BOI National Swasthya Bima Policy | Health Insurance Plan From Bank Of India

Posted on Wednesday, February 23rd, 2011

1. Salient Feature

BOI National Swasthya Bima policy is a unique Health Policy designed especially for the Account holders of Bank of India.  The entire family consisting of the account holder, spouse and two dependent children upto the age of 21 years can be covered under this policy.

This policy covers Hospitalization expenses for account holder and family.  In case of Hospitalization Expenses, the entire family is covered for the Floater Sum Insured as opted for, i.e., either one or all members of the family, as stated above, can utilize the Sum Insured during the policy period.

Age: 3 months to 65 years.  However, renewals are allowed upto 80 years at a premium to be fixed by the Company.

Terms & Conditions:

The Proposal Form attached to this Prospectus should be duly filled and submitted to the Bank of India Branch, where the a/c. holder has an a/c.

2 stamp size photographs of insured and covered family members to be affixed/attached in the Proposal form for making ID cards by TPA.

The premium will be deducted from the a/c by the bank and paid to National Insurance Co. Ltd.,

Effective date of cover will be from the date of receipt of premium by NICL DO/BO.

A Receipt, Policy & IT Certificate will be issued by NICL.

The TPA will send Guide Book & ID Cards to the insured.

Premium paid is eligible for IT benefit.

2. Scope Of Cover

1) Room, Boarding expenses as provided by the Hospital/Nursing Home.

2)  Nursing expenses.            ­

3)  Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees.

4) Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical appliances, Medicines & Drugs, Diagnostic Materials and X-Ray, Dialysis, Chemotherapy, Radiotherapy, Cost of pacemaker, Artificial Limbs and cost of organs and similar expenses.

5) Coverage options – 8 Slabs ranging from Rs.50,000/- to Rs.5,00,000/-, is available.

In Built Additional Covers:

1) Ambulance Charges – In case of emergencies, reasonable amount can be reimbursed not exceeding Rs.1000/- (Rupees one thousand only) per Policy period.

2) In case of Hospitalisation of children, covered in the policy below 12 years, a lump sum amount of Rs.1000/- (Rupees one thousand only) per policy period towards the out-of-pocket expenses. The payment will be made on the basis of a declaration from the parent without insisting on any supporting bill/cash memo.

3) Cost of Health Check-up allowed @ 1% of the Sum Insured after completion of three continuous claim free years of policy.

4)  Pre & Post Hospitalisation Expenses for first 30 days and 60 days respectively from the date of illness/injury.

5)  Pre-existing diseases are not covered.  However, Pre-existing diseases will be covered after three consecutive continuous claims free policy years which include policies taken from other Insurance Companies.

6)   Maternity Benefit and Baby Care Expenses are also reimbursed up to 5% of the sum insured.

7)   Treatment of NRIs in Indian Hospitals is allowed.

8)   Treatment in Hospitals in Nepal and Bhutan are also covered in Indian Currency.

9)   In case of death in hospital, funeral expenses are reimbursed up to Rs.1000/- over and above the sum insured subject to original illness/accident claim admitted under the policy.

Other Features:

1)       Hospitalisation Expenses, the entire family is covered for the Floater Sum Insured as opted i.e. either any one or all of the entire family, as stated above, can avail of the Sum Insured opted.

2)       Tax benefit available under Section 80D of IT Act.

3)       Premium will be paid through the Bank.

4)       Period of Insurance one year.

5)       The claims will be serviced by TPAs.

6)       Minimum hospitalisation for 24 hours.

3. Exclusions

1. All diseases/injuries, which are pre-existing when the cover incepts for the first time.  This exclusion will be deleted after three consecutive continuous claims free policy years in respect of all diseases provided, there was no hospitalisation for pre-existing ailment during such three years of insurance. For this purpose policy/policies issued by other insurance companies for last three continuous consecutive years will be considered provided there was no hospitalisation for pre-existing ailment during such three years of insurance.

2. Any hospitalization expenses incurred in the first 30 days from the commencement date of Insurance cover except in case of Injury arising out of accident.

3. During the 1st year of operation of insurance cover the expenses on treatment of diseases such as Cataract, Benign, Prostatic Hypertrophy, and Hysterectomy for Hemorrhagic, or Fibromyoma, Hernia, Hydrocele, congenital internal disease, Fistula in anus, Piles, Sinusitis and related disorders are not payable. If these diseases are pre existing it will be covered after three consecutive continuous claims free policy years.

4. Circumcision, 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 an accident or as apart of any illness.

5. Cost of spectacles and contact lenses, hearing aids.

6. Dental treatment or surgery of any kind unless requiring hospitalization.

7. Convalescence, general debility, run-down condition or rest cure, congenital external disease or defects or anomalies, Sterility, Infertility, Venereal disease, intentional self injury and use of intoxication drugs/alcohol, AIDS.

8. Charges incurred at Hospital or Nursing Home primarily for diagnosis purpose only.

9. Expenses on vitamins and tonics unless forming part of treatment for injury or diseases as certified by the attending physician.

10. Expenses in excess of 5% of the Sum Insured as mentioned in the schedule due to treatment due to treatment arising from or traceable to pregnancy (including voluntary termination of pregnancy) and child birth (including Caesarean Section) and allied maternity benefits. No expenses will be payable for any treatment arising from or traceable to Voluntary Termination of Pregnancy.

11. Naturopathy Treatment.

12. The benefits like Cumulative Bonus and Cost of Health Check up, enjoyed under the previous Policy/Policies, issued by any other Insurance Company shall not be available under this Policy.

(N.B. Company’s Liability in respect of all claims admitted during the period of Insurance shall not exceed the Floater Sum Insured per family as mentioned in the schedule).

4. Premium Payable

Floater Sum Insured (Rs.)                             Premium including Service Tax at 12.24% (Rs.)

50,000                                                                   930/-

1.0 lac                                                                    1746/-

1.5 Lac                                                                   2,635/-

2.0 lacs                                                  3390/-

2.5 Lacs                                                 4,059/-

3.0 lacs                                                  4729/-

4.0 lacs                                                  5899/-

5.0 lacs                                                  7071/-

5. Claims Procedure

Hospitalisation claims will be settled by the Third Party Administrators (TPA).

The details of the claims procedure for emergency/planned hospitalization and the contact phone nos. of TPA’s are given in the TPA Guidebook.  Insured as well as the Family is eligible either for cashless treatment and or reimbursement of claims method of claims settlement.

Documents to be submitted:

A)For Cashless Claim(If treatment is taken in the Panel  Hospital of TPA):

“Pre Authorization Form” given in the TPA Guide Book.

B)Reimbursement (If treatment is taken in  hospital not in Panel or in Panel of TPA)

1 Claim Form

2 Discharge Summary

3 Prescription with Bills

4 Test Reports

5 Any other documents required by NICL/TPA

NICL office/TPA will take decision on the basis of documents submitted and the terms, conditions, exceptions and exclusions of the policy.

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