National Insurance Company Limited

CIN - U10200WB1906GOI001713 IRDAI Regn. No. - 58

National Mediclaim Policy

Customer Information Sheet

This document provides key information about your policy. You are also advised to go
through your policy document.

DESCRIPTION Policy
S TITLE
(Please refer to applicable Policy Clause Number in next Clause
No.
column) No.
Name of
1. Insurance National Mediclaim Policy
Product
2. Policy No.
Type of
Indemnity
3. Insurance
Product
Individual Sum Insured (SI): Rs.
4. Sum Insured
5. Policy Expenses in respect of: 3
Coverage a. Admission in Hospital beyond 24 hrs 3.1
(what the b. Room Charges 3.2
policy c. Medical Practitioner’s Fees 3.3
covers?) d. Other Expenses 3.4
e. Hemodialysis, Chemotherapy (other than oral), Radiotherapy 3.5
f. Modern Treatments 3.6
g. Treatment necessitated due to participation as a non- 3.7
professional in hazardous or adventure sports
h. Pre-hospitalisation (treatment prior to admission in hospital) of 3.8
45 days
i. Post-hospitalisation (treatment after discharge from hospital) 3.9.1
within 60 days from date of discharge
j. Procedures requiring less than 24 hours of hospitalization (day 3.9.2
care). 3.9.3
k. AYUSH Treatment 3.9.4
l. HIV/ AIDS Treatment 3.9.5
m. Mental Illness Treatment 3.9.6
n. Organ Donor’s Medical Expenses 3.9.7
o. Ambulance Charges 3.9.8
p. Morbid Obesity Treatment
q. Correction of Refractive Error (equal to or more than 7.5 3.10.1
dioptres)
Other Benefit: Reinstatement of Basic Sum Insured (available to 3.11
Basic SI of ₹ 6L and above)
Good Health Incentive:
a. Cumulative Bonus (CB) 3.11.1
b. Preventive Health Check Up 3.11.2
6. Exclusions Waiting Period EXCLUSIONS 4
(what the a. Pre-Existing Diseases (Excl 01) 4.1
policy does b. Specified disease/procedure waiting period (Excl 02) 4.2
not cover) c. First 30 days waiting period (Excl 03) 4.3

Exclusions 5
d. Investigation& Evaluation (Excl 04) 5.1
e. Rest Cure, Rehabilitation and Respite Care (Excl 05) 5.2
National Insurance Co. Ltd. National Mediclaim Policy
Regd. Office Premises No. 18-0374, Plot no. Page 1 of 6 UIN: NICHLIP25036V082425
CBD-81, New Town, Kolkata - 700156
 f. Obesity/ Weight Control (Excl 06) 5.3
g. Change-of-Gender Treatments (Excl 07) 5.4
h. Cosmetic or Plastic Surgery (Excl 08) 5.5
i. Hazardous or Adventure Sports (Excl 09) 5.6
j. Breach of Law (Excl 10) 5.7
k. Excluded Providers (Excl 11) 5.8
l. Drug/Alcohol Abuse (Excl 12) 5.9
m. Non-Medical Admissions (Excl 13) 5.10
n. Vitamins, Tonics (Excl 14) 5.11
o. Refractive Error (Excl 15) 5.12
p. Unproven Treatments (Excl 16) 5.13
q. Birth control, Sterility and Infertility (Excl 17) 5.14
r. Maternity (Excl 18) 5.15
s. Hormone Replacement Therapy 5.16
t. General Debility, Congenital External Anomaly 5.17
u. Self Inflicted Injury 5.18
v. Stem Cell Surgery 5.19
w. Circumcision 5.20
x. Vaccination or Inoculation. 5.21
y. Massages, Steam Bath, Alternative Treatment (Other than 5.22
AYUSH)
z. Dental treatment 5.23
aa. Domiciliary Hospitalization & Out Patient Department (OPD) 5.24
treatment
bb. Stay in Hospital which is not Medically Necessary. 5.25
cc. Spectacles, Contact Lens, Hearing Aid, Cochlear Implants 5.26
dd. Non Prescription Drug 5.27
ee. Treatment not Related to Disease for which Claim is Made 5.28
ff. Equipments 5.29
gg. Items of personal comfort 5.30
hh. Service charge/ registration fee 5.31
ii. Home visit charges 5.32
jj. War 5.33
kk. Radioactivity 5.34
ll. Treatment taken outside the geographical limits of India 5.35

Exclusions in Mental Illness Cover 3.9.4

Exclusions in Organ Donor’s Medical Expenses 3.9.5
7. Waiting a. Initial waiting period: 30 days for all illnesses (not applicable 4.3
period in case of continuous renewal or accidents)
b. Specific waiting periods (Not applicable for claims arising 4.2
due to an accident):
o Ninety (90) Days for 3 diseases/procedures/conditions
o One (1) year for 5 diseases/procedures
o Two (2) years for 20 diseases/procedures
o Three (3) years for 4 diseases/procedures

c. Pre-Existing Diseases: Covered after thirty six (36) months 4.1

8 Financial Coverage shall be subject to the following Sub Limits: (SI here
limits of means basic sum insured and cumulative bonus, if any)
coverage i. Room Charges - Up to 25% of SI (Any One Illness) 3.1
i. Sub-limit a. Room Rent - Up to 1% of SI, subject to max of INR 10,000 3.1.i
(It is a pre- per day
defined limit b. ICU charges - Up to 2% of SI subject to max of INR 20,000 3.1.ii
and the per day
insurance ii. Medical Practitioner’s Fees - Up to 25% of SI (Any One 3.2
National Insurance Co. Ltd. National Mediclaim Policy
Regd. Office Premises No. 18-0374, Plot no. Page 2 of 6 UIN: NICHLIP25036V082425
CBD-81, New Town, Kolkata - 700156
 company will Illness)
not pay any iii. Other Expenses - Up to 50% of SI (Any One Illness). 3.3
amount in iv. Hemodialysis, Chemotherapy (other than oral), 3.4
excess of this Radiotherapy – Up to 50% of SI or the PPN Package Rate
limit) v. Modern Treatments – Up to 25% of SI 3.5
vi. Treatment necessitated due to participation as a non- 3.6
professional in hazardous or adventure sports – Up to 25%
of SI
vii. Ambulance Charges – 1% of SI subject to maximum of INR 3.9.6
2,000 in a Policy Period

ii. Co- Optional Co-payment 6.17.7

payment (It The Insured may opt for Optional Co-payment, with discount in
is a specified premium. Insured may choose either of the two Co-payment
amount/perce options:
ntage of the  20% Co-payment on each admissible claim, with a 25%
admissible discount in premium
claim amount  10% Co-payment on each admissible claim, with a 12.5%
to be paid by discount in premium
policyholder/i
nsured).

iii. Not applicable

Deductible
iv. Any other Not applicable
limit
9. Claims/ For Cashless Service
Claim i. Notification of claim to be provided as per table below. 6.17.1
Procedure Notification of claim TPA must be informed:
for Cashless facility
In the event of planned At least seventy two (72) hours prior
hospitalisation to the Insured Person’s admission to
Network Provider
In the event of Within twenty four (24) hours of the
emergency Insured Person’s admission to
hospitalisation Network Provider
ii. Cashless Facility for treatment in Network Providers or any
other provider can be availed, if TPA service is opted. 6.17.2
Treatment may be taken in a network provider / PPN or any
other provider and is subject to pre-authorisation by the TPA.
Updated list of network provider/PPN is available on the
website of the Company and the TPA mentioned in the
schedule.
iii. Cashless request form available with the Network Provider and
TPA shall be completed and sent to the TPA for authorization.
iv. The TPA upon getting cashless request form and related
medical information from the Insured Person/ Network Provider
shall issue a pre-authorization letter within an hour to the
Hospital after verification.
v. At the time of discharge, the Insured Person has to verify and
sign the discharge papers, pay for non-medical and
inadmissible expenses.
vi. The TPA shall grant the final authorization within three hours
of the receipt of discharge authorization request from the
Hospital.
vii. The TPA reserves the right to deny pre-authorization in case
National Insurance Co. Ltd. National Mediclaim Policy
Regd. Office Premises No. 18-0374, Plot no. Page 3 of 6 UIN: NICHLIP25036V082425
CBD-81, New Town, Kolkata - 700156
 the Insured Person/ Network Provider is unable to provide any
required details related to the pre authorization request.
viii. In case of denial of Cashless Facility, the Insured Person may
obtain the treatment as per treating Medical Practitioner’s
advice and submit the necessary documents to the Company
or the TPA for reimbursement of claim.

For Reimbursement of Claim 6.17.3

ix. Notification of claim to be provided as per table below.
Notification of claim Company/TPA must be informed:
for Reimbursement
In the event of At least seventy two (72) hours prior to
planned the Insured Person’s admission to
hospitalisation Hospital
In the event of Within twenty four (24) hours of the
emergency Insured Person’s admission to Hospital
hospitalisation
x. For reimbursement of claims the insured person may submit
the necessary documents to TPA (if claim is processed by
TPA)/Company (if claim is processed by the Company)
within the prescribed time limit.

Type of claim Time limit for submission of 6.17.5

documents to Company/TPA
Reimbursement of Within thirty (30) days of date
hospitalization, pre of discharge from Hospital
hospitalisation expenses and
ambulance charges
Reimbursement of post Within thirty (30) days from
hospitalisation expenses completion of Post
Hospitalisation treatment
Reimbursement of At least forty five (45) days
Preventive Health Check-Up before the expiry of the fifth
expenses Policy Period

Claim Settlement 6.3

xi. The Company shall settle or reject a claim, as the case may
be, within 15 days from the date of receipt of last necessary
document.
xii. In the case of delay in the payment of a claim, the Company
shall be liable to pay interest to the policyholder from the
date of receipt of last necessary document to the date of
payment of claim at a rate 2% above the bank rate.
xiii. However, where the circumstances of a claim warrant an
investigation in the opinion of the Company, it shall initiate
and complete such investigation at the earliest, in any case
not later than 30 days from the date of receipt of last
necessary document. In such cases, the Company shall
settle or reject the claim within 45 days from the date of
receipt of last necessary document.
xiv. In case of delay beyond stipulated 45 days, the
Company shall be liable to pay interest to the policyholder at
a rate 2% above the bank rate from the date of receipt of
last necessary document to the date of payment of claim

National Insurance Co. Ltd. National Mediclaim Policy

Regd. Office Premises No. 18-0374, Plot no. Page 4 of 6 UIN: NICHLIP25036V082425
CBD-81, New Town, Kolkata - 700156
 Turn Around Time (TAT) for claims settlement:
xv. TAT for preauthorization of cashless facility –1 hour from
the time last necessary document is received by TPA
xvi. TAT for cashless final bill authorization – 3 hours
from the time discharge bill is received by TPA
Network Hospital Details:
https://nationalinsurance.nic.co.in/en/health-insurance/city-wise-
list-ppn-hospitals
Helpline Number: 1800 345 0330
Downloading Claim form:
https://nationalinsurance.nic.co.in/en/health-insurance
10 Policy Helpline: 1800 345 0330
Servicing E-mail:
Phone :
Post:
11. Grievances/ In case of any grievance the insured person may contact the 7
Complaints company through
Website: https://nationalinsurance.nic.co.in/en/grievance
Toll free: 1800 345 0330
E-mail: customer.relations@nic.co.in
Phone : (033) 6811 0000
Post: CRM Dept., National Insurance Co. Ltd., Premises No. 18-
0374, Plot no. CBD-81, Rajarhat, New Town, Kolkata - 700156
Insurance Ombudsman – As per Appendix II attached to Policy.
Dedicated Email ID for Senior Citizens: health.srcitizens@nic.co.in
12 Things to Free Look Period 6.13
Remember You may cancel the insurance policy if you don’t want it, within 30
days from the beginning of the policy. (Not applicable on renewals)
If the insured has not made any claim during the Free Look Period,
the insured shall be entitled to
i. a refund of the premium paid less any expenses incurred by
the Company on medical examination of the insured person
and the stamp duty charges or
ii. where the risk has already commenced and the option of
return of the policy is exercised by the insured person, a
deduction towards the proportionate risk premium for period
of cover or
iii. Where only a part of the insurance coverage has
commenced, such proportionate premium commensurate
with the insurance coverage during such period.

Policy Renewal
A health insurance policy shall be renewable provided the product 6.9
is not withdrawn, except in case of established fraud or non-
disclosure or misrepresentation by the Insured

Migration and Portability:

● The insured person will have the option to migrate the policy 6.7
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.
● The insured person will have the option to port the policy to
other insurers by applying to such insurer to port the entire policy 6.8
along with all the members of the family, if any, at least 15 days
before, but not earlier than 60 days from the policy renewal date as
per IRDAI guidelines related to portability
National Insurance Co. Ltd. National Mediclaim Policy
Regd. Office Premises No. 18-0374, Plot no. Page 5 of 6 UIN: NICHLIP25036V082425
CBD-81, New Town, Kolkata - 700156
 Change in Basic Sum Insured:
i. Basic Sum insured can be enhanced only at the time of 6.23
renewal.
ii. For the incremental portion of the Basic Sum Insured, the
Waiting Periods shall apply. Coverage on enhanced Basic
Sum insured shall be available after the completion of
Waiting Periods.

Moratorium Period: 6.11

After completion of sixty continuous months under the policy no
look back to be applied. This period of sixty months is called as
Moratorium Period. The moratorium would be applicable for the
sums insured of the first policy and subsequently completion of
eight continuous years would be applicable from the date of
enhancement of sums insured only on the enhanced limits.
After the expiry of Moratorium Period no health insurance policy
shall be contestable except for proven fraud and permanent
exclusions specified in the policy contract.
13 Your  Please disclose all Pre-Existing Disease/s or condition/s before 6.1
Obligations buying a Policy. Non-disclosure may affect the claim
settlement.
 The policy shall be void and all premium paid thereon shall be
forfeited to the Company in the event of misrepresentation, mis
description or non-disclosure of any material fact by the
policyholder.
"Material facts" for the purpose of this policy shall mean all
relevant information sought by the company in the proposal
form and other connected documents to enable it to take
informed decision in the context of underwriting the risk.

Legal Disclaimer
The information must be read in conjunction with the policy document. In case of any conflict
between the CIS and the policy document the terms and conditions mentioned in the policy
document shall prevail.

Declaration by the Policy Holder:

I have read the above and confirm having noted the details.

Place:

Date: (Signature of the Policyholder)

Insurance is the Subject matter of Solicitation

National Insurance Co. Ltd. National Mediclaim Policy

Regd. Office Premises No. 18-0374, Plot no. Page 6 of 6 UIN: NICHLIP25036V082425
CBD-81, New Town, Kolkata - 700156