INDIVIDUAL MEDICLAIM

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INDIVIDUAL MEDICLAIM
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MEDICLAIM COVERAGE

• The Individual Medishield Policy covers
• Hospitalisation Expenses Domiciliary
  Hospitalisation (treatment at home in case
  patient is not in condition to be moved to
  hospital) incurred for treatment of disease /
  injury sustained during policy period. The
  expenses can be under following category
• ROOM EXPENSES

NURSING EXPENSES
SURGEON
Anaesthesia, Blood, Oxygen
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COVERAGE

AMBULANCE CHARGES
HEALTH CHECKUP
MEDICAL EMERGENCY ASSISTANCE SERVICES
PRE POST HOSPITALISATION
DOMICILIARY HOSPITALISATION
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ELIGIBILITY
AGE LIMIT-(Medical Check Up)
NATIONALITY
SPOUSE
ELIGIBILITY FOR FAMILY COVERAGE
UNMARRIED CHILDREN
DEPENDANT PARENTS
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THINGS TO REMEMBER
FOR A MINIMUM PERIOD OF 24 HOURS
BENEFIT UNDER INCOME TAX
CUMULATIVE BONUS
DOMICILIARY HOSPITALISATION COVERED UPTO 20 OF
BASIC SI
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EXCLUSIONS
ILLNESS CONTRACTED DURING FIRST YEAR OF POLICY
PRE-EXISTING DISEASES
30 DAYS WAITING PERIOD
WAR NUCLEAR RISKS
CIRCUMCISSION
COST OF SPECTACLES
DENTAL / TREATMENT
COSMETIC TREATMENT
AIDS
TREATMENT OUT OF CHILDBIRTH
NATUROPATHY
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EXCLUSIONS
PREGNANCY
OUT PATIENT TREATMENT
DIAGNOSTIC EXPENSES
TRAVEL / TRANSPORTATION EXPENSES
RACING,BUNGEE JUMPING, PARACHUTING
ADVENTURE SPORTS
EXTERNAL MEDICAL EQUIPMENT
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New Exclusions

• Genetic Disorders, stem cell implantation/surgery
• All Non Medical Expenses including personal
  comfort convenience items or services.
• Treatment of Obesity, Hormone Replacement
  Therapy, Sex Change

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CRITICAL ILLNESSES

• Paralytic Stroke
• Cancer
• Renal Failure
• Coronary Artery Disease(Angioplasty removed)
• Major Organ Transplant
• Major Injuries(loss of eyes along with loss of
  limbs)
• End Stage Liver Disease
• Major Burns
• Coma
• Multiple Sclerosis

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Cumulative Bonus

• Within 15 days of the expiry of the earlier
  cover.
• 15 CB-Medical test at the age of 55 years.
• 10 CB-Medical test at the age of 50 years.

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DOCUMENTS REQUIRED FOR CLAIMS
CASH MEMO
CLAIM FORM
DISCHARGE SUMMARY, BILLS
DIAGNOSTIC TEST REPORTS
DOCTORS REPORT
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Revision in Individual Mediclaim -WHY THE
CHANGES?

• Demand for introducing new / modified products
• A product differentiator through Value Added
  Services, apart from the Critical Illness option
• Some concerns on interpretation of Policy wording
  in the event of claims
• Need to update Policy wording in view of
  developments in medical science
• Review of prices by the competition a step
  towards rationalization

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OPPORTUNITIES

• We are introducing a unique concept in the
  country
• First mover advantage
• Tieup with a leading global Company Assist
  America
• Medical Emergency Services (AAMES)
• Similar value addition to other products
  possible
• Give a push to our Retail business in line with
  Corporate
• strategy
• Ensure sustainable profitable growth with brand
• building.

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SALIENT FEATURES

• No charge backs to ITGI or maximum limits
• stipulated
• No preexisting exclusion applicable for these
• assistance services
• No geographical or territorial exclusions in
  India
• No adventure sports exclusions for these services
• Available to all insured persons w.e.f. 1st May
  2007
• Direct service to insured person free of cost. No
• facility for cash payment or reimbursement of
• expenses incurred
• Services available for domestic travel not
  exceeding
• 90 days but beyond 150 kms. of residence

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TPA AND AAMES

• We continue with Paramount as our TPA
• We have chosen only select services of AAMES to
  avoid an overlap and confusion on who is to
  render which service in the event of a claim
• AAMES gets into action in the event of medical
  emergency before actual hospitalization
• The TPAs role starts when the insured person is
  hospitalized
• TPA arranges and facilitates cashless services at
  medical establishments

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EMERGENCY ASSISTANCE SERVICES

• Medical Consultation, Evaluation Referral
  Access to a 24hours,365 Days a Year Operations
  Center
• Emergency Medical Evacuation In case of a
  Medical Emergency when an adequate medical
  facility is not available, an emergency
  evacuation can be arranged
• Medical Repatriation When medically necessary,
  repatriation to the insured address can be done
  if adviced by ASSEMSILs physican.
• Transportation to Join Patient A family
  friend/personal friend can be given a round
  economy trip to the hospital of the insured if
  the insured needs to be hospitalized for more
  than 7 days.
• Care and/or Transportation of Minor Children If
  the insureds minor child/children is/are left
  unattended as a result of the insureds medical
  situtation,ASSEMSIL will provide the child with
  transportation to a safe place.

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• Emergency Message Transmission AAEMSIL will
  receive transmit messages to/from home.
• Return of Mortal Remains AAEMSIL will arrange
  and pay for the death of mortal remains.
• Emergency Cash Coordination AAEMSIL will assist
  in coordinating the transfer of emergency cash.

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CONDITIONS FOR EMERGENCY ASSISTANCE

• The emergency medical and personal assistance
  services are available to those traveling beyond
  150 kms within India from their residence for a
  period of not more than 90 days in a trip.
• The services shall be provided by Assist America
  Medical Emergency Services (India ) Private Ltd
  which is the Indian group company of Assist
  America

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• The benefits will be provided as direct services
  to the Insured by AAMESIL free of cost. No
  facility of any cash payment or reimbursement of
  expenses incurred directly by the Insured or
  through any other service / agency.
• With effect from the date of its implementation
  (i.e. 1.5.2007), all Individual Medishield
  Policies will be issued with the revised wordings
  which include the Emergency Medical and Personal
  Assistance Services provided by AAMESIL. This
  would apply to all fresh Policies, as well as our
  renewals effected from and after that date.

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FREQUENTLY ASKED QUESTIONS

• Will AAMESIL transport a family member or friend
  to be with the insured?
• Yes. If you are traveling alone and it seems
  likely that you will be hospitalized for more
  than seven days, AAMESIL will transport a family
  member or friend to your location.
• What happens when the insured is ready to be
  discharged but he/she still needs assistance?
• If the insured still needs assistance at the
  point of discharge from the hospital, AAMESIL
  will arrange for the insured to come home with a
  medical/non-medical escort.
• Are there other services that the insured should
  know about?
• AAMESIL also provides emergency message
  transmission, care of minor children left
  unattended due to the medical incident, return of
  mortal remains, prescription assistance and legal
  and interpreter referrals.

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• Are the insureds spouse and children covered?
• Spouse and minor children are eligible for
  services if they are covered under the terms of
  our Iffco Tokios (ITGI) Individual Medi-Shield
  Insurance Policy.
• If the insureds doctor at home tells him that he
  needs to go to a particular hospital for
  treatment, will AAMESIL transport the insured?
• No. AAMESIL assists travellers who are
  travelling more than 150 kilometers from home and
  need emergency medical help in such a situation.
• If the insured has an accident or illness, and if
  he or the hospital arranges for all the necessary
  transportation, will AAMESIL reimburse me for the
  expenses involved?
• No. AAMESIL is a Service Provider, not an
  Insurance Company. AAMESIL will make the
  arrangements for all services, which will be free
  of charge for the insured.