Some of the tests conducted/treatment were not relevant to the disease for which

    patient was admitted.

    Some costs like consumables are not payable by the insurance company.

    Examples are :-

    With a view to cover some of these payments some TPA's insist that 5% of the

    hospital bill will be paid by the patient. You should not be surprised if you are

    asked to pay 5% of the bill even if you are covered under cashless scheme. In the

    event of consumables are not 5% or more than 5% there is good possibility that

    you may get part of this paid to you at time of finalization of their claim.

    As a customer you should see that information being given at time ofadmission

    into the hospital, discharge certificate, claim form is consistent. Any follow up

    letter being sent to the insurance company should be well drafted and consistent tothe claim lodged.

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    NEED FOR MEDICLAIM INSURANCE

    You are expected to live longer than your parents or grandparents. An average

    Indian used to live for barely 40 years at the time of Independence. By 2016, an

    average Indian would live for about 68 or 70 years.

    Life can come at you fast. It's simply impossible to know what's around the corner.

    This is why we all have to take necessary precautions. In other words; do you have

    health insurance? Some people actually have no medical insurance whatsoever.

    This is completely absurd in the unpredictable world we live in. That random fall

    or dreadful car accident could happen today. Are you prepared to grapple with

    those hospital bills? The fact is, medical insurance is just an inevitability of life.You always want to have it just in case. If the time does arise when you need it,

    you will thank God you planned ahead.

    However, a longer life need not mean healthier life. Lifestyle-related diseases such

    as high blood pressure, diabetes, obesity, and extraordinary stress are all on the

    rise. In short, we are looking at a combination of longer but possibly a less healthy

    life span. At the same time, healthcare costs have been escalating rapidly.

    Landing up in hospital is the last thing we want to think about. It happens to

    someone else not meyou think. But we all go through tough times and only the

    ones that plan ahead come out unscathed. The massive cost of treatment is a

    double-whammy for many who already have to contend with the illness. If you

    become seriously ill, your entire wealth accumulated over decades can disappear in

    combating the illness. If your savings can vanish in the blink of the eye what is thebest solution? The answer to this ominous question is opting for health insurance.

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    WHY MEDICLAIM INSURANCE IS A MUST (Example)

    I heard a story recently from an acquaintance of mine who has no medical

    insurance. She never expected to use such a thing. Sure, maybe dental on

    occasion, but never medical. I mean come on, the girl's only 23 years old. Whatcould happen? Well, this is what happened. She manages a truck stop, and while

    conversing with an employee one night, a brute strolls in with a nasty temper.

    Before she knew it, the employee she was conversing with is being attacked by

    the brute. Now, when she decided to intervene and be the hero, she was stabbed in

    the shoulder. Wow, what a reality check. You try and do the right thing, and life

    smacks you in the face. Now comes the problem with having no medical insurance.

    After being hospitalized for a couple weeks, her medical bills are now around

    30grand. However, this is not the end of it. She still has to go through physicaltherapy; not to mention the mental anguish of almost dying. How much will

    the psychiatrist charge? The point is, you simply can't know what's in store for you.

    Life is so random for us all. I wanted to use this girl's recent story as an

    example because it's true. Sure it's sad, but still reality.

    These days, no medical insurance equals trouble down the road. Even a

    minor hospitalization can set you back for a long while. The problem is that mostof us dont believe that we will ever use it. Get rid of your fantasies and purchase

    decent medical insurance plan today. Don't end up in the emergency room with

    nonmedical insurance. If nothing else, insurance offers you piece of mind.

    Although I have not used my medical insurance yet, I understand I may need it in

    the future. I choose to be prepared for what lies ahead.

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    PRECAUTIONARY MEASURES TO BE TAKEN

    The following must first take root,

    Judicial reforms that clearly link compensation along with avoidable errors.

    Government support for a nationwide response to medical error costs.

    Development of initiatives by health insurance firms to reduce the number

    of avoidable errors.

    State and local support for further uniformity in model regulations and rules.

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    IRDA MAY ENSURE AFFORDABLE HEALTH

    COVER TO ALL, EVEN AFTER 65 YEARS

    Hyderabad: Senior citizens have good chances of getting a health cover even

    after they turn 65. Insurance regulator IRDA is vetting a proposal to make healthcover affordable to all senior citizens. A final view will be taken on providing

    guaranteed access to health insurance for this segment by the end of this year, said

    a top official of the regulatory body. The proposal is based on the

    recommendations of an expert panel on health insurance last year. The panel

    recommended allowing senior citizens to enter the health insurance system up to

    65 years of ageor higherat the discretion of the insurer.

    If they do so, they should be given guaranteed renewal of their insurance without

    any upper age limit. As a transitional measure since guaranteed access isbeing provided to senior citizens for the first timethere should be no upper age

    limit for entry or renewal for a period of three years from the date the IRDA issues

    the regulations, the panel had said. It had made out a case for insurers to fix a

    baseprice of Rs 3,000 every year for a sum insured of Rs 1,00,000 (at 50 years).

    Weare examining these recommendations of the panel we reckon that health

    insurance should be made affordable, given the mounting health care-costs, said

    DVS Sastry, director general, IRDA at a seminar on effective cross selling of

    insurance and mutual fund products organized by Watson Wyatt and the IndianInstitute of Banking and Finance here. Several senior citizens have registered

    complaints withthe regulator about insurance companies denying renewals.

    Industry experts, however, reckon that people should enter health insurance

    schemes at an early age to enable insurance companies distribute their risks

    better. Currently, health insurance penetration is minuscule in India. The total

    premium from health insurance stood at Rs 4,970 crore in FY 08, marking a 55%

    growth over FY07.Currently, there are only two standalone healthStar Health

    and Allied Insurance and Apollo DKV offering pure health products. Thegovernment is looking at raising the cap on foreign direct investment (FDI) in

    insurance from 26% to 49%. It is also considering a minimum capital requirement

    of Rs 50 crore for health insurance companies to make it attractive for new-

    entrants. Consumers are expected to get a better deal in terms of pricing whencompetition intensifies among these players.

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    Deduction U/s 80D for mediclaim premium available to

    individual HUF and senior citizen

    Deduction in respect of Medical Insurance Premium (Mediclaim) paid to keep in

    force insurance by individual either on his own health or on the health of spouse,

    dependent parents and children or HUF on the health of any members of the

    family. A Mediclaim policy is a must because should you fall sick or meet with an

    accident, your medical bills could wipe out your savings.

    Features of Mediclaim policy

    1. Premium based on Age:- As in term insurance, the premium rates willvary among the insurers and will also depend on your age. The older you are,the heftier the premium. For instance, Mediclaim policy from GeneralInsurance Corporation has a fixed premium till 35 years and then it changes in10-year slabs.

    2. Who is it available to?Individual (resident or nonresident, Indian Citizen or foreign citizen):- Incase an

    individual is taking the deduction, the medical insurance policy can be taken in the

    name of any of the following: the taxpayer or the spouse, parents or dependent

    children* of the taxpayer.

    HUF(Hindu undivided Family may be resident or nonresident) :- In case a HUF is

    taking the deduction, the medical insurance policy can be taken in the name of any

    member of the family.

    Note

    Dependent Children (i.e. legitimate or legally adopted children). Children above

    18 years, if employed, can not be covered. Male children, if not employed, but abonafide student can be covered up to age of 25 years. Female children, if not

    employed, can be covered until the time she is married.

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    Parents need bot be dependent on the Assesses.

    Parents of Individual or Spouse both are covered.

    3.Entry Age: This insurance is available to a person between the age of 18 to59years. However, the Policy can be renewed up to the age of 80 years.

    a) Children above the age of 3 months can be covered provided parents arecovered concurrently and suitable premium is paid. If the child above 18 yearsis employed or if the girl child is married, he or she shall cease to be coveredunder the policy. However male child can be covered up to the age of25 years if he is a bonafide reg ula r st ude nt and ful ly dep end enton primary insured. Female child can be covered up to the time,she is unmarried.

    b) If the insured has taken continuous Mediclaim insurance policywi th us for a t leas t 5 years pr ior to a t ta in ing the age of 80years the policy can be renewed beyond the age of 80 up to the ageof 90 years as a special case with the approval of Regional In charge on caseto case basis. The premium chargeable shall be 10%of the premium for 75-80years age slabs for proposers above 85 and 20% of the premium for 75-80 ageslabs for proposers above 90.

    c)

    No inclusion of family member during currency of policy is permissibleexcept for a new born child between the ages of 3 months to 6 months andnewly married spouse within 60 days of marriage. Otherwise inclusion offamily member shall be allowed only at the time of renewal. Pro rata

    premium shall be charged for such inclusion during the currency of thepolicy for the unexpired period.

    4. Sum Insured:Minimum sum insured shall be Rs 50,000/- and can be increasedin multiples of Rs

    25,000/-upto Rs 5 lacs. The sum insured must be identical for primary insured and

    the dependents. However, the children may be covered for 50% Sum Insured as per

    4 above.

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    5. Payment of Mediclaim Premium out of taxable Income:-The amount must have

    beenpaid using the taxpayers income chargeable to tax.

    6. In addition to deduction u/s, 80C, 80CC and 80CCD,:- This is an additional

    deduction available which do not include deduction u/s80C, 80CCC and

    80CCD for which overall limit is Rs. 1,00,000.

    7. Partly contribution: If part payment is done by you and part payment by

    the parent, both can claim deduction to the extent of their contribution subject to

    maximum allowed but amount should be paid directly to insurance company

    and paid through mode other than by cash.8.

    8. Mode of payment:

    The premium may be paid by any mode of payment

    other than cash. Note prior to 1st April 2009, premium payment was required to be

    done only by cheque. Credit card or other online payment mechanism where not

    allowed. Now all payment modes except cash payment are accepted.9.

    9. Which Mediclaim Premium is allowed? : -

    Mediclaim premium paid

    under Medical insurance scheme of General Insurance Corporation approved by

    the Central Government, or any other insurer approved by the Insurance

    Regulatory &Development Authority (IRDA).10.

    10.What is the amount of the deduction?

    For Individual

    Basic deduction: Mediclaim premium paid for Self, Spouse or dependantchildren. Maximum deduction Rs 15,000. In case any of the personsspecified above is a senior citizen (i.e. 65 years or more as of end of the

    year) and Mediclaim Insurance premium is paid for such senior citizen,

    deduction amount is enhanced to Rs. 20,000.

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    Additional deduction: Mediclaim premium paid for parents. Maximumdeduction Rs 15,000. In case any of the parents covered by the

    Mediclaim policy is a senior citizen, deduction amount is enhanced to Rs.

    20,000.

    For HUF

    Mediclaim premium paid for any member of the HUF. Maximum deductions15,000. In case any member of the HUF covered by the Mediclaim policy is a

    senior citizen, deduction amount is enhanced to Rs. 20,000.Senior citizen:

    means who is at least of 65 year of age or more at any time during the previous

    year.

    EXAMPLE- 1

    1. An individual assesses pays (through any mode other than cash) during

    the previous year medical insurance premium out of his taxable income, as under:

    (i) Rs 12,000/- to keep in force an insurance policy on his health and on the health

    of his wife and dependent children;

    (ii) Rs 17,000/- to keep in force an insurance policy on the health of his parents.Under the new provisions he will be allowed a deduction of Rs 27,000/-(Rs.

    12,000/- + Rs. 15,000/-) if neither of his parents is a senior citizen. However ,if any

    of his parents is a senior citizen, he will be allowed a deduction of Rs29,000/-

    (Rs.12,000/- + Rs.17,000/). Whether the parents are dependent or not, is not a

    consideration for deciding the deduction under the new provisions.

    Further, in the above example, if cost of insurance on the health of the parents is

    Rs30,000/-, out of which Rs 17,000/- is paid (by any non-cash mode) by the son

    and Rs 13,000/- by the father ( who is a senior citizen), out of their respective

    taxable income, the son will get a deduction of Rs17,000/- ( in addition to thededuction of Rs 12,000/- for the medical insurance on self and family) and the

    father will get deduction of Rs 13,000/-.

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    EXAMPLE 2

    An individual assessee pays through credit card during the previous year healthinsurance premium as under:1.Rs. 12,000 to keep in force an insurance policy on

    his health and on the health of his wife and children2.Rs. 17,000 to keep in force

    an insurance policy on the health of his parents.

    Under the proposed new provisions, he will be allowed a deduction of Rs.27,000(Rs. 12,000 + Rs. 15,000) if neither of his parents is a senior citizen.However, if any of his parents is a senior citizen, he will be allowed a deduction ofRs. 29,000(Rs . 12 ,00 0 + R s. 17, 000 ) . Whe th er t he p are nts aredependent or not, is not a consideration for deciding the deduction underSection 80D.

    EXAMPLE- 3

    Question:- In the last budget, the finance minister announced exemptionsfor Mediclaim charges paid for senior citizens. However, I am not sure if it hasyet been notified and effective. I need to take medical insurance for both my

    parents, who are senior citizens. I would appreciate if you can let me know.

    Answer:-Earlier Sec 80D deduction in respect of medical insurance premium wasRs 15,000 for an individual and Rs 20,000 for a senior citizen. However, from thisyear, if someone were to buy medical insurance for his parent/s, an additionaldeduction of Rs 15,000 (over and above Rs 15,000) will be available. Ifsuch parent/s were senior citizen, the additional deduction would be Rs 20,000. Soa person insuring himself, his spouse, children and parents could potentially get adeduction of Rs 35,000. This provision is effective from 1.4.08.

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    Appendix: Section 80D of the Income Tax Act

    Deduction in respect of medical insurance premium.

    80D. (1) In computing the total income of an assessee, being anindividual or a Hindu undivided family, there shall be deducted suchsum, as specified in sub-section (2) or sub-section (3), payment of which ismade by any mode, other than cash, in the previous year out of his incomechargeable to tax.

    (2) Where the assessee is an individual, the sum referred to in sub-section (1)shall be the aggregate of the following, namely:

    (a) the whole of the amount paid to effect or to keep in force aninsurance on the heal th of the assessee or h is fami ly as does notex ce ed in th e ag g r eg a te fi ft e en thousand rupees; and

    (b) the whole of the amount paid to effect or to keep in force aninsurance on the health of the parent or parents of the assessee as does notexceed in the aggregate fifteen thousand rupees.Explanation. For the purposes of clause (a), family means the spouse anddependant children of the assessee.

    (3) Where the assessee is a Hindu undivided family, the sum referred toin sub-section (1) shall be the whole of the amount paid to effect or tokeep in force an insurance on the health of any member of that Hindu undividedfamily as does not exceed in the aggregate fifteen thousand rupees.

    (4) Where the sum specified in clause (a) or clause (b) of sub-section (2) or in sub-sec t i o n ( 3 ) i s p a i d t o e f f ec t o r k eep i n f o r ce an i n su r an ce o nt he h ea l th o f an y person specified therein, and who is a senior citizen, the

    provisions of this section sha l l h ave e f f ec t a s i f fo r t he wo rd s f i f t een

    thousand rupees, the words twenty thousand rupees had beensubstituted.

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    Explanation. For the purposes of this sub-section, senior citizen means an

    individual resident in India who is of the age of sixty-five years or more at anytime

    during the relevant previous year.

    (5) The insurance referred to in this section shall be in accordance with a schememade in this behalf by

    (a) the General Insurance Corporation of India formed under section 9 of the

    General Insurance Business (Nationalization) Act, 1972 (57 of 1972) and

    approved by the Central Government in this behalf; or

    (b) any other insurer and approved by the Insurance Regulatory and Development

    Authority established under sub-section (1) of section 3 of the Insurance

    Regulatory and Development Authority Act, 1999 (41 of 1999).]

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    FREQUENTLY ASKED QUESTIONS

    Q: Why do I need Health Insurance?

    A: The advent, of multi-specialty hospitals equipped with latesttechnology and facilities with availability of costly but more effective and newermedicines, lead to higher cost of treatment to be born by the patient.Health Insurance takes care of the unforeseen hospitalization expenses, whichyou may require to incur in case of any ailment or accident.

    Q: What is Mediclaim Policy?

    A: Mediclaim Policy is a hospitalization benefit policy, which takes careof medical expenses incurred during Hospitalization / Domiciliary Hospitalizationof the Insured for treatment of illness / disease / injury contracted during the

    policy period. Pre-hospitalization medical expenses incurred 30 days beforeadmission and Post-hospitalization expenses 60 days after discharge from thehospital are also covered under the policy but all such expenses should be

    consistent with the diagnosis for which the patient was hospitalized.

    Q: What are the medical expenses covered under Mediclaim policy?

    A: The policy covers reimbursement of reasonable and necessaryexpenses for treatment of illness / disease / injury contracted during thecurrency of the policy l i k e r o o m r en t , n u r s i n g ca r e , Do c t o r s f e e ,investigations charges, medicine charges, operation theatre and likeexpenses, which fall within the available limit up to the maximum of SumInsured in any one period of insurance stated in the policy schedule.

    Q: What are the expenses not covered under Mediclaim policy?

    A: Mediclaim policy does not cover the following:

    1. Expenses incurred on cost of Spectacles, Contact Lenses, Hearing Aids, DentalTreatment unless requiring Hospitalization, Sterility, Intentional self injury andother exclusion clauses mentioned in the policy

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    2. . Expenses incurred at Hospitals/Nursing Homes primarily for Diagnostic, X-Rays or Laboratory examination, which are not consistent with or incidental tothe diagnosis and treatment of the positive existence of any ailment.3.Ambulance charges, registration / admission / file charges, extra food charges,

    attendant charges etc.

    Q: Can my whole family be covered under a single Mediclaim

    policy?

    A:Yes, your spouse, 2 dependent children & dependent parents can be coveredand family discount of 10% is available on the Premium paid for them.

    Q: What is the age limit for Mediclaim policy?

    A: The Insurance is available to persons between age of 5 and 80 years.

    Children between the age of 3 months and 5 years can be covered provided one or

    both parents are covered concurrently.

    Q: Can treatment be taken from any Hospital/ Nursing Home?

    A: This claim is payable only when the treatment is taken in a Hospital/Nursing

    Home in India which is either:

    Registered as a Hospital or Nursing Home with the local authorities, and is underthe supervision of a registered and qualified medical practitioner, OR

    Which complies with the minimum criteria:

    It has at least 15 beds

    A fully equipped operation theatre of its own where surgical operations are being

    carried out.

    A fully qualified nursing staff around the clock under its employment.

    Fully qualified doctor in-charge round the clock.

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    Q: Are all the systems of medicine covered under Mediclaim?

    A: No, Mediclaim policy covers treatment taken from Allopathic,

    Homeopathic,Ayurvedic and Unani systems of medicines but it does not cover

    Naturopathy treatment

    Q: Does Mediclaim policy cover benefits for treatment taken

    outside India?

    A: No but Mediclaim protection is available for illness / disease / injury contractedanywhere in the World provided the treatment is taken in India.

    Q: What happens when I have to undergo a treatment like dialysis and I am

    discharged on the same day?

    A: When treatment such as Dialysis, Chemotherapy, Radiotherapy etc. is taken inthe Hospital / Nursing Home and the insured is discharged the same day, thetreatment would be considered to be taken under Hospitalization section ofthe policy and the claim would be admissible.

    Q: Who can avail group Mediclaim Policy?A: Any Homogeneous Group / Association / Institution / Corporate body provided

    it has at least 100 persons to be covered and a Central Administration.

    Q: What will the policy pay?

    1.Actual hospitalization expenses, subject to a maximum of Rs. 15,000 to Rs.3

    lakhs, sum insured chosen at the inception of the policy.

    2.Actual domiciliary hospitalization expenses limited to Rs.3,000 to Rs.45,000,

    depending on the sum insured chosen at inception.

    3.Cost of the health check up is reimbursable at the end of four continuous claimfree underwriting years.

    4.The sum insured will be increased by 5% as cumulative bonus for every claim

    free year.

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    5.Maternity expenses incurred in hospital or nursing home as in-patient, subject to

    the limit specified or Rs. 50,000/- whichever is lower will be paid. This will be

    given on payment of extra premium and policy being limited to cover maternity

    benefits. All terms, benefits and conditions of the cover aresubject to the

    definitions of various terms under the policy.

    Q:What will the policy not pay?

    Broadly, the policy will not pay claims under the following circumstances:

    1.Domiciliary Hospitalization: Pre and post hospitalization treatment, treatment of

    asthma, chronic nephritis and nephritis syndrome, gastro-enteritis, diabetes

    mellitus, hypertension, influenza, cough and cold, all psychiatric disorders,

    tonsillitis and upper respiratory tract infection and rheumatism or any treatment

    relating to illness or disease already inexistence at the time of proposal.

    2.Any disease or injury during the first 30 days of commencement of the policy

    (accidental injury is not exclusion).

    3.In the first year of cover, cataract, benign prostatic hypertrophy, hysterectomy,

    hernia, hydrocoele, congenital internal diseases, fistula in an, piles, sinusitis and

    related disorders or any pre-existing disease or illness, that is not covered during

    renewal also.

    4.Vaccination, inoculation, circumcision or cosmetic treatment, plastic surgery,

    dental treatment, unless requiring hospitalization necessitated due to the accident

    or as a part of any illness.

    5.General debility conditions, sterility, venereal diseases, intentional self-injury,

    use of intoxicants.

    6.Any treatment related to pregnancy, childbirth and voluntary medical termination

    of pregnancy during the first 12 weeks of pregnancy.

    7.Cost of spectacles, contact lenses and hearing aids

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    Case Studies

    Case study 1

    Claims not allowed in some case

    Case Study - 1 Claim rejected by New India Assurance on the grounds of

    exclusion of cancer in the insurance policy In 1998, Mrs. Laxmi Subramanyam's

    had carcinoma of left breast and she got treated. In 2001 both husband and wife

    took a Mediclaim policy with New India Assurance. The policy excluded

    carcinoma of left breast because it was pre- existing. Later, she was diagnosed with

    carcinoma of right breast, which was not a recurrence, according to the doctor of

    Tata Memorial Hospital, Mumbai, but a new case of carcinoma, so she had a fulltreatment at Tata Memorial Hospital. He has submitted his claim of Rs. 80,000 to

    the Third Party Administrator of New India Assurance Co. Ltd., i.e., Raksha TPA

    Private Ltd. But they rejected the claim on the grounds thats he had claimed for

    the left breast, which was an exclusion in the Policy. When he sent his grievance to

    CNBC Watch, then they got in touch with the insurance company and the company

    agreed to accept claim. Prior to this Mr. K S Subramanyam had written the

    following letter to New India Assurance Co. Ltd. My wife and me are covered with

    New India Assurance Co. Ltd. for Mediclaim since May 2001. This is the fourthconsecutive year we are insured, with no claims till recently. My wife had cancer

    on her left breast in 1993, was operated upon at Tata Memorial Hospital, had a full

    course of chemotherapy (in India & UAE), and was having regular check-ups at

    UAE till April 2001 (when we returned to India for good). There are two letters

    from the hospital where she was undergoing chemotherapy and regular check-ups,

    to the effect that as of December1998, she remains a symptomatic and free of any

    detectable disease. These letters were attached at the time of applying for the first

    Mediclaim Policy in May 2001. Still, they excluded carcinoma of the left breastand its complication in the Policy, and I had no other alternative but to agree, since

    only the four Govt. Insurance Companies offered Mediclaim. Now in

    December 2004, she had a small lump in her right breast and diagnosis proved it

    was in the very early stage of carcinoma. She had the lump removed at Tata

    Memorial Hospital, and as per their recommendation, underwent a full course

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    of radiotherapy. When I submitted my claim to the Third Party Administrator of

    New India Assurance Co. Ltd., i.e., Raksha TPA Private Ltd., in February 2005,

    first they rejected the claim on the grounds that I have claimed for the left breast,

    which is exclusion in the Policy. This means that they have not scrutinized the

    claim properly, and the intention was very clear: not to admit the claim. When Iwrote to them saying that the claim is not for the left breast, but the right one, now

    I am given to understand that they are not taking any action, as, according to them,

    once a person has cancer, then they don't admit any claim for the future, even if it

    not a recurrence. I have a letter issued by the Chief of Surgical Oncology, Tata

    Memorial Hospital, clearly saying that this case is a new one and not a recurrence

    of the old case of 1993. Nobody gives me a proper reply at Raksha TPA, and every

    time they say that the file is "put up for re-processing," but nothingis happening.

    This seems just harassing the policyholder with no intention of settling the claim.Since I have three letters (two from Oncology Consultants in UAE stating that she

    was free of any Detectable disease as far back as 1998, and the letter from Chief of

    Surgery of Tata Memorial Hospital, stating that this case isa new one and not a

    recurrence of the old case), I feel that Raksha TPA may not beright in rejecting my

    claim. I shall be thankful to have your advice on how I should proceed, in getting

    my claim admitted and settled. Regards, K. S. Subramanyam Response by the

    company In cases of cancer the chances of recurrence is 8% to10% higher but

    while taking the policy, only cancer of left breast was excluded. Moreover, the

    doctor at Tata Memorial Hospital has certified that right breast cancer was a fresh

    case of cancer, hence we grant their claim of Rs 80,000.

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    Hypertension since t