WHY MEDISHIELD POLICY ?

 INCREASED POPULATION CAUSES MORE

POLLUTION -> DISEASES.
 COST OF LIVING IS INCREASING.
 INCREASED POPULATION AND HIGH
VEHICULAR TRAFFIC -> ACCIDENTS
 FAST LIFE, URBANISATION, STRESS
TRAFFIC-CONGESTION -> More accidents
 TREATMENT COST VERY HIGH AND SPOILS
THE BUDGET OF FAMILY.
 CAN BE USED AS A TOOL FOR TAX SAVING.
 WHAT IS COVERED
If the Insured Person sustains any Injury or contracts any
Disease and if Medically necessary, he/she has to incur
Hospitalisation expenses IN INDIA, then the Policy will
pay Reasonable and Customary Charges for following :-
a) Room/ Boarding/ Nursing Expenses/ Registration Fee
(subject to limits enclosed)
b) Fees for Medical Practitioner/ Anaesthetist/ Consultant.
c) Other Expenses like Anesthesia, Blood, Oxygen,
Operation Theatre, Surgical Appliances, Medicines and
Drugs, Diagnostic Materials and X-ray, Dialysis,
Chemotherapy, Radiotherapy, Cost of Pacemaker,
Artificial Limbs, Cost of Organ and similar expenses.
d) Ambulance Charges 1% of Basic SI or Rs 1500/-
 WHAT IS COVERED ……contd
e) DAILY ALLOWANCE . An amount equivalent to 0.1% of
the basic sum insured or rs. 250/- per day whichever
is less, for the duration of hospitalisation.
f) PACKAGE CHARGES. If the hospital bill is on the basis
of package charges, policy pays 80% of sum insured
(Basic Sum Insured + Optional Extension).
g) DONOR EXPENSES. Hospitalisation Expenses of
person donating an organ within the overall S.I.
h) PRE - & POST HOSPITALISATION EXPENSES. Payable
for 60 days each.
i) CUMULATIVE BONUS. Basic Sum Insured is increased
by 5% for each claim free year subject to maximum of
50% only, if the policy is renewed within 15 days.
 WHAT IS COVERED ……contd
e) DAILY ALLOWANCE . An amount equivalent to 0.1% of
the basic sum insured or rs. 250/- per day whichever
is less, for the duration of hospitalisation.
f) PACKAGE CHARGES. If the hospital bill is on the basis
of package charges, policy pays 80% of sum insured
(Basic Sum Insured + Optional Extension).
g) DONOR EXPENSES. Hospitalisation Expenses of
person donating an organ within the overall S.I.
h) PRE - & POST HOSPITALISATION EXPENSES. Payable
for 60 days each.
i) CUMULATIVE BONUS. Basic Sum Insured is increased
by 5% for each claim free year subject to maximum of
50% only, if the policy is renewed within 15 days.
 WHAT IS COVERED ……contd

In case of a claim, the existing Cumulative Bonus will

be reduced by 10% of Basic S.I. at the next renewal
but the basic S.I. shall be maintained.
j) AYURVEDIC HOSPITALISATION. Ayurvedic hospitalisation
expenses including pre-hospitalisation and post
hospitalisation expenses subject to 10% of the basic
sum insured.
k) DOMICILIARY HOSPITALISATION. Up to 20% of S.I.
SPECIAL NOTE :- The amounts payable for Doctor’s Fee
and Other Expenses i.e. (b) & (c) above shall be limited
to the charges applicable to entitled category of room.
 IMPORTANT DEFINITIONS.
1) HOSPITAL /Nursing Home means any institution established for
indoor care and treatment of disease or injuries which is either
registered as a hospital or nursing home with the local
authorities & is under the supervision of a registered & qualified
medical practitioner or it must complies with following criteria :-
a) Has at least 15 in-patient beds. (10 beds in towns where
population is less than 10 lakhs)
b) Has fully equipped operation theatre of its own for
carrying out surgical operation.
c) Has qualified nursing staff under its employment round
the clock.
d) Be under charge of fully qualified medical practitioner(s)
round the clock.
e) Maintains daily records of patients and will make these
accessible to the insurance company’s authorized
personnel/representative.
IMPORTANT DEFINITIONS…CONTD
2) HOSPITALISATION. Means treatment person as inpatient in
an hospital/nursing home for a minimum period of 24 hours.
The above time limit of 24 hours will not be mandatory for
the specific 121 treatments listed as day care surgeries in
the annexure to the policy
3) MEDICALLY NECESSARY means a treatment
> which is ordered by a registered medical practitioner and
which is required for the diagnosis or direct treatment of a
medical condition, and
> is appropriate and consistent with symptoms & findings
or diagnosis & treatment of the insured person’s medical
condition, and
> is provided in accordance with generally accepted
medical practice on a national basis, and
> the treatment should not be of an experimental nature
 IMPORTANT DEFINITIONS…CONTD
4) ANY ONE ILLNESS Means continuous period of illness
including relapse within 45 days from the date of discharge
from hospital/nursing home where treatment may have been
taken. Occurrence of same illness after a lapse of 45 days
as stated above will be considered as fresh illness for the
purpose of this policy.
5) PRE-HOSPITALISATION Means relevant medical expenses
incurred up to 60 days prior to hospitalisation on disease/
illness/ injury sustained,
6) POST HOSPITALISATION Means relevant medical expenses
incurred during period up to 60 days after hospitalisation on
disease/ illness/ injury sustained.
7) MEDICAL PRACTITIONER Means a person holding a degree/
diploma of a recognised institution registered by medical
council of respective state of India or Central Council of
Indian Medicine. It includes physician, surgeon & specialist.
 IMPORTANT DEFINITIONS…CONTD
8) DOMICILIARY HOSPITALISATION Means a Medical
Treatment for a period of more than 3 days for such type
of illness, disease or injury which in the normal course would
require hospitalisation of insured person, but actually taken at
home under any of the following circumstances :-
> The condition of the patient is such that he/she cannot be moved to
the Hospital / Nursing Home
OR
> The patient cannot be moved to Hospital / Nursing Home for lack of
accommodation therein.
9) REASONABLE AND CUSTOMARY CHARGES means a charge
for medical care directly related to the treatment which shall
be considered reasonable and customary to the extent that it
does not exceed general level of charges being made by
other entities of similar standing in the locality for the persons
of the comparatble sex & age for similar disease / injury.
 IMPORTANT DEFINITIONS…CONTD
10) PRE-EXISTING CONDITION Means any condition, disease or
injury or related condition(s) for which Insured had signs or
symptoms, and / or were diagnosed, and / or received
medical advice/ treatment, within 48 months prior to your
first policy with us.
11) CRITICAL ILLNESS means any Disease or Manor Injuries as
listed below :-
a) Paralytic Stroke. b) Cancer. c) Renal Failure. d) Coronary
Artery Disease. e) Major Organ Transplant. f) Major Injuries
g) End Stage Liver Disease. h) Major Burns. i) Coma.
j) Multiple Sclerosis.
If the insured is diagnosed for any of the Critical Illness, the
policy will reimburse an additional SUM INSURED equal to
the Basic Sum Insured stated in the policy.
 IMPORTANT DEFINITIONS…CONTD
13) OPTIONAL EXTENSION. The policy can be taken with the
Optional Extension for Critical Illness by paying the premium
for such extension.
14) THIRD PARTY ADMINISTRATOR Means a service provider as
mentioned in the schedule of the policy who will provide
medical services if Insured has to undergo hospitalization as
an inpatient in any network hospital in the country
15) NETWORK means all such hospitals, or other providers that
the insurer/third party administrator have mutually agreed
with to provide services like cashless access to insured
persons.
 GENERAL CONDITIONS
1) WHO CAN TAKE THIS POLICY ?
A) Persons of any nationality normally residing in INDIA may
take this policy.
B) Policy covers treatment taken in INDIA only.
C) Age limit is 5 to 70 years but for new covers (Medical
Reports required for proposers above 45 years)
D) Children between the age of 3 months and 5 years can be
considered provided one or both the parents are covered
concurrently.
2) FAMILY COVERAGE Policy provides cover for insured & any
one or more of the following :-
> Spouse
> Dependent unmarried children with age between 91 days
and 23 years who are financially dependent on insured.
> Dependent parents up to the age of 60.
FAMILY DISCOUNT
2 family members 5%
3 or more members 10%
 GENERAL CONDITIONS
3) MEDICAL CHECK-UP FORMALITY.
> For Proposers of age group 46 to 55 years, a Medical
Examination Report, as per the format is required with the
following reports :-
1. FBS and PP2BS. 2. Corresponding Urine Sugar Report
3. ECG. 4. Serum Cholesterol.

> For Proposers of age ABOVE 55 years, a Medical

Examination Report, as per the format is required with the
following reports : -
1. FBS and PP2BS. 2. Corresponding Urine Sugar Report
3. ECG. 4. Lipid profile 5. Computerised Tread Mill Test or
2-D Echo.
 GENERAL CONDITIONS
4) RENEWAL. The Policy can be renewed by mutual consent
every year by paying the premium on or before the expiry of
the policy.
The policy has to be renewed within expiry date or within a
maximum of 15 days beyond which the continuity benefits will
not be available.
Insurers are not on risk during the gap period, if any.
5) CANCELLATION. Insurers may cancel the policy by sending
30 days notice by registered post & allow a PRO-RATA refund
of the premium for the expired period.
Insured can also cancel the policy by sending a notice by
registered post and the refund will be allowed on SHORT
PERIOD scale as stated in the policy.
>>> However, no refund can be given in respect of such
insured persons who have preferred a claim in the policy.
 CLAIM PROCEDURE
1) CLAIM INTIMATION. It should be written & immediate.
> Planned Admission : 72 hours before hospitalization.
> Emergency Cases : Not later than 48 hours from the
time of hospitalization.
2) CLAIM SUBMISSION. Claim Form & all supporting documents
must be submitted within 30 days from the date of discharge.
In extreme hardship cases, this limit for submission of
documents can be 90 days from the date of discharge.
3) RESPONSE TO QUERIES IN CLAIM. Within 15 days from the
date of query letter.
4) FAILURE TO COMPLY WITH ABOVE. Claim shall be rejected.
5) POSITION AFTER A CLAIM. Once a claim is paid, the sum
insured for the subject person will stand reduced by such
amount for the remaining period of the policy.
 POLICY EXCLUSIONS… Policy will not pay
1) PRE-EXISTING CONDITIONS. Any condition(s) as defined
earlier, until 36 months of continuous coverage have elapsed
since inception of first Individual Medishield Policy with ITGI.
2) FIRST 30 DAYS EXCLUSION. Any expense on for any disease
which incepts during first 30 days of commencement of this
insurance cover.
This exclusion shall not apply in case of the insured person having been
covered under this policy or group or individual edical insurance policy with
any of Indian Insurance Companies for a continuous period of preceding 12
months without a break exceeding 15 days.
POLICY EXCLUSIONS… Policy will not pay
3) FIRST YEAR EXCLUSION. Any expense incurred in the FIRST
YEAR of operation of the insurance cover on treatment of
the following diseases :
Cataract, Benign Prostatic Hypertrophy, Hysterectomy for
menorrhagia or fibromyoma, Hernia, Hydrocele, Congenital
Internal Disease. Fistula in anus, Piles, Sinusitis,
Choletithiasis and Cholecystectomy
This exclusion shall not apply in case of the insured person having been covered
under this policy or group or individual edical insurance policy with any of Indian
Insurance Companies for a continuous period of preceding 12 months without a
break exceeding 15 days.

4) However, if the above diseases are Pre-Existing at the time

of the first proposal, they will fall under Exclusion No 1 and
will be covered after THREE continuous years of insurance
with ITGI.
 POLICY EXCLUSIONS… Policy will not pay
5) EXTERNAL APPLIANCES. Cost of spectacles/ contact lens/
hearing/ aids.
6) DENTAL TREATMENT. Dental treatment or surgery of any kind,
unless requiring HOSPITALISATION.
7) WAR & ALLIED RISKS injury or diseases directly or indirectly
caused by war, invasion, act of foreign enemy, war like
operation (whether war be declared or not).
Circumcision, unless necessary for the treatment of a disease
not otherwise excluded or required as a result of accidental
bodily injury.
vaccination unless forming part of post-bite treatment,
Inoculation.
Cosmetic or aesthetic treatment of any description (including
any complications arising thereof), plastic surgery except those
relating to treatment of injury or disease .
 POLICY EXCLUSIONS… Policy will not pay
8) NOT A DISEASE. Convalescence, general debility, run
down condition or rest cure, congenital disease or
defects or anomalies, sterility, venereal disease,
intentional self injury and use of intoxicating drugs/
alcohols.
9) HIV/ AIDS. Any expense on treatment related to HIV,
AIDS and all related medical conditions.
10) PURELY DIAGNOSITC TESTS. Expenses on diagnostic
x-ray, or laboratory examinations unless related to the
active treatment of disease or injury falling within ambit
of hospitalisation or domiciliary hospitalisation claim.
11) PREGNANCY & CHILDBIORTH. Expenses on treatment to
pregnancy (other than ectopic pregnancy), childbirth,
miscarriage, abortion or complications of any of these,
including caesarean section and any infertility, sub fertility
or assisted conception treatment.
 POLICY EXCLUSIONS… Policy will not pay
(12) NUCLEAR RISKS. Any expense on injury or diseases directly
or indirectly caused by nuclear weapons / material.
(13) TERRORISM. Any expense on injury and diseases directly or
indirectly caused by or contributed to by an act of terrorism.
(14) OUTPATIENT. Any expense on treatment of insured person
as outpatient in a hospital.
(15) NATUROPATHY ETC. Any expense on naturopathy,
experimental or alternative medicine, however, this
exclusion shall not apply to AYURVEDIC treatment needing
hospitalisation, and taken at the ayurvedic hospitals.
(16) ACCUPRESSURE ETC. Any expense on procedure and
treatment including acupressure, acupuncture, magnetic
and such other therapies etc.
(17) TRANSPORTATION EXPENSES. Travel or transportation
expenses, other than ambulance service charges.
 POLICY EXCLUSIONS… Policy will not pay
(18) HAZARDOUS SPORTS ACTIVITIES. Any expense related to
disease/injury suffered whilst engaged in speed contest or
racing of any kind (other than on foot), ballooning,
parachuting, paragliding, and activities of similar hazard.
(19) EXTERNAL MEDICAL EQUIPMENTS Like wheelchairs,
crutches AND similar External instruments used in treatment
of various diseases.
(20) GENETIC DISORDERS. And stem cell implantation/ surgery.
(21) ALL NON MEDICAL EXPENSES Including personal comfort
and convenience services, such as telephone, aya/ barber or
baby food, cosmetics, napkins, toiletry items etc, and similar
incidental expenses.
(22) OBESITY, WEIGHT CONTROL PROGRAMMES, HORMONE
REPLACEMENT, SEX CHANGE TREATMENTS Etc.
(23) Some common ailments are not covered under Domiciliary
Hospitalisation section (list of 13 diseases given with policy)
 EMERGENCY ASSISTANCE SERVICES
These are value added services provided with this policy at no
additional costs. They are provided by a special Service Provider
when the insured person is travelling within 150 Kms are more
away from the residential address stated in the policy. These
services are available under the policy but insured cannot claim
any reimbursement for them. The services are as below :-
1) Medical Consultation.
2) Emergency Medical Evacuation.
3) Medical Repatriation.
4) Transportation to join patient.
5) Care &/or Transportation of Minor Children.
6) Emergency Message Transmission.
7) Return of Mortal Remains.
8) Emergency Cash Coordination.
 TYPES OF MEDICLAIM POLICIES
We have more than 60 policies in the market from different 18
Insurers and they can be grouped as below :-
NAME OF THE DESCRIPTION OF THE POLICY Total
POLICY Products
Individual policy Sum Insured on Individual Basis 18
Floater policy Sum Insured FLOATS on family 17
Critical illness Covers specified Critical Diseases 07
Senior citizen Meant for Senior Citizens 06
Top – up policy Claims paid subject to “EXCESS” 04
Special policy Policies with Customised covers 13

TOTAL 65
 They have
Insurers 1 been loosing money
have undercut each massively thanks to low
other to book group insurance Premium and high
at low costs with huge coverage 2
benefits
A Gridlock
Insurers are caught in a
Catch22 They have
Insurers have
situation and you are paying given claims
Reacted by
the
Removing TPAs, administration
Hiking rates and
price
to TPAs who
Rejecting claims
which is hurting did a shoddy job
customers
3
Hospitals are
5 overcharging, given the shortage
Of quality healthcare 4