Varishtha Medical Insurance by National Insurance Co. Ltd.

Varishtha Medical Insurance policy has been designed by National Insurance Company to cater to the needs of Senior Citizens. It covers Hospitalization and Domiciliary Hospitalization Expenses under Section I as well as expenses for treatment of Critical Illnesses ,if opted for, under Section II.

Claims will be settled by the Third Party Administrators (TPA).  They will send details of the claims procedure for emergency/planned hospitals.

It should be noted that for a medical insurance policy issued by National Insurance Co. Ltd. no claim will be paid, if a critical illness as specified in the policy incepts or manifests during the first 90 days of the inception of the policy.

Salient Features :

This policy has been designed to cater to the needs of our Senior Citizens. It covers Hospitalization and Domiciliary Hospitalization Expenses under Section I as well as expenses for treatment of Critical Illnesses ,if opted for, under Section II. Diseases covered under Critical Illnesses are as under:

• Coronary Artery Surgery
• Cancer
• Renal Failure i.e. Failure for both kidneys
• Stroke
• Multiple Sclerosis
• Major Organ Transplants like kidney, Lung, Pancreas or Bone marrow
• Paralysis and blindness at extra premium

Sum Insured: Sum Insured is fixed per person.
Under Hospitalization & Domiciliary Hospitalization Cover sum Insured is Rs.1,00,000/- and under Critical Illness cover Sum Insured is Rs.2,00,000/-.

Age Group: For fresh entry in to the scheme-60 years to 80 years. However, for renewal, age limit will be extended up to 90 years in which case the premium of 76-80 age band will be loaded by 10% up to 85 years and 20% up to 90 years of age.

Preacceptance Medical Check up: No Medical Check up is required if the insured was covered under any Health Insurance Policy of National Insurance Company or other Insurance companies uninterruptedly for preceding three years. Other persons have to undergo medical check up at their own cost for Blood/Urine Sugar, Blood Pressure, Echo-cardiography and eye check up including retinoscopy.

Note: Please refer to the policy documents for the complete Insurance Policy subject to the insurance Company.

Scope of Cover / Benefits : 

Section I- Hospitalization and Domiciliary Hospitalization Expenses Cover:
In the event of any claim/s becoming admissible under this section, the Company will pay to the Insured person the amount of such expenses as would fall under different heads mentioned below and as are reasonably and necessarily incurred hereof by or on behalf of such Insured Person but not exceeding the Sum Insured in aggregate mentioned in the Schedule hereto.

1. Company's overall liability in respect of claims arising due to Cataract is Rs.10,000/- and that of Benign Prostatic Hyperplasia is Rs 20,000/- only.
2. Company's liability in respect of all claims admitted during the period of Insurance shall not exceed the Sum Insured for the person as mentioned in the Schedule.
3. Liability of the company under Domiciliary Hospitalization clause is limited to 20% of the Sum Insured under Section I and within the overall limit of sum Insured under section I.
4. Hospitalization expenses of person donating an organ during the course of organ transplant will also be payable subject to the sub limits under “C” above applicable to the insured person within the overall sum insured of the insured person.
5. Ambulance charges up to a maximum limit of Rs.Rs.1000/- in a policy year will be reimbursed.

Note: Please refer to the policy documents for the complete Insurance Policy subject to the insurance Company.

Premium Rates/ Chart :

• For fresh entrants to National Insurance above premium will be loaded by 10%.
• Under Mediclaim Section(Section I), if the insured intends to cover pre-existing diseases of Hypertension and/or Diabetes from the inception of the policy he/she has to pay additional premium @10% for either hypertension or diabetes & 20% for hypertension & diabetes for first year of the policy. However, if a fresh entrant suffers from blood pressure/hypertension and/or diabetes and opts for Critical Illness cover, the same may be covered at additional premium @10% for either hypertension or diabetes & 20% for hypertension & diabetes provided no organ of the proposer is affected in consequence of blood pressure and/ or diabetes. If the medical report indicates occurrence of any such consequential complication, those proposals will be declined.
• Loading for preexisting Diabetes and/or Hypertension to be applied on Total Premium for first year and on Critical Illness Premium only from 2nd year onwards.
• At the time of taking this policy, if a person suffers from any of the terminal diseases referred under Critical Illness cover mentioned below, that particular disease will never be covered under Section II of this policy even on payment of additional premium.

• Paralysis and Blindness may be covered under Critical Illness by loading the Critical Illness premium by 15% in each case or 25% in case of both covers together.
• Under Group Policy, if the incurred claim ratio of the group exceeds 70% then the renewal premium will be loaded on 70% as if basis i.e. if the incurred claim ratio of any policy year exceeds 70% renewal premium will be loaded in such a way that the incurred claim ratio of expiring policy becomes 70%.

Note: Please refer to the policy documents for the complete Insurance Policy subject to the insurance Company.

Terms & Conditions :

• Upon the happening of any event, which may give rise to a claim under this policy notice with full particulars shall be sent to the Company within 7 days from the date of Injury/Hospitalization/Domiciliary Hospitalization.
• Claim must be filed within 30 days from date of discharge from the Hospital.Note: Waiver of this condition may be considered in extreme cases of hardship where it is proved to the satisfaction of the Company that under the circumstances in which the Insured was placed it was not possible for him or any other person to give such notice or file claim within the prescribed time limit.
• All medical surgical treatment under this policy shall have to be taken in India and admissible claims thereof shall be payable in Indian currency.
• Any Medical Practitioner authorized by the Company shall be allowed to examine the Insured person in case of any alleged injury or disease requiring hospitalization when and so often as the same may reasonably be required on behalf of the Company.
• If at the time when any claim arises under this policy there is in existence any other insurance (other than Cancer Insurance Society) whether it be effected by or on behalf of any insured person in respect of whom the claim may have arisen covering the same loss, liability, compensation, costs or expenses the Company shall not be liable to pay or contribute more than its ratable proportion of any loss, liability, compensation, costs or expenses. The benefits under this policy shall be in excess of the benefits available under the Cancer Insurance Policy.
• ENTIRE CONTRACT: the policy, proposal form, prospectus and declaration given by the insured shall constitute the complete contract of insurance. Only insurer may alter the terms and conditions of this policy/ contract. Any alteration that may be made by the insurer shall only be evidenced by a duly signed and sealed endorsement on the policy.
• COMMUNICATION: Every notice or communication to be given or made under this policy shall be delivered in writing at the address of the policy issuing office / Third Party Administrator as shown in the Schedule.
• PAYMENT OF PREMIUM: The premium payable under this policy shall be paid in advance. No receipt for premium shall be valid except on the official form of the Company signed by a duly authorized official of the company. The due payment of premium and the observance and fulfilment of the terms, provisions, conditions and endorsements of this policy by the Insured Person in so far as they relate to anything to be done or complied with by the Insured Person shall be condition precedent to any liability of the Company to make any payment under this policy. No waiver of any terms, provisions, conditions and endorsements of this policy shall be valid, unless made in writing and signed by an authorised official of the Company.
• NOTICE OF CLAIM: Immediate notice of claim with particulars relating to Policy Number, ID Card No., Name of insured person in respect of whom claim is made, Nature of disease / illness / injury and Name and Address of the attending medical practitioner / Hospital/Nursing Home etc. should be given to the Company / TPA while taking treatment in the Hospital / Nursing Home by Fax, Email. Such notice should be given within 48 hours of admission or before discharge from Hospital / Nursing Home, whichever is earlier, unless waived in writing by the Company.
• CLAIM DOCUMENTS: Final claim along with hospital receipted original Bills/Cash memos/reports, claim form and list of documents as listed below should be submitted to the Company / TPA within 7 (seven) days of discharge from the Hospital / Nursing Home.
  • Original bills, receipts and discharge certificate / card from the hospital
  • Medical history of the patient recorded by the Hospital.
  • Original Cash-memo from the hospital (s) / chemist (s) supported by proper prescription.
  • Original receipt, pathological and other test reports from a pathologist / radiologist including film etc supported by the note from attending medical practitioner / surgeon demanding such tests.
  • Attending Consultants / Anaesthetists / Specialist certificates regarding diagnosis and bill / receipts etc.
  • Surgeon’s original certificate stating diagnosis and nature of operation performed along with bills / receipts etc.
  • Any other information required by TPA / Insurance Company.

All documents must be duly attested by the insured person.

• FRAUD / MISREPRESENTATION / CONCEALMENT: The Company shall not be liable to make any payment under this policy in respect of any claim, if such claim be in any manner (intentionally or recklessly or otherwise) misrepresented or concealed or involve any non disclosure of material facts or making false statements or submitting fake bills whether by the Insured Person or Institution / Organization on his behalf. Such action shall render this policy null and void and all claims hereunder shall be forfeited. Company may take suitable legal action against the Insured Person / Institution / Organization as per Law.
  Note: Please refer to the policy documents for the complete Insurance Policy subject to the insurance Company.

Exclusions :

The Company shall not be liable to make any payment under this Policy in respect of any expenses whatsoever incurred by any person in connection with or in respect of:

1. All diseases/injuries which are pre existing when the cover incepts for the first time. However, those diseases will be covered after one claim free year under this policy. Cost of treatment towards dialysis, chemotherapy & radiotherapy for diseases existing prior to the commencement of this policy is excluded from the scope of cover of this policy even after one claim free year. Only two preexisting diseases (Diabetes and/or Hypertension) will be covered from the inception of the policy provided the company receives additional premium for covering these preexisting diseases and mentions the same in the schedule. . However, any ailment already manifested or being treated and attributable to diabetes and/or hypertension or consequences thereof at the time of inception of insurance will not be covered even on payment of additional premium for covering diabetes and/or hypertension.
2. Any disease other than those stated in Clause 4.3, contracted by the Insured Person during the first 30 days from the commencement date of the policy. This condition 2 shall not however apply in case of the Insured Person having been covered under this Scheme or group insurance scheme with any one of the Indian Insurance Companies for a continuous period of preceding 12 months without any break.
3. During the first one year of the operation of the policy the expenses incurred on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal Disease, Fistula in anus, Chronic fissure in anus, Piles, Pilonidal Sinus, Sinusitis, Stone disease of any site, Benign Lumps/growths in any part of the body, CSOM(Chronic Suppurative Otitis Media), joints replacements of any kind unless arising out of accident, surgical treatment of Tonsils, Adenoids and deviated nasal septums and related disorders are not payable. If these diseases (other than Congenital Internal Disease/Defects) are pre-existing at the time of proposal, they will be covered only after one claim free year as mentioned in column 4.1 above. If the Insured is aware of the existence of Congenital Internal Disease/Defect before inception of the policy, the same will be treated as pre-existing.
4. Injury or disease directly or indirectly caused by or arising from or attributable to War Invasion Act of Foreign Enemy Warlike operations (whether war be declared or not).
5. Vaccination or inoculation or change of life or cosmetic or aesthetic treatment of any description, plastic surgery other than as may be necessitated due to as accident or as part of any illness.
6. The cost of spectacles and contact lenses, hearing aids. 
7. Any Dental treatment or surgery which is a corrective, cosmetic or aesthetic procedure, including wear and tear, unless arising from accidental injury and which requires hospitalization for treatment.
8. Convalescence, general debility, `Run Down’ condition or rest cure, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self-injury and use of intoxicating drugs / alcohol, rehabilitation therapy in any form.
9. All expenses arising out of any condition directly or indirectly caused to or associated with Human T-Cell Lymphotrophic Virus Type III (HTLB-III) or Lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or variations Deficiency Syndrome or any Syndrome or condition of a similar kind commonly referred to as AIDS.
10. Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-Ray or laboratory examinations or other diagnostic studies not consistent with nor incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury for which confinement is required at a Hospital / Nursing Home.
11. Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician.
12. Injury or disease directly or indirectly caused by or contributed to by nuclear weapons/materials.
13. Treatment arising from or traceable to pregnancy childbirth including caesarean section.
14. Naturopathy treatment

Note: Please refer to the policy documents for the complete Insurance Policy subject to the insurance Company.