PNB Oriental Royal Mediclaim Policy
(www.pnbindia.com – Financial Services – Insurance Business – Non Life Insurance -)
v The Product has been got designed exclusively for PNB Customers and only the A/c Holders of PNB will be eligible to take cover under the Scheme.
v The product available in all PNB Branches across the country.
v A Family Floater Scheme.
v Cover for 4 family members under single premium
v Age Group covered: 3 months to 80 years.
v No Medical Examination for entry at any stage.
v Cashless facility available at a large Net Work of Hospitals. The policy will be serviced by TPAs (Third Party Administrators).
v Premium much lower and quite comparable with all available health insurance products in the market.
v Uniform Premium for persons of all age-groups up to 80 years’ age.
v Cover available for Minimum Sum Insured of Rs.1 Lac, up to Rs. 5 Lac, in multiple of Rs.1.00 Lac. The Premium Structure (Inclusive of Service Tax) is as under:
|Sum-Insured||Premium Current Rates|
|1 Lac||1717 1749|
|2 Lac||3259 3320|
|3 Lac||4536 4620|
|4 Lac||5674 5780|
|5 Lac||6705 6850|
- v Other benefits such as Ambulance Charges, Cost of Health Check-up, Hospital Cash etc. also available under the Scheme.
1.1 Salient Features of the policy.
b) The group policy will be issued in accordance with IRDA guidelines, in the name of PNB (called insured) with a schedule of names of the Account Holders / Employees of PNB including his/her eligible family members as per the following definition.
(a) THE PROPOSER i.e., PNB ACCOUNT HOLDER or EMPLOYEE
(b) HIS/HER SPOUSE AND
(c) TWO DEPENDENT CHILDREN (i.e. legitimate or legally adopted children) AGED 3 COMPLETED MONTHS ONWARDS AS UNDER :
1.2 The policy reimburses reasonable and necessary expenses of Hospitalisation and / or Domiciliary Hospitalisation expenses as detailed below only for illness / diseases contracted or injury sustained by the Insured Persons during the policy period upto the limit of Sum Insured.
1.3 Cash less Facility: This facility is available in the Network Hospitals through the appointed TPAs of the company.
2.1. ‘‘HOSPITAL/NURSING HOME’: means any institution in India established for indoor care and treatment of sickness and injuries and which either
a) Is duly licensed and registered as a Hospital or Nursing Home with the appropriate authorities and is under the supervision of a registered and qualified Medical Practitioner.
b) In areas where licensing and registration facilities with appropriate authorities are not available, the institution must be one recognised in locality as Hospital / Nursing Home and should comply with minimum criteria as under
The term ‘Hospital/Nursing Home’ shall not include an establishment which is a place of rest, a place for the aged, a place for drug addicts or a place for alcoholics, a hotel or a similar place.
Note: In case of Ayurvedic / Homeopathic / Unani treatment, Hospitalisation expenses are admissible only when the treatment is taken as in-patient, in a Government Hospital / Medical College Hospital.
2.2 HOSPITALISATION PERIOD: Expenses on Hospitalisation are admissible only if hospitalisation is for a minimum period of 24 hours, except in cases of specialized treatment as detailed here below
i. Haemo Dialysis,
ii. Parentral Chemotherapy,
iv. Eye Surgery,
v. Lithotripsy (kidney stone removal),
viii. Dental surgery following an accident
x. Coronary Angioplasty
xi. Coronary Angiography
xii. Surgery of Gall bladder, Pancreas and bile duct
xiii. Surgery of Hernia
xiv. Surgery of Hydrocele.
xv. Surgery of Prostrate.
xvi. Gastrointestinal Surgery.
xvii. Genital Surgery.
xviii. Surgery of Nose.
xix. Surgery of throat.
xx. Surgery of Appendix.
xxi. Surgery of Urinary System.
xxii. Treatment of fractures / dislocation excluding hair line fracture, Contracture releases and minor reconstructive procedures of limbs which otherwise require hospitalisation.
xxiii. Arthroscopic Knee surgery.
xxiv. Laparoscopic therapeutic surgeries.
xxv. Any surgery under General Anaesthesia.
xxvi. Or any such disease / procedure agreed by TPA/Company before treatment.
NOTE: PROCEDURES / TREATMENTS USUALLY DONE IN OUT PATIENT DEPARTMENT ARE NOT PAYABLE UNDER THE POLICY EVEN IF CONVERTED TO DAY CARE SURGERY / PROCEDURE OR AS IN PATIENT IN THE HOSPITAL FOR MORE THAN 24 HOURS.
2.3 DOMICILIARY HOSPITALISATION BENEFIT means Medical treatment for a period exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at a hospital/nursing home as in-patient but actually taken whilst confined at home in India under any of the following circumstances namely:
accommodation in any hospital in that city / town / village.
Subject however to the condition that Domiciliary Hospitalisation benefit shall not cover
a) Expenses incurred for pre and post hospital treatment and
b) Expenses incurred for treatment for any of the following diseases :
Note: Liability of the Company under this clause is restricted as stated in the schedule attached hereto.
2.4 INSURED PERSON:Means PNB Account Holder/Employee and his/her family members as are named on the schedule of the policy.
2.5 ENTIRE CONTRACT: This policy / proposal and declaration given by the insured constitute the complete contract of this policy. Only Insurer may alter the terms and conditions of this policy. Any alteration that may be made by the insurer shall only be evidenced by a duly signed and sealed endorsement on the policy.
2.6 NETWORK HOSPITAL: means hospital that has agreed with the TPA to participate for providing cashless health services to the insured persons. The list is maintained by and is available with the TPA and the same is subject to amendment from time to time.
2.7 THIRD PARTY ADMINISTRATOR (T.P.A.) : means any Company which has obtained licence from IRDA to practice as a THIRD PARTY ADMINISTRATOR and is appointed by the Company.
2.8 PRE-HOSPITALISATION: Relevant medical expenses incurred during the period upto 30 days prior to hospitalisation on disease/ illness/ injury sustained will be considered as part of claim mentioned under item 1.2 above.
2.9 POST-HOSPITALISATION: Relevant medical expenses incurred for the period of 60 days after hospitalisation on disease/illness/injury sustained will be considered as part of claim mentioned under item 1.2 above.
2.10 MEDICAL PRACTITIONER: means a person who holds a degree/diploma of a recognised institution and is registered by Medical Council of any State of India. The term Medical Practitioner would include Physician, Specialist and Surgeon.
2.11 QUALIFIED NURSE: means a person who holds a certificate of a recognised Nursing Council.
2.12 IN-PATIENT: An Insured person who is admitted to hospital and stays for at least 24 hours for the sole purpose of receiving the treatment for suffered ailment / illness / disease / injury / accident during the currency of the policy.
2.13 REASONABLE & NECESSARY EXPENSES: means reasonable and necessary surgical / medical expenses with in the scope of treatment of the condition for which the insured person was hospitalized.
2.14 CASHLESS FACILITY: means the TPA may authorize upon the Insureds’ request for direct settlement of admissible claim as per agreed charges between Net work Hospitals & the TPA. In such cases the TPA will directly settle all eligible amounts with the Net work Hospitals and the Insured Person may not have to pay any bills after the end of the treatment at Hospital to the extent the claim is covered under the policy.
2.15 I .D. CARD: means the card issued to the Insured Person by the TPA to avail Cashless facility in the Network Hospital.
2.16 LIMIT OF INDEMNITY: means the amount stated in the schedule against the name of each insured person which represents maximum liability for any and all claims made during the policy period in respect of that insured person for hospitalization taking place during the currency of the policy.
2.17 ANY ONE ILLNESS: Any one illness will be deemed to mean continuous period of illness and it includes relapse within 105 days from the date of discharge from the Hospital / nursing home from where the treatment was taken. Occurrence of the same illness after a lapse of 105 days as stated above will be considered as fresh illness for the purpose of this policy.
3 RENEWAL OF POLICY:
I) The Company shall not be responsible or liable for non-renewal of policy due to non-receipt or delayed receipt (i.e. After the due date) of the proposal form or of the medical practitioners report wherever required or due to any other reason whatsoever.
II) Notwithstanding this, however, the decision to accept or reject for coverage any person upon renewal of this insurance shall rest solely with the Company. The company may at its discretion revise the premium rates and / or the terms & condition of the policy every year upon renewal thereof. Renewal of this policy is not automatic; premium due must be paid by the proposer to the company before the due date.
III) The Company normally sends renewal notice but not sending it will not tantamount to deficiency in services.
4.1 During the period of insurance cover, the expenses on treatment of following ailment / diseases / surgeries for specified periods are not payable if contracted and / or manifested during the currency of the policy.
|i||Benign ENT disorders and surgeries i.e. Tonsillectomy, Adenoidectomy, Mastoidectomy, Tympanoplasty etc.||1 year|
|ii||Polycystic ovarian diseases .||1 year|
|iii||Surgery of hernia.||2 years|
|iv||Surgery of hydrocele.||2 years|
|v||Non infective Arthritis.||2 years|
|vi||Undescendent Testes.||2 Years|
|viii||Surgery of benign prostatic hypertrophy.||2 Years|
|ix||Hysterectomy for menorrhagia or fibromyoma.or myomectomy or prolapse of uterus .||2 Years|
|x||Fissure / Fistula in anus.||2 Years|
|xii||Sinusitis and related disorders.||2 Years|
|xiii||Surgery of gallbladder and bile duct excluding malignancy.||2 Years|
|xiv||Surgery of genito urinary system excluding malignancy.||2 Years|
|xv||Pilonidal Sinus.||2 Years|
|xvi||Gout and Rheumatism.||2 Years|
|xix||Calculus diseases.||2 Years|
|xx||Surgery for prolapsed inter vertebral disk unless arising from accident.||2 Years|
|xxi||Surgery of varicose veins and varicose ulcers.||2 Years|
|xxii||Congenital internal diseases.||2 Years|
|xxiii||Joint Replacement due to Degenerative condition.||4 Years|
|xxiv||Age related osteoarthritis and Osteoporosis..||4 Years|
4.2 Injury or disease directly or indirectly caused by or arising from or attributable to War, Invasion, Act of Foreign Enemy, War like operations (whether war be declared or not) or by nuclear weapons / materials.
4.3 Circumcision (unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to any accident), vaccination, inoculation or change of life or cosmetic or of aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness.
4.4 Cosmetic surgery for correction of eye sight, cost of spectacles, contact lenses, hearing aids etc.
4.5 Any dental treatment or surgery which is corrective, cosmetic or of aesthetic procedure, filling of cavity, root canal including wear and tear etc unless arising from disease or injury and which requires hospitalisation for treatment.
4.6 Convalescence, general debility, “run down” condition or rest cure, congenital external diseases or defects or anomalies, sterility, any fertility, sub-fertility or assisted conception procedure, venereal diseases, intentional self-injury/suicide, all psychiatric and psychosomatic disorders and diseases / accident due to and or use, misuse or abuse of drugs / alcohol or use of intoxicating substances or such abuse or addiction etc.
4.7 All expenses arising out of any condition directly or indirectly caused by, or associated with Human T-cell Lymph tropic Virus Type III (HTLD – III) or Lymohadinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome or condition of similar kind commonly referred to as AIDS, HIV and its complications including sexually transmitted diseases..
4.8 Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic purposes which is not followed by active treatment for the ailment during the hospitalised period.
4.9 Expenses on vitamins and tonics, mineral bottled water and allied items unless forming part of treatment for injury or disease as certified by the attending physician.
4.10 Any Treatment arising from or traceable to pregnancy, childbirth, miscarriage, caesarean section, abortion or complications of any of these including changes in chronic condition as a result of pregnancy. .
4.11 Naturopathy treatment, unproven procedure or treatment, experimental or alternative medicine and related treatment including acupressure, acupuncture, magnetic and such other therapies etc.
4.12 Expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalization or primary reasons for admission. Private nursing charges, Referral fee to family doctors, Out station consultants / Surgeons fees etc.
4.13 Genetical disorders and stem cell implantation / surgery.
4.14 External and or durable Medical / Non medical equipment of any kind used for diagnosis and or treatment including CPAP, CAPD, Infusion pump etc., Ambulatory devices i.e. walker, Crutches, Belts, Collars, Caps, splints, slings, braces, Stockings etc of any kind, Diabetic foot wear, Glucometer / Thermometer and similar related items etc and also any medical equipment which is subsequently used at home etc.
4.15 All non medical expenses including Personal comfort and convenience items or services such as telephone, television, Aya / barber or beauty services, diet charges, baby food, cosmetics, napkins, toiletry items etc, guest services and similar incidental expenses or services etc.
4.16 Change of treatment from one pathy to other pathy unless being agreed / allowed and recommended by the consultant under whom the treatment is taken.
4.17 Treatment of obesity or condition arising therefrom (including morbid obesity) and any other weight control programme, services or supplies etc.
4.18 Any treatment required arising from Insured’s participation in any hazardous activity including but not limited to scuba diving, motor racing, parachuting, hang gliding, rock or mountain climbing etc unless specifically agreed by the Insurance Company.
4.19 Any treatment received in convalescent home, convalescent hospital, health hydro, nature care clinic or similar establishments.
4.20 Any stay in the hospital for any domestic reason or where no active regular treatment is given by the specialist.
4.21 Out patient Diagnostic, Medical and Surgical procedures or treatments, non-prescribed drugs and medical supplies, Hormone replacement therapy, Sex change or treatment which results from or is in any way related to sex change.
4.22 Massages, Steam bathing, Shirodhara and alike treatment under Ayurvedic treatment.
4.23 Any kind of Service charges, Surcharges, Admission fees / Registration charges etc levied by the hospital.
4.24 Doctor’s home visit charges, Attendant / Nursing charges during pre and post hospitalization period.
4.25 Treatment which is continued before hospitalization and continued during and after discharge for an ailment / disease / injury different from the one for which hospitalization was necessary.
Period on Risk Rate of premium to be charged
Upto 1 Month 1/4th of the annual rate
Upto 3 Months 1/2 of the annual rate
Upto 6 Months 3/4th of the annual rate
Exceeding 6 months Full annual rate
It is clearly agreed and understood that no difference or dispute shall be referable to arbitration as herein before provided, if the Company has disputed or not accepted liability under or in respect of this policy.
It is hereby expressly stipulated and declared that it shall be a condition precedent to any right of action or suit upon this policy that award by such arbitrator/ arbitrators of the amount of the loss or damage shall be first obtained.
a) The insured person hereby agrees to and authorizes the disclosure to the insurer or the TPA or any other person nominated by the insurer of any and all Medical records and information held by any Institution / Hospital or Person from which the insured person has obtained any medical or other treatment to the extent reasonably required by either the insurer or the TPA in connection with any claim made under this policy or the insurer’s liability thereunder.
b) The insurer and the TPA agree that they will preserve the confidentiality of any documentation and information that comes into their possession pursuant to (a) above and will only use it in connection with any claim made under this policy or the insurer’s liability thereunder.
i) Claim in respect of Cashless Access Services will be through the TPA provided admission is in a listed hospital in the agreed list of the networked Hospitals / Nursing Homes and is subject to pre admission authorization. The TPA shall, upon getting the related medical details / relevant information from the insured person / network Hospital / Nursing Home, verify that the person is eligible to claim under the policy and after satisfying itself will issue a pre-authorisation letter / guarantee of payment letter to the Hospital / Nursing Home mentioning the sum guaranteed as payable, also the ailment for which the person is seeking to be admitted as in-patient.
ii) The TPA reserves the right to deny pre-authorisation in case the hospital / insured person is unable to provide the relevant information / medical details as required by the TPA. In such circumstances denial of Cashless Access should in no way be construed as denial of claim. The insured person may obtain the treatment as per his/her treating doctor’s advice and later on submit the full claim papers to the TPA for reimbursement within 7 days of the discharge from Hospital / Nursing Home.
iii) Should any information be available to the TPA which makes the claim inadmissible or doubtful requiring investigations, the authorisation of cashless facility may be withdrawn. However this shall be done by the TPA before the patient is discharged from the Hospital.
This Prospectus shall form part of your proposal form. Signatures hereunder confirm that you have noted the contents of the prospectus.
Note: For legal interpretation only English version will be valid.
INSURANCE ACT 1938 SECTION 41 – PROHIBITION OF REBATE
Section 41 of the Insurance Act 1938 provides as follows:
Any person making default in complying with provision of this section shall be punishable with fine, which may extend to Rs.500/-.
No person shall allow, or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy nor shall any person taking out or renewing or continuing a policy accept any rebate except such rebate as may be allowed in accordance with the published prospectus or tables of the Insurer
|THE ORIENTAL INSURANCE CO LTD : HO NEW DELHI|
|GROUP MEDICLAIM INSURANCE (FAMILY FLOATER) SCHEME FOR PNB ACCOUNT HOLDERS /EMPLOYEES|
|PREMIUM CHART (PREMIUM RATES ARE INCLUSIVE OF SERVICE TAX)|
|SUM INSURED(In Rupees)||MEDICLAIM (In Rupees)|
|AGE GROUP 03 MONTHS TO 80 YEARS|
THE ORIENTAL INSURANCE COMPANY LIMITED
HEAD OFFICE: A-25/27, ASAF ALI ROAD, NEW DELHI-110002
P N B -ORIENTAL ROYAL
MEDICLAIM INSURANCE POLICY (WITH FAMILY FLOATER) FOR
PUNJAB NATIONAL BANK ACCOUNT HOLDERS / EMPLOYEES
|S. No.||Name of the insured’s /proposer||Relationship with Proposer||Sex M/F||Date of Birth||Age||Occupation||Sum Insured (Rs.)|
|ACCOUNT NO :|
|S.NO.||First Name of the Insured||Name of the Beneficiary||Relation with Insured|
I/We declare that the statements made by me/us in this proposal form are true and to the best of my / our knowledge and belief and I/we hereby agree that this declaration shall form the basis of the contract between me/us and The Oriental Insurance Company Limited. I/we also declare that if any additions or alterations are carried out after the submission of this proposal form and / or issuance of policy documents. The same would be conveyed to the Oriental Insurance Company Limited immediately. I further consent and authorize the Oriental Insurance Company Limited and /or any of its authorized representatives to seek medical information from any hospital/medical practitioner who has attended or may attend in future concerning any disease or illness. I further declare that I have read the prospectus and have understood the same. I accept the policy, subject to terms, exceptions and conditions prescribed therein and further disclose that In the event of finding any thing contrary to what has been declared by me, I shall be held responsible for all consequences thereof and insurance company shall incur no liability under this insurance.
I/we also hereby authorise PNB to debit the premium payable under the policy to my/our Bank Account Number: ______________________________________ with PNB Branch ____________________________________ at _________________________________________.
|Place||Signature of Proposer (PNB A/c Holder)|
|Date||Name of Proposer|
|COUNTER SIGNATURE BY PNB BRANCH MANAGER|
|BRANCH CODE, LOCATION AND CITY|
INSURANCE ACT 1938 SECTION 41 – PROHIBITION OF REBATES
Section 41 of the Insurance Act 1938 provides as follows:
Any person making default in complying with provision of this section shall be punishable with fine which may extend of Rs. 500/-.
No person shall allow, or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect if any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy nor shall any person taking out or renewing or continuing a policy accept any rebate except such rebate as may be allowed in accordance with the published prospectus or tables of the insurer.