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Anytimers
 
AB Arogyadaan Scheme
 
 SALIENT FEATURES OF THE AB AROGYADAAN GROUP MEDICLAIM INSURANCE POLICY

I)  STRUCTURE OF AB AROGYADAAN POLICY & SUM INSURED SLABS :
On introduction of Super Top Up Policy from 09.06.2014 onwards, the Structure of AB Arogyadaan is revised as under –
a)   Main Policy
b)   Super Top Up Policy

a)   MAIN POLICY :
The Main Policy under AB Arogyadaan Scheme consists of the following five Sum Insured slabs under Plan A and Plan B -                         (Rs in Lakhs)

1

2

3

4

5

b)  SUPER TOP UP POLICY:
Super Top Up Policy is a unique policy introduced from 09.06.2014 onwards.  Both existing and new Policyholders are eligible to opt for Super Top Up Policy.  There are five Sum Insured slabs under Plan A and Plan B –
                                                                                                
                                                                                                                      (Rs in Lakhs)

3

5

7

10

15

Policyholders requiring Sum Insured of more than Rs. 5 Lakhs can opt for Super Top Up Policy. 
Including Super Top Up Policy, the total Sum Insured available to the Customer would be –
                                                                                                  (Rs in Lakhs)

8

10

12

15

20

 
  2.THIRD PARTY ADMINISTRATOR(TPA)
A policyholder shall be availing the services of Third Party Administrator (TPA) on the panel of the insurer.


The TPA will be issuing Photo Identity Card to the policyholder as soon as the policy has been issued by Insurance Company. The TPA has identified network of Hospitals across the Country, wherein Cashless Treatment is available on producing this Identity Card. However, Policy Holder is free to approach non network hospitals also but they may have to first honor the bill and seek reimbursement from TPA.

 
 3. ROLE OF TPA

M/s United India Insurance Company Ltd has empanelled M/s Good Health Plan Ltd (GHPL) as TPA for administering of this scheme from 09.06.2010 onwards.

A. POLICY HOLDER HOSPITALIZED IN NETWORK HOSPITAL

In case the Policyholder chooses to get admitted in the network hospital, the said hospital will take care to get clearance from TPA for Cashless Treatment, in which case the Policyholder has to pay amount over and above the eligibility limits (mentioned in 3(E) below) and certain disallowable expenses at the time of discharge from the Hospital

.

B. POLICY HOLDER HOSPITALIZED IN NON NETWORK HOSPITAL

In case the Policy Holder approaches non network hospital, they may have to first honor the bill and claim bill amount from TPA. Claim Documents should be submitted by the Claimants to TPA, within 30 days from the date of discharge from the Hospital.
 
 3. DETAILS OF HOSPITALIZATION EXPENSES COVERED

In the event of any claim(s) becoming admissible under this scheme, the Insurance company will pay through TPA to the Hospital / Nursing Home or the insured person the amount of such expenses as would fall under different heads mentioned below, and as are reasonably and necessarily incurred thereof by or on behalf of such Insured Person, but not exceeding the Sum Insured in aggregate mentioned in the schedule hereto.

A) Room, Boarding and Nursing Expenses as provided by the Hospital/Nursing Home up to 1% of Sum Insured per day or actual amount incurred whichever is less. This also includes Nursing Care, RMO charges, IV Fluids/Blood Transfusion/Injection administration charges and the like.

B) If admitted in IC Unit, the Company will pay up to 2% of Sum Insured per day or actual amount incurred whichever is less.

C) Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees
Anesthetist, Blood, Oxygen, Operation Theatre Charges, surgical appliances, Medicines & Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, cost of prosthetic devices implanted during surgical procedure like Pacemaker, relevant laboratory diagnostic tests, etc & similar expenses.

D) All Hospitalization Expenses (excluding cost of organ, if any) incurred for donor in respect of Organ transplant.

 

 
 E) Due to introduction of Super Top Up Policy the claims in respect of the following specified illness shall be restricted by the insurer  due to increase in Sum Insured Slabs –


Hospitalization Benefits

Limits for each Hospitalization

 

Cataract

10% of the Sum Insured subject to a maximum of Rs. 25,000/-

Hernia

15% of the Sum Insured subject to a maximum of Rs. 30,000/-

Hysterectomy / Myomectomy

20% of the Sum In sured subject to a maximum of Rs. 50,000/-

Following Specified major surgeries –

  • Cardiac Surgeries
  • Cancer Surgeries
  • Brain Tumor Surgeries
  • Pacemaker Implantation for Sick, Sinus Syndrome
  • Hip Replacement
  • Knee Joint Replacement

80% of the Sum Insured subject to a maximum of Rs. 16 Lakhs

However,  Policyholders who have opted for Super Top Up Policy  will be eligible for Room Rent of 1% of Threshold Sum Insured subject to maximum of   Rs. 5,000/-or actual whichever is less.

PRE & POST HOSPITALIZATION CLAIMS :

Hospitalization Benefits

Limits for each Hospitalization

Pre & Post Hospitalization in respect of any illness

Actual expenses subject to a maximum of 10% of Sum Insured Policy-wise that is under Main Policy and Super Top Policy respectively.

 

 

 
 
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