National Mediclaim Policy (NMP)
National Mediclaim Policy (NMP)
National Mediclaim Policy (NMP)
Issuing Office
National Mediclaim Policy
1 RECITAL CLAUSE
Whereas the proposer designated in the Schedule hereto has by a proposal together with declaration and medical reports, which
shall be the basis of this Contract and is deemed to be incorporated herein, has applied to National Insurance Company Ltd.
(hereinafter called the Company), for the insurance hereinafter set forth, in respect of person(s) named in the Schedule hereto
(hereinafter called the Insured Persons) and has paid the premium as consideration for such insurance.
2 OPERATIVE CLAUSE
The Company undertakes that if during the Policy Period stated in the Schedule, any Insured Person(s) shall suffer any illness or
disease (hereinafter called Illness) or sustain any bodily injury due to an Accident (hereinafter called Injury), requiring
Hospitalisation of such Insured Person(s), for In-Patient Care at any hospital/nursing home (hereinafter called Hospital) or for
Day Care Treatment at any Day Care Center, following the Medical Advice of a duly qualified Medical Practitioner, the
Company shall indemnify the Hospital or the Insured, Reasonable and Customary Charges incurred for Medically Necessary
Treatment towards the Coverage mentioned herein.
Provided further that, the amount payable under the Policy in respect of all such claims during the Policy Period shall be subject
to the coverage, terms, exclusions, conditions, definitions and sub limits contained herein as well as shown in the Table of
Benefits, and shall not exceed the Sum Insured (i.e., Basic Sum Insured and Cumulative Bonus) and Reinstated Basic Sum
Insured (if applicable as per terms) of the Insured Person.
Note: Sub limits as mentioned in Section 2.1, 2.2 and 2.3 above, will not apply in case of treatment undergone as a package for a
listed procedure in a Preferred Provider Network (PPN).
3.1 Terms specific to Day Care Procedure, Ayurveda and Homeopathy, HIV/ AIDS Cover, Mental Illness Cover, Organ
Donor’s Medical Expenses, Ambulance Charges, Morbid Obesity Treatment and Correction of Refractive Error
In addition to the applicable Sub Limits (mentioned above), Hospitalisation due to any of the following shall be subject to the
terms mentioned against each.
Exclusions
Any kind of Psychological counselling, cognitive/ family/ group/ behavior/ palliative therapy or other kinds of psychotherapy for
which Hospitalisation is not necessary shall not be covered.
3.1.6Ambulance Charges
The Company shall reimburse the Insured the expenses incurred for emergency ambulance charges, up to 1% of Sum Insured
subject to maximum ₹ 2,000/- in a Policy Period for each Insured Person, for transportation to the Hospital or from the Hospital to
another Hospital or from the Hospital to diagnostic center and return during the same Hospitalisation.
Ambulance charges shall be admissible provided a Hospitalisation claim has been admitted under the Policy.
Note: The expenses that are not covered in this policy are placed under List-l of Appendix-II. The list of expenses that are to be
subsumed into room charges, or procedure charges or costs of treatment are placed under List-II, List-III and List-IV of
Appendix-II respectively.
In case of claim(s) during a Policy Period in respect of an Insured Person, who has accumulated CB for earlier claim free Policy
Periods, the accumulated CB will be reduced on the next Renewal at the rate of 5% of Basic Sum Insured of the expiring policy.
However, Basic Sum Insured will be maintained and not be reduced.
Note: Claims under Section 3.3.2 shall not be counted as a claim under the Policy.
5.20. Circumcision
Circumcision unless necessary for treatment of a disease (if not excluded otherwise) or necessitated due to an accident.
5.22. Massages, Steam Bath, Alternative Treatment (Other than Ayurveda and Homeopathy)
Massages, steam bath, expenses for alternative or AYUSH treatments (other than Ayurveda and Homeopathy), acupuncture,
acupressure, magneto-therapy and similar treatment.
5.29. Equipments
External/durable medical/non-medical equipments/instruments of any kind used for diagnosis/ treatment including CPAP, CAPD,
infusion pump, ambulatory devices such as walker, crutches, belts, collars, caps, splints, slings, braces, stockings, diabetic foot-
wear, glucometer, thermometer and similar related items (as listed in respective Appendix-II) and any medical equipment which
could be used at home subsequently.
5.33. War
War (whether declared or not) and war like occurrence or invasion, acts of foreign enemies, hostilities, civil war, rebellion,
revolutions, insurrections, mutiny, military or usurped power, seizure, capture, arrest, restraints and detainment of all kinds.
5.34. Radioactivity
Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from or from any other cause or event
contributing concurrently or in any other sequence to the loss, claim or expense. For the purpose of this exclusion:
a) Nuclear attack or weapons means the use of any nuclear weapon or device or waste or combustion of nuclear fuel or the
emission, discharge, dispersal, release or escape of fissile/ fusion material emitting a level of radioactivity capable of causing
any Illness, incapacitating disablement or death.
b) Chemical attack or weapons means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical
compound which, when suitably distributed, is capable of causing any Illness, incapacitating disablement or death.
c) Biological attack or weapons means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing)
micro-organisms and/or biologically produced toxins (including genetically modified organisms and chemically synthesized
toxins) which are capable of causing any Illness, incapacitating disablement or death.
6 CONDITIONS
6.3 Communication
i. All communication should be made in writing.
ii. For Policies serviced by TPA, ID card, PPN/Network Provider related issues to be communicated to the TPA at the address
mentioned in the Schedule. For claim serviced by the Company, the Policy related issues to be communicated to the Policy
issuing office of the Company at the address mentioned in the Schedule.
iii. Any change of address, state of health or any other change affecting any of the Insured Person, shall be communicated to the
Policy issuing office of the Company at the address mentioned in the Schedule
iv. The Company or TPA shall communicate to the Insured at the address mentioned in the Schedule.
6.5.4 Documents
The claim is to be supported with the following original documents and submitted within the prescribed time limit.
i. Completed claim form
ii. Medical practitioner’s prescription advising admission for inpatient treatment.
iii. Cash-memo from the hospital (s)/chemist (s) supported by proper prescription from attending medical practitioner for Pre
Hospitalisation, Hospitalisation and Post Hospitalisation.
iv. Payment receipt, investigation test reports and associated plates/CDs in original, supported by the prescription from attending
medical practitioner for Pre Hospitalisation, Hospitalisation and Post Hospitalisation.
v. Attending medical practitioner’s certificate regarding Diagnosis along with date of Diagnosis and bill, receipts etc.
vi. Surgeon’s certificate regarding Diagnosis and nature of operation performed along with bills, receipts etc.
vii. Bills, receipt, sticker of the Implants.
viii. Bills, payment receipts, medical history of the patient recorded, discharge certificate/ summary, break up of final bill from the
hospital etc.
ix. Any other document required by Company/TPA.
Note
In the event of a claim lodged under the Policy and the original documents having been submitted to any other insurer, the
Company shall accept the copy of the documents listed under condition 6.5.4 and claim settlement advice, duly certified by the
other insurer subject to satisfaction of the Company.
6.5.5 Time limit for submission of claim documents to the Company/ TPA
Type of claim Time limit
Reimbursement of Hospitalisation, Pre Hospitalisation Within thirty (30) days of date of discharge from Hospital
expenses and ambulance charges
Reimbursement of post Hospitalisation expenses Within thirty (30) days from completion of Post Hospitalisation
treatment
Reimbursement of Preventive Health Check-Up expenses At least forty five (45) days before the expiry of the fifth Policy
Period
6.10 Fraud
If any claim made by the insured person, is in any respect fraudulent, or if any false statement, or declaration is made or used in
support thereof, or if any fraudulent means or devices are used by the insured person or anyone acting on his/her behalf to obtain
any benefit under this policy, all benefits under this policy and the premium paid shall be forfeited.
6.11 Cancellation
i. The Company may cancel the policy at any time on grounds of misrepresentation non-disclosure of material facts, fraud by
the insured person by giving 15 days’ written notice. There would be no refund of premium on cancellation on grounds of
misrepresentation, non-disclosure of material facts or fraud
ii. The policyholder may cancel this policy by giving 15 days’ written notice and in such an event, the Company shall refund
premium for the unexpired policy period as detailed below.
6.13 Arbitration
i. If any dispute or difference shall arise as to the quantum to be paid by the Policy, (liability being otherwise admitted) such
difference shall independently of all other questions, be referred for arbitration as per Arbitration and Conciliation Act 1996,
as amended from time to time.
ii. 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 the Policy.
iii. It is hereby expressly stipulated and declared that it shall be a condition precedent to any right of action or suit upon the
Policy that award by such arbitrator/arbitrators of the amount of expenses shall be first obtained.
6.14 Disclaimer
If the Company shall disclaim liability to the Insured Person for any claim hereunder and if the Insured Person shall not within
twelve (12) calendar months from the date of receipt of the notice of such disclaimer notify the Company in writing that he does
not accept such disclaimer and intends to recover his claim from the Company, then the claim shall for all purposes be deemed to
have been abandoned and shall not thereafter be recoverable hereunder.
6.18 Migration
The insured person will have the option to migrate the policy to other health insurance products/plans offered by the company by
applying for migration of the policy at least 30 days before the policy renewal date as per IRDAI guidelines on Migration. If such
person is presently covered and has been continuously covered without any lapses under any health insurance product/plan offered
by the company, the insured person will get the accrued continuity benefits in waiting periods as per IRDAI guidelines on
migration.
6.19 Portability
The insured person will have the option to port the policy to other insurers by applying to such insurer to port the entire policy
along with all the members of the family, if any, at least 45 days before, but not earlier than 60 days from the policy renewal date
as per IRDAI guidelines related to portability. If such person is presently covered and has been continuously covered without any
lapses under any health insurance policy with an Indian General/Health insurer, the proposed insured person will get the accrued
continuity benefits in waiting periods as per IRDAI guidelines on portability.
6.23 Nomination
The policyholder is required at the inception of the policy to make a nomination for the purpose of payment of claims under the
policy in the event of death of the policyholder. Any change of nomination shall be communicated to the company in writing and
such change shall be effective only when an endorsement on the policy is made. In the event of death of the policyholder, the
Company will pay the nominee {as named in the Policy Schedule/Policy Certificate/Endorsement (if any)} and in case there is no
subsisting nominee, to the legal heirs or legal representatives of the policyholder whose discharge shall be treated as full and final
discharge of its liability under the policy.
7 DEFINITION
7.1 Accident means a sudden, unforeseen and involuntary event caused by external, visible and violent means.
7.2 AIDS means Acquired Immune Deficiency Syndrome, a condition characterised by a combination of signs and symptoms,
caused by Human Immunodeficiency Virus (HIV), which attacks and weakens the body’s immune system making the HIV-
positive person susceptible to life threatening conditions or other conditions, as may be specified from time to time.
7.3 Any One Illness means continuous period of Illness and it includes relapse within forty five (45) days from the date of last
consultation with the Hospital where treatment was taken.
7.4 AYUSH Treatment refers to the medical and/ or Hospitalisation treatments given Ayurveda, Yoga and Naturopathy,
Unani, Sidha and Homeopathy systems.
7.5 AYUSH Hospital is a healthcare facility wherein medical/surgical/para-surgical treatment procedures and interventions
are carried out by AYUSH Medical Practitioner(s) comprising of any of the following:
7.6 Break in Policy occurs at the end of the existing Policy Period when the premium due on a given Policy is not paid on or
before the Renewal date or within Grace Period.
7.7 Cashless Facility means a facility extended by the Company to the Insured where the payments, of the costs of treatment
undergone by the Insured in accordance with the Policy terms and conditions, are directly made to the Network Provider by
the Company to the extent pre-authorization approved.
7.8 Condition Precedent means a Policy term or condition upon which the Company’s liability under the Policy is conditional
upon.
7.9 Contract means prospectus, proposal, Policy, and the policy Schedule. Any alteration with the mutual consent of the
Insured Person and the Company can be made only by a duly signed and sealed endorsement on the Policy.
7.10 Congenital Anomaly means a condition which is present since birth, and which is abnormal with reference to form,
structure or position.
a) Internal Congenital Anomaly
Congenital Anomaly which is not in the visible and accessible parts of the body.
b) External Congenital Anomaly
Congenital Anomaly which is in the visible and accessible parts of the body.
7.11 Co-Payment means a cost sharing requirement under a health insurance policy that provides that the Insured will bear a
specified percentage of the admissible claims amount. A Co-Payment does not reduce the Sum Insured.
7.12 Cumulative Bonus means any increase or addition in the Sum Insured granted by the Company without an associated
increase in premium.
7.13 Day Care Centre means any Institution established for Day Care Treatment of Illness and/ or Injuries or a medical setup
with a Hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision
of a registered and qualified Medical Practitioner AND must comply with all minimum criteria as under:
i. has qualified Nursing staff under its employment;
ii. has qualified Medical Practitioner (s) in charge;
iii. has a fully equipped operation theatre of its own where Surgical Procedures are carried out
iv. maintains daily records of patients and shall make these accessible to the Company’s authorized personnel.
7.14 Day Care Treatment means medical treatment, and/or Surgical Procedure (as listed in Appendix I) which is:
i. undertaken under general or local anesthesia in a Hospital/Day Care Centre in less than twenty four (24) hrs because of
technological advancement, and
ii. which would have otherwise required a Hospitalisation of more than twenty four (24) hours.
Treatment normally taken on an Out-Patient basis is not included in the scope of this Definition.
7.15 Dental Treatment means a treatment carried out by a dental practitioner including examinations, fillings (where
appropriate), crowns, extractions and surgery.
7.16 Diagnosis means diagnosis by a Medical Practitioner, supported by clinical, radiological, histological and laboratory
evidence, acceptable to the Company.
7.17 Grace Period means the specified period of time immediately following the premium due date during which a payment can
be made to renew or continue a Policy in force without loss of continuity benefits such as Waiting Periods and coverage of
Pre-Existing Diseases. Coverage is not available for the period for which no premium is received.
7.18 Hospital means any Institution established for In-Patient Care and Day Care Treatment of Illness/ Injuries and which has
been registered as a Hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act,
2010 or under the enactments specified under Schedule of Section 56(1) of the said Act, OR complies with all minimum
criteria as under:
7.19 Hospitalisation means admission in a Hospital for a minimum period of twenty four (24) consecutive ‘In-Patient care’
hours except for specified procedures/ treatments, where such admission could be for a period of less than twenty four (24)
consecutive hours.
7.20 ID Card means the card issued to the Insured Person by the TPA for availing Cashless Facility in the Network Provider.
7.21 Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function
and requires medical treatment.
i. Acute Condition means a disease, illness or injury that is likely to respond quickly to treatment which aims to return the
person to his or her state of health immediately before suffering the disease/ illness/ injury which leads to full recovery.
ii. Chronic Condition means a disease, illness, or injury that has one or more of the following characteristics
a) it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and / or tests
b) it needs ongoing or long-term control or relief of symptoms
c) it requires rehabilitation for the patient or for the patient to be special trained to cope with it
d) it continues indefinitely
e) it recurs or is likely to recur
7.22 Injury means accidental physical bodily harm excluding illness or disease solely and directly caused by external, violent,
visible and evident means which is verified and certified by a Medical Practitioner.
7.23 In-Patient Care means treatment for which the Insured Person has to stay in a Hospital for more than twenty four (24)
hours for a covered event.
7.24 Insured/ Insured Person means person(s) named in the Schedule of the Policy.
7.25 Intensive Care Unit means an identified section, ward or wing of a Hospital which is under the constant supervision of a
dedicated Medical Practitioner(s), and which is specially equipped for the continuous monitoring and treatment of patients
who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably
more sophisticated and intensive than in the ordinary and other wards.
7.26 ICU (Intensive Care Unit) Charges means the amount charged by a Hospital towards ICU expenses which shall include
the expenses for ICU bed, general medical support services provided to any ICU patient including monitoring devices,
critical care nursing and intensivist charges.
7.27 Medical Advice means any consultation or advice from a Medical Practitioner including the issue of any prescription or
follow up prescription.
7.28 Medical Expenses means those expenses that an Insured Person has necessarily and actually incurred for medical treatment
on account of Illness or Accident on the advice of a Medical Practitioner, as long as these are no more than would have
been payable if the Insured Person had not been insured and no more than other Hospitals or doctors in the same locality
would have charged for the same medical treatment.
7.29 Medical Practitioner means a person who holds a valid registration from the Medical Council of any state or Medical
Council of India or Council for Indian Medicine or for Homeopathy set up by the Government of India or a State
Government and is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and
jurisdiction of the licence.
7.30 Medically Necessary Treatment means any treatment, tests, medication, or stay in Hospital or part of a stay in Hospital
which
i. is required for the medical management of Illness or Injury suffered by the Insured Person;
ii. must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or
intensity;
iii. must have been prescribed by a Medical Practitioner;
iv. must conform to the professional standards widely accepted in international medical practice or by the medical community in
India.
7.31 Mental Illness means a substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs
judgment, behaviour, capacity to recognise reality or ability to meet the ordinary demands of life, mental conditions
7.32 Network Provider means hospitals enlisted by the Company, TPA or jointly by the Company and TPA to provide medical
services to an Insured Person by a Cashless Facility.
In cities with Preferred Provider Network (Definition 7.38), PPN are the only Network Providers.
7.33 Non- Network Provider means any Hospital, Day Care Centre or other provider that is not part of the network.
7.34 Notification of Claim means the process of intimating a claim to the Company or TPA through any of the recognized
modes of communication.
7.35 OPD (Out-Patient) Treatment means the one in which the Insured Person visits a clinic / Hospital or associated facility
like a consultation room for Diagnosis and treatment based on the advice of a Medical Practitioner. The Insured is not
admitted as a Day Care or In-Patient.
7.36 Policy Period means period of one (01) year as mentioned in the Schedule for which the Policy is issued.
7.37 Pre Existing Disease means any condition, ailment, injury or disease
a) That is/are diagnosed by a physician within 48 months prior to the effective date of the Policy issued by the Company or its
reinstatement or
b) For which Medical Advice or treatment was recommended by, or received from, a physician within 48 months prior to the
effective date of the Policy issued by the Company or its reinstatement.
7.38 Preferred Provider Network (PPN) means Network Providers in specific cities which have agreed to a cashless packaged
pricing for specified planned procedures for the policyholders of the Company. The list of planned procedures is available
with the Company/TPA and subject to amendment from time to time.
7.39 Pre-hospitalisation Medical Expenses means Medical Expenses incurred during predefined number of days preceding the
Hospitalisation of the Insured Person, provided that:
i. Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalisation was required, and
ii. The In-patient Hospitalisation claim for such Hospitalisation is admissible by the Company.
7.40 Proposer means an eligible person who proposes to enter into insurance Contract with the Company, to cover self and/ or
any other eligible person(s), and pays the premium as consideration for such insurance.
7.41 Post-hospitalisation Medical Expenses means Medical Expenses incurred during predefined number of days immediately
after the Insured Person is discharged from the Hospital provided that:
i. Such Medical Expenses are for the same condition for which the Insured Person’s Hospitalisation was required, and
ii. The inpatient hospitalisation claim for such hospitalisation is admissible by the Company.
7.42 Psychiatrist means a Medical Practitioner possessing a post-graduate degree or diploma in psychiatry awarded by an
university recognised by the University Grants Commission established under the University Grants Commission Act,
1956, or awarded or recognised by the National Board of Examinations and included in the First Schedule to the Indian
Medical Council Act, 1956, or recognised by the Medical Council of India, constituted under the Indian Medical Council
Act, 1956, and includes, in relation to any State, any medical officer who having regard to his knowledge and experience in
psychiatry, has been declared by the Government of that State to be a psychiatrist.
7.43 Qualified Nurse means a person who holds a valid registration from the Nursing Council of India or the Nursing Council
of any state in India.
7.44 Reasonable and Customary Charges means the charges for services or supplies, which are the standard charges for the
specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking
into account the nature of the Illness/ Injury involved.
7.45 Renewal means the terms on which the Contract of Insurance can be renewed on mutual consent with a provision of Grace
Period for treating the Renewal continuous for the purpose of gaining credit for Pre-Existing Diseases, time-bound
Exclusions and for all Waiting Periods.
7.46 Room Rent means the amount charged by a Hospital towards Room and Boarding expenses and shall include the
associated Medical Expenses.
7.47 Schedule means a document forming part of the Policy, containing details including name of the Insured Person(s), age,
relation with the Proposer, Basic Sum Insured, Cumulative Bonus, premium and the Policy Period.
7.49 Surgery or Surgical Procedure means manual and / or operative procedure (s) required for treatment of an Illness or
Injury, correction of deformities and defects, diagnosis and cure of diseases, relief of suffering and prolongation of life,
performed in a Hospital or Day Care Centre by a Medical Practitioner.
7.50 Third Party Administrator (TPA) means a Company registered with the Authority, and engaged by an Insurer, for a fee or
remuneration, by whatever name called and as may be mentioned in the agreement, for providing health services.
7.51 Unproven/ Experimental Treatment means treatment, including drug experimental therapy, which is not based on
established medical practice in India, is experimental or unproven.
7.52 Waiting Period means a period from the inception of this Policy during which specified Illness/treatments are not covered.
On completion of the Waiting Period, Illness/treatments shall be covered provided the Policy has been continuously
renewed without any break.
8 REDRESSAL OF GRIEVANCE
In case of any grievance the insured person may contact the company through
Website: https://nationalinsurance.nic.co.in/ Post: National Insurance Co. Ltd.,
Toll free: 1800 345 0330 6A Middleton Street, 7th Floor,
E-mail: customer.relations@nic.co.in CRM Dept.,
Phn : (033) 2283 1742 Kolkata - 700 071
Insured person may also approach the grievance cell at any of the company’s branches with the details of grievance.
If Insured person is not satisfied with the redressal of grievance through one of the above methods, insured person may contact the
grievance officer (Office in-Charge) at that location.
For updated details of grievance officer, kindly refer the link: https://nationalinsurance.nic.co.in/
If Insured person is not satisfied with the redressal of grievance through above methods, the insured person may also approach the
office of Insurance Ombudsman of the respective area/region for redressal of grievance as per Insurance Ombudsman Rules 2017
(Annexure IV).
Grievance may also be lodged at IRDAI Integrated Grievance Management System -https://igms.irda.gov.in/