National Super Top Up Mediclaim Policy

Health DEPARTMENT, MBRO-III

1

National Super Top Up Mediclaim policy (NSTM)

• National Super Top Up Mediclaim Policy is a high threshold health insurance indemnity product, covering the members of a family under a single sum insured on floater basis or each member on individual sum insured basis.
• Claim under the Policy is payable provided the cumulative medical expenses for the insured (individual basis) or the family (floater basis) in a policy period exceeds the threshold. - Threshold means the amount of Cumulative Medical Expenses, as chosen by the insured and mentioned in the schedule, up to which no amount can be claimed under this Policy.
• Base policy is optional.
• Cumulative Medical Expenses means the aggregate of medical expenses incurred during the policy period of this Policy towards one or more out of the Coverages mentioned.
• Tax Rebate: The insured can avail tax benefits for the premium paid, under Section 80D of Income Tax Act 1961. The certificate gets generated only when payment is made directly by any other mode than cash. For Payment done partly by cash and partly by cheque, TDS will not be generated.

2

UNDERWRITING GUIDELINES �&� COVERAGES

3

Eligibility

• Policy can be opted on individual and floater basis. In policies issued on floater basis, at least two family members, as defined in the family definition, shall be covered.
• Policy can be opted with or without a Base Policy (i.e., any Indemnity Based Health Insurance Product offered by any General Insurance Company covering the same members).
• Entry age of Proposer should be between eighteen years and sixty five years.

4

Eligibility – Cont.

• Children between the entry age of three months and eighteen years may be covered, provided parent(s) is/are covered at the same time.
• Dependent male child up to twenty five (25) years of age or till the person is employed, whichever is earlier
• Dependent female child, till the person is employed or married
• Family members allowed under same policy.
• Proposer
• Spouse
• Dependent legitimate or legally adopted children
• Parents/ Parents-in law
• Midterm inclusion of family members at pro-rata premium is allowed only in case of
• newborn between the age of three months and six months
• spouse within sixty days of marriage
• (Members other than above may be included only at renewal. On inclusion of a new member, waiting period as per applicable sections in the policy shall apply for the new member.)
• The Policy can be renewed throughout the lifetime of all the insured persons, except the following.
• Dependent male child only up to twenty five years, shall be allowed renewal if not employed.
• Dependent female child if not employed, shall only be allowed renewal till marriage.

5

Sum Insured (SI) & Threshold

6

• For Policy issued on individual basis, both Threshold and sum insured shall apply on individual basis on each insured person.

​

• For Policy issued on floater basis, both Threshold and sum insured shall apply on floater basis to all the insured persons collectively.

TABLE OF BENEFITS

7

8

9

10

11

Enhancement of S.I

• Sum insured and/or Threshold can be enhanced at the time of renewal, to the next slab only.

​

• For the incremental portion of the sum insured, the waiting periods and conditions as mentioned in exclusions in the policy shall apply.

​

• Coverage on enhanced sum insured shall be available after the completion of waiting periods.

​

12

Hazardous or Adventure sports

Expenses related to treatment necessitated due to participation as a non-professional in hazardous or adventure sports are now covered.

​

Maximum amount admissible for Any One Illness shall be lower of 25% of Sum Insured (i.e., Basic Sum Insured and Cumulative Bonus)

​

This is also as per IRDAI Guidelines on Standard Exclusion dated 27.09.2019.

​

The relevant exclusion on the matter is also modified accordingly.

​

13

HIV/AIDS Treatment

The Company shall pay to the hospital or reimburse the insured the medical expenses for treatment of HIV (Human Immunodeficiency Virus), AIDS (Acquired Immune Deficiency Syndrome), and complications of AIDS, after a waiting period of 3 months from the inception of the Policy.

​

The stages of covered HIV infection are:

• Acute HIV infection – acute flu-like symptoms
• Clinical latency – usually asymptomatic or mild symptoms
• AIDS – full-blown disease; CD4 < 200

​

Exclusions

• The Company shall not be liable to make any payment in respect of any expenses incurred in connection with or in respect of treatment of HIV/AIDS pre-existing at the inception of the Policy.

14

Morbid Obesity Treatment

• The Company shall pay to the hospital or reimburse the insured the medical expenses for bariatric surgery/surgical intervention required for the treatment of Morbid Obesity, after a waiting period of 36 months from the inception of the Policy.
• Bariatric surgery for the purpose of this section shall mean any medical procedures performed on people who have morbid obesity (i.e., BMI>40).
• Morbid Obesity is a medical term describing people who have a Body Mass Index (BMI) of at least 40 and with significant medical problems caused by or made worse by their weight.
• Exclusions: The Company shall not be liable to make any payment in respect of any expenses incurred for bariatric surgery in connection with or in respect of
• Insured person less than 18 years of age
• Infertility
• Psychiatric disorder

15

Maternity

• The Company shall pay to the hospital or reimburse the actual medical expenses incurred for delivery or termination, up to the first two deliveries or terminations of pregnancy during the lifetime of the insured or his spouse covered under the Policy, after a waiting period of 36 months from the date of inclusion of the insured person in the Policy.

Coverage:

• Medical expense for delivery (normal or caesarean).
• Medical expense for lawful medical termination of pregnancy.
• Hospitalisation expenses, if medically necessary, up to a maximum of thirty days for pre-natal and sixty days for post-natal treatment.
• Note: Ectopic pregnancy is otherwise covered and is payable under Section 2.1.1 ‘In-patient treatment’ of the policy, provided such pregnancy is established by medical reports.

16

Maternity - Exclusions

​

The Company shall not be liable to make any payment in respect of any expenses incurred in connection with or in respect of

​

• Insured and insured persons above forty five years of age.
• More than one delivery or termination in a policy period.
• Surrogacy
• Pre and post hospitalisation expenses other than pre and post natal hospitalization is not covered.

​

17

Modern Treatments

• 12 modern treatment are now covered under this policy as per IRDAI Guidelines on Standard Exclusion dated 27.09.2019.
• Maximum amount admissible for any one Modern Treatment shall be 25% of Sum Insured (i.e., Basic Sum Insured and Cumulative Bonus)
• The 12 modern treatments are as follows:
• Uterine Artery Embolization and HIFU (High intensity focused ultrasound)
• Balloon Sinuplasty
• Deep Brain stimulation
• Oral chemotherapy
• Immunotherapy- Monoclonal Antibody to be given as injection
• Intra vitreal injections
• Robotic surgeries
• Stereotactic radio surgeries
• Bronchical Thermoplasty
• Vaporisation of the prostrate (Green laser treatment or holmium laser treatment)
• IONM - (Intra Operative Neuro Monitoring)
• Stem cell therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered.

18

Correction of Refractive Error

• The Company shall indemnify the Hospital or the Insured, the Medical Expenses (including Pre and Post Hospitalisation Expenses) incurred for expenses related to the treatment for correction of eye sight due to refractive error equal to or more than 7.5 dioptres. �
• Two years Waiting Period

​

• This is As per IRDAI Guidelines on Standard Exclusion dated 27.09.2019.

​

Coverage for Mental Illness

• The Company shall indemnify the Hospital or the Insured the Medical Expenses (including Pre and Post Hospitalisation Expenses) related to Mental Illnesses, provided the treatment shall be undertaken at a Hospital with a specific department for
• Mental Illness, under a Medical Practitioner qualified as Psychiatrist
• Professional having a post-graduate degree (Ayurveda) in Mano Vigyan Avum Manas Roga or a post-graduate degree (Homoeopathy) in Psychiatry.

​

Hospital Cash

• The Company shall pay the insured a daily hospital cash allowance up to the limit as shown in the Table of Benefits for a maximum of five days, provided the hospitalisation exceeds three days & a claim has been admitted under Section 1.2.1.

Illustration

• In case of hospitalisation of 3 days, threshold not exhausted – No Hospital Cash payable
• In case of hospitalisation of 5 days, threshold not exhausted – No Hospital Cash payable
• In case of hospitalisation of 5 days, threshold exhausted – Hospital Cash payable for 4^th and 5^th day only, i.e., 2 days
• In case of hospitalisation of 10 days, threshold exhausted – Hospital Cash payable for 4^th to 8^th day, i.e., maximum 5 days
• Hospitalisation of less than 24 hours shall not be considered for the purpose of payment of Hospital Cash

Migration to Policy without Threshold

The Company shall allow the insured persons to migrate to any indemnity health insurance product (for same or lower sum insured without any threshold) of the Company with continuity coverage in terms of waiver of waiting periods to the extent of benefits covered under this Policy, provided the insured person has been covered under National Super Top Up Mediclaim Policy before attaining the age of 45 years and has continuously renewed the Policy for 5 years without interruption.

​

Conditions

• Migration to any other indemnity health insurance product shall be subject to the Underwriting Guidelines of the said product, including Pre Policy Health Check-up (if applicable).
• This option can be exercised by the Insured Person at the time of renewal only.
• Insured person has to apply to the Policy issuing office for the migration at least 45 days prior to the renewal date.
• On migration, terms and rates of the migrated policy shall apply.

22

Good Health Incentives

Cumulative Bonus (CB)

• At the time of renewal, cumulative bonus allowed shall be an amount equal to 5% (five percent) of sum insured (excluding CB) of the expiring policy in respect of an insured person (for Policy issued on individual basis) or family (for Policy issued on floater basis), provided no claims were reported under the expiring policy.

​

• In the event of a claim being reported under the expiring policy the cumulative bonus with respect to the insured person/ family shall be reduced by an amount equal to 5% (five percent) of sum insured (excluding CB) of the expiring policy. However, the reduction of CB will not impact sum insured (excluding CB).

​

• Cumulative bonus shall be aggregated over the years and available, subject to maximum of 50% (fifty percent) of the sum insured(excluding CB) of the current policy.

23

EXCLUSIONS

24

Pre-Existing Diseases (Excl 01)

• All pre-existing disease/s or any complication arising thereof shall be considered as a part of the pre-existing disease/s. Such diseases or complications thereof shall be covered after the Policy has been continuously in force for twelve months, as per the table given below.

25

Specified disease/procedure waiting period (Excl 02)

• Expenses related to the treatment of the listed Conditions, surgeries/treatments shall be excluded until the expiry of 90 days/ one year/ two year/ four years (as specified against specific disease/ procedure) of continuous coverage after the date of inception of the first policy with us. This exclusion shall not be applicable for claims arising due to an accident
• In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
• If any of the specified disease/procedure falls under the waiting period specified for Pre-Existing Diseases, then the longer of the two waiting periods shall apply.
• The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a specific exclusion.
• If the Insured Person is continuously covered without any break as defined under the applicable norms on portability stipulated by IRDAI, then waiting period for the same would be reduced to the extent of prior coverage.

​

26

Specified disease/procedure waiting period (Excl 02) - Cont

• 90 Days Waiting Period: Life style conditions namely:
• Hypertension and related complications as mentioned in
• Diabetes and related complications as mentioned in
• Cardiac conditions

​

One year waiting period

• Benign ENT disorders, Tonsillectomy, Adenoidectomy, Mastoidectomy, Tympanoplasty, Cataract, Benign prostatic hypertrophy, Hernia, Hydrocele, Fissure/Fistula in anus, Piles (Haemorrhoids), Sinusitis and related disorders, Polycystic ovarian disease, Non-infective arthritis, Pilonidal sinus, Gout and Rheumatism, Hypertension and related complications as mentioned in 4.1, Diabetes and related complications as mentioned in 4.1, Calculus diseases, Surgery of gall bladder and bile duct excluding malignancy, Surgery of genito-urinary system excluding malignancy, Surgery for prolapsed intervertebral disc unless arising from accident, Surgery of varicose vein, Hysterectomy 

​

27

Specified disease/procedure waiting period (Excl 02) - Cont

​

Two years waiting period

• Following diseases even if pre-existing shall be covered after two years of continuous cover from the inception of the Policy.
• Treatment for joint replacement unless arising from accident
• Osteoarthritis and osteoporosis
• Refractive error of the eye more than 7.5 dioptres.
• Internal Congenital Anomaly
• Stem Cell Therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered.

After expiry of twenty four months any claim arising out of the above conditions or complications thereof will be paid as per the table given below

​

28

Permanently Excluded Diseases

​

In respect of the existing diseases, disclosed by the insured and mentioned in the policy schedule (based on insured's consent), policyholder is not entitled to get the coverage for specified ICD codes. (as listed in Appendix-III)

​

Please note that the Permanently excluded disease clause will only be applicable to new proposals, i.e. w.e.f 15^th September, 2020, and not on renewal policies of NSTMP.

Other Exclusions

• First 30 days waiting period (Excl 03)
• Investigation & Evaluation (Excl 04)
• Rest Cure, Rehabilitation and Respite Care (Excl 05)
• Obesity/ Weight Control (Excl 06)
• Change-of-Gender Treatments (Excl 07)
• Cosmetic or Plastic Surgery (Excl 08)
• Hazardous or Adventure Sports (Excl 09)
• Breach of Law (Excl 10)
• Excluded Providers (Excl 11)
• Drug/Alcohol Abuse (Excl 12)
• Non Medical Admissions (Excl 13)
• Vitamins, Tonics (Excl 14)
• Refractive Error (Excl 15)
• Unproven Treatments (Excl16)
• Birth control, Sterility and Infertility (Excl 17)
• Hormone Replacement Therapy
• General Debility, Congenital External Anomaly

​

​

30

Other Exclusions

• Self Inflicted Injury
• Stem Cell Surgery
• Circumcision
• Vaccination or Inoculation.
• Massages, Steam Bath, Alternative Treatment (Other than Ayurveda and Homeopathy)
• Dental treatment
• Out Patient Department (OPD) or Domiciliary treatment
• Stay in Hospital which is not Medically Necessary.
• Spectacles, Contact Lens, Hearing Aid, Cochlear Implants
• Non Prescription Drug
• Treatment not Related to Disease for which Claim is Made
• Equipments
• Items of personal comfort
• Service charge/ registration fee
• Home visit charges
• War
• Radioactivity
• Treatment taken outside the geographical limits of India

​

​

31

CLAIM SETTLEMENT GUIDELINES

32

Top up Policy vs Super Top of Policy

These policies offer cover for a sum Insured, over and above a threshold limit

​

5 lakhs Top up with Threshhold of 2 lakhs

5 lakhs Super top up with Threshold of 2 lakhs

​

Difference:

Top up - the claim per illness over threshold.

​

Super Top up: for all claims, i.e when your Cumulative Medical expenses exceeds the threshold.

33

ADMISSIBILITY

• Claim shall be admissible for the hospitalisation during which the cumulative medical expenses, admissible as per this policy, in respect of hospitalisation(s) of any insured person (individual plan) or one or more insured persons (floater plan) in a policy period exceeds the threshold and for all subsequent hospitalisation(s) during the policy period.

​

• Threshold is the amount not payable or the deductible chosen, irrespective of existence of any Base Policy.

​

• Cumulative Medical Expenses means the aggregate of medical expenses as admissible in terms of the coverage under the policy and incurred during the policy period of this Policy towards one or more out of the Coverages mentioned.

34

ADMISSIBILITY – Cont.

• For claims admissible under the Policy (once Cumulative Medical Expenses exceed the Threshold) Coverages mentioned in both Sections 2.1 and 2.2 of the policy shall be payable.

​

• Maximum liability of the Company under the policy for all admissible claims during the policy period shall be the individual/ floater sum insured opted.

​

• The insured shall preserve and submit all original documents and/ or certified copies of documents related to all hospitalisation(s) during this policy period to enable the Company to calculate the cumulative medical expenses and threshold, for determining admissibility and payment of claims.

​

35

Procedure for Claims

CASHLESS

• For the first claim under the Policy (i.e., the claim in which cumulative medical expenses exceeds the threshold) cashless facility shall be available provided all evidences and documents are produced prior to cashless authorization, to substantiate that the Cumulative Medical Expenses (CME) exceeds the Threshold. However, for all subsequent claims cashless facility shall be available subject to the conditions given hereunder.
• Cashless facility for treatment in network hospitals can be availed, only if TPA service is opted.
• Treatment must be taken in a network provider and is subject to pre authorization by the TPA. Booklet containing list of network provider shall be provided by the TPA. Updated list of network provider is available on website of the Company and the TPA mentioned in the schedule.
• Cashless request form available with the network provider and TPA, shall be completed and sent to the TPA for authorization and upon getting cashless request form and related medical information from the insured person/ network provider, TPA shall issue pre-authorization letter to the hospital after verification.

​

36

• At the time of discharge, the insured person has to verify and sign the discharge papers and pay for non-medical and inadmissible expenses.
• The TPA reserves the right to deny pre-authorization in case the insured person is unable to provide the relevant medical details.
• In case of denial of cashless access, the insured person may obtain the treatment as per treating medical practitioner’s advice and submit the claim documents to the TPA for processing as a “reimbursement claim”.

​

Procedure for Reimbursement of Claims

• For reimbursement of claims the insured person may submit the necessary documents to TPA (if claim is processed by TPA)/Company (if claim is processed by the Company) within the prescribed time limit.

37

Multiple Policies

• In case of multiple policies taken by an insured person during a period from one or more insurers to indemnify treatment costs, the insured person shall have the right to require a settlement of his/her claim in terms of any of his/her policies. In all such cases the insurer chosen by the insured person shall be obliged to settle the claim as long as the claim is within the limits of and according to the terms of the chosen policy.
• Insured person having multiple policies shall also have the right to prefer claims under this policy for the amounts disallowed under any other policy / policies even if the sum insured is not exhausted. Then the insurer shall independently settle the claim subject to the terms and conditions of this policy.
• If the amount to be claimed exceeds the sum insured under a single policy, the insured person shall have the right to choose insurer from whom he/she wants to claim the balance amount.
• Where an insured person has policies from more than one insurer to cover the same risk on indemnity basis, the insured person shall only be indemnified the treatment costs in accordance with the terms and conditions of the chosen policy.

Thank you

39