National Insurance Company Limited

CIN - U10200WB1906GOI001713 IRDAI Regn. No. - 58

National Super Top Up Mediclaim Policy

PROSPECTUS
1.1 Product
National Super Top Up Mediclaim Policy is a high threshold indemnity health insurance product, covering the members of a
family under a single sum insured on floater basis or each member on individual sum insured basis. Claim under the Policy is
payable provided the cumulative medical expenses for the insured (individual basis) or the family (floater basis) in a policy period
exceeds the threshold. The Policy covers expenses in respect of inpatient treatment (allopathy and AYUSH) reasonably and
customarily incurred for treatment of a disease or an injury contracted/sustained during the policy period. The Policy also covers
pre hospitalisation and post hospitalisation expenses, 140+ day care procedures/surgeries, organ donor’s medical expenses,
hospital cash, doctor’s home visit, nursing, aya and attendant charges, ambulance charges, HIV/ AIDS treatment, bariatric surgery
and maternity.

Important:
i. Claim shall be admissible for the Hospitalisation during which the Cumulative Medical Expenses in respect of
Hospitalisation(s) of any Insured Person (individual plan) or one or more Insured Persons (floater plan) in a Policy Year of
the Policy Period exceeds the Threshold and for all subsequent Hospitalisation(s) during the Policy Year.
ii. Threshold shall be determined taking into account the Cumulative Medical Expenses incurred in one or more
hospitalisation(s) during the each Policy Year of the Policy Period of this Policy for Coverage mentioned in Section 1.2
only, irrespective of existence of any Base Policy covering the said hospitalisation(s).
iii. For claims admissible under the Policy after Cumulative Medical Expenses exceeds the Threshold, Coverage mentioned in
both Section 1.2 and Section 1.3 shall be payable.
iv. Maximum liability of the Company under the policy for all admissible claims during each Policy Year of the Policy Period
shall be the individual/ floater Sum Insured opted.
v. The insured shall preserve and submit all original documents and/ or certified copies of documents related to all
hospitalisation(s) during the policy period to enable the Company to calculate the cumulative medical expenses and
threshold, for determining admissibility and payment of claims.

1.2 Coverage

1.2.1 In-patient Treatment

The Company shall indemnify the Medical Expenses incurred for all Hospitalisation(s):
i. Room Rent and Intensive Care Unit Charges (including diet charges, nursing care by qualified nurse, RMO charges,
administration charges for IV fluids/blood transfusion/injection)
ii. Medical Practitioner(s) fees
iii. Anaesthesia, blood, oxygen, operation theatre charges, surgical appliances
iv. Medicines and drugs
v. Diagnostic procedures
vi. Prosthetics and other devices or equipment if implanted internally during a surgical procedure.
vii. Dental treatment, necessitated due to an injury
viii. Plastic surgery, necessitated due to illness or injury
ix. Hormone replacement therapy, if medically necessary
x. Vitamins and tonics, forming part of treatment for illness/injury as certified by the attending medical practitioner
xi. Circumcision, necessitated for treatment of an illness or injury

1.2.1.1 Treatment related to participation as a non-professional in hazardous or adventure sports

Expenses related to treatment necessitated due to participation as a non-professional in hazardous or adventure sports, subject to
Maximum amount admissible for Any One Illness shall be lower of 25% of Sum Insured.

1.2.2 Pre Hospitalisation

The Company shall indemnify the Medical Expenses incurred up to thirty days immediately before the insured Person is
Hospitalised, 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
Pre hospitalisation shall be considered as part of the hospitalisation claim.

1.2.3 Post Hospitalisation

The Company shall indemnify the Medical Expenses incurred up to sixty days immediately after the insured person is discharged
from hospital, 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
Post hospitalisation shall be considered as part of the hospitalisation claim.

National Insurance Co. Ltd.

National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 1
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
1.2.4 Day Care Procedure
The Company shall indemnify the Medical Expenses and pre and post hospitalisation expenses, for day care procedures which
require hospitalisation for less than twenty four hours, provided that
i. day care procedures/surgeries (as listed in Appendix -I) are undergone by an insured person in a hospital/day care centre
(but not in the outpatient department of a hospital)
ii. any other surgeries/procedures (not listed in Appendix-I) which due to advancement of medical science require
hospitalisation for less than twenty four hours and for which prior approval from the Company/TPA is mandatory.

1.2.5 AYUSH Treatment:

The Company shall indemnify Medical Expenses incurred for Inpatient Care treatment under Ayurveda, Yoga and Naturopathy,
Unani, Siddha and Homeopathy systems of medicines during each Policy Period up to the limit of Sum Insured as specified in the
Policy Schedule in any AYUSH Hospital.

1.2.6 Organ Donor’s Medical Expenses

The Company shall indemnify the Medical Expenses incurred in respect of an organ donor’s Hospitalisation during the Policy
Period for harvesting of the organ donated to an Insured Person, provided that:
i. The organ donation confirms to the Transplantation of Human Organs Act 1994 (and its amendments from time to time)
ii. The organ is used for an Insured Person and the Insured Person has been medically advised to undergo an organ transplant
iii. The Medical Expenses shall be incurred in respect of the organ donor as an in-patient in a Hospital.
iv. Claim has been admitted under Section “In patient treatment” in respect of the Insured Person undergoing the organ
transplant.

Exclusions:
The Company shall not be liable to make payment for any claim under this Cover which arises for or in connection with any of the
following:
i. Pre-hospitalization Medical Expenses or Post- Hospitalization Medical Expenses of the organ donor.
ii. Costs directly or indirectly associated with the acquisition of the donor’s organ.
iii. Medical Expenses where the organ transplant is experimental or investigational.
iv. Any medical treatment or complication in respect of the donor, consequent to harvesting.
v. Any expenses related to organ transportation or preservation.

1.2.7 HIV/ AIDS Treatment

The Company shall indemnify the Medical Expenses for In-patient Care, Pre-Hospitalisation expenses and Post-Hospitalisation
expenses, related to following stages of HIV infection:
1. Acute HIV infection – acute flu-like symptoms
2. Clinical latency – usually asymptomatic or mild symptoms
3. AIDS – full-blown disease; CD4 < 200

1.2.8 Morbid Obesity Treatment

The Company shall indemnify the Medical Expenses for In-patient Treatment, pre hospitalisation expenses and post
hospitalisation expenses, incurred for surgical treatment of obesity that fulfils all the following conditions and subject to Waiting
Period of thirty six (36) months:
1. Treatment has been conducted is upon the advice of the Medical Practitioner, and
2. The surgery/Procedure conducted should be supported by clinical protocols, and
3. The Insured Person is 18 years of age or older, and
4. Body Mass Index (BMI) is;
a) greater than or equal to 40 or
b) greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less
invasive methods of weight loss:
i. Obesity-related cardiomyopathy
ii. Coronary heart disease
iii. Severe Sleep Apnea
iv. Uncontrolled Type 2 Diabetes

1.2.9 Maternity
The Company shall indemnify Maternity Expenses as described below for any female Insured Person, and also Pre-Natal and
Post-Natal Hospitalisation expenses per delivery, including expenses for necessary vaccination for the New Born Baby, subject to
the limit as shown in the Table of Benefits. The female Insured Person should have been continuously covered for at least 36
months before availing this benefit:
The New Born Baby shall be automatically covered from birth under the Sum Insured available to the mother during the
corresponding Policy Period, for up to 3 months of age. On attaining 3 months of age, the New Born Baby shall be covered only if
specifically included in the Policy mid-term and requisite premium paid to the Company.

Maternity Expenses means:

a) Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred
during Hospitalization);
b) Expenses towards lawful medical termination of pregnancy during the Policy Period.
Note: Ectopic pregnancy is covered under “In-patient Treatment”, provided such pregnancy is established by medical reports.
National Insurance Co. Ltd.
National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 2
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
Exclusions:
The Company shall not be liable to make any payment under the cover in respect of any expenses incurred in connection with or
in respect of:
1. Covered female Insured Person below eighteen (18) years and above forty-five (45) years of age.
2. Delivery or termination within a Waiting Period of thirty six (36) months. However, the Waiting Period may be waived
only in the case of delivery, miscarriage or abortion induced by accident.
3. Delivery or lawful medical termination of pregnancy limited to two deliveries or terminations or either has been paid
under the Policy and its Renewals.
4. More than one delivery or lawful medical termination of pregnancy during a single Policy Period.
5. Ectopic pregnancy.
6. Pre and post hospitalisation expenses, other than pre and post natal treatment.

1.2.10 Modern Treatment

The Company shall indemnify the Medical Expenses for In-Patient Treatment or Day Care Procedure along with Pre-
Hospitalisation expenses and Post-Hospitalisation expenses incurred for following Modern Treatments (wherever medically
indicated), subject to the limit of 25% of the Sum Insured for the related modern procedure/ component/ medicine of each Modern
Treatment during the Policy Period:
Modern Treatment Coverage
UAE & HIFU Limit is for Procedure cost only
Balloon Sinuplasty Limit is for Balloon cost only
Deep Brain Stimulation Limit is for implants including batteries only
Only cost of medicines payable under this limit, other incidental
Oral Chemotherapy
charges like investigations and consultation charges not payable.
Immunotherapy Limit is for cost of injections only.
Limit is for complete treatment, including Pre & Post
Intravitreal injections
Hospitalization
Robotic Surgery Limit is for robotic component only.
Stereotactic Radio
surgeries Limit is for radiation procedure.
Limit is for complete treatment, including Pre & Post
Bronchial Thermoplasty
Hospitalization
Vaporization of the
prostrate Limit is for LASER component only.
IONM Limit is for IONM procedure only.
Limit is for complete treatment, including Pre & Post
Stem cell therapy
Hospitalization

1.2.11 Mental Illness Cover

The Company shall indemnify the Medical Expenses (including Pre and Post Hospitalisation Expenses) related to Mental
Illnesses, provided the treatment shall be undertaken at a Hospital with a specific department for Mental Illness, under a Medical
Practitioner qualified as Psychiatrist or a professional having a post-graduate degree (Ayurveda) in Mano Vigyan Avum Manas
Roga or a post-graduate degree (Homoeopathy) in Psychiatry or a post-graduate degree (Unani) in Moalijat (Nafasiyatt) or a post-
graduate degree (Siddha) in Sirappu Maruthuvam.

Exclusions:
1. 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.
2. Any treatment of the following Mental Illnesses shall be covered after Waiting Period of 2 years:
i. Depression (ICD - F32; F33).
ii. Schizophrenia (ICD - F20; F21; F25).

1.2.12 Correction of Refractive Error

The Company shall indemnify the Medical Expenses for In-patient Treatment, including pre hospitalisation expenses and post
hospitalisation expenses, incurred for expenses related to the treatment for correction of eye sight due to refractive error equal to
or more than 7.5 dioptres, subject to Waiting Period of two (02) years as per Section 4.2.f.iii.

Note: The expenses that are not covered in this policy are placed under List-l of Appendix-II of the Policy. 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 of the Policy respectively.

1.3 Additional Benefits

Following benefits shall be payable only for claims admissible under the policy, after crossing of the Threshold.

1.3.1 Hospital Cash

The Company shall pay the Insured a daily hospital cash allowance up to the limit as shown in the Table of Benefits for a
maximum of five days, provided
i. The hospitalisation exceeds three days.
ii. a claim has been admitted under Section 1.2.1

National Insurance Co. Ltd.

National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 3
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
1.3.2 Doctor’s Home Visit/ Aya/ Nurse/ Attendant Charges during Post Hospitalisation
The Company shall reimburse the insured, for medically necessary expenses incurred for doctor’s home visit, nursing care by
qualified nurse, aya, attendant charges during post hospitalisation up to the limit as shown in the Table of Benefits., provided the
related hospitalisation claim has been admitted under Section 1.2.1 and the physical mobility of the insured person outside
residence is severely restricted due to the illness/ injury requiring hospitalization.

1.3.3 Ambulance Charges

The Company shall reimburse the insured the expenses incurred for actual emergency ambulance charges (by road only) for
transportation to the hospital, or from one hospital to another hospital, provided a claim has been admitted under Section 1.2.1.
Ambulance charges will be paid once for any one illness for each insured person.

1.4 Migration to Policy without Threshold

The Company shall allow the insured persons to migrate to any existing indemnity health insurance product of the Company (for
same or lower sum insured without any threshold) of the Company with continuity coverage in terms of waiver of waiting periods
to the extent of benefits covered under this Policy, provided the insured person has been covered under National Super Top Up
Mediclaim Policy before attaining the age of 45 years and has continuously renewed the Policy for 5 years without interruption.

Conditions:
1. Migration to any other indemnity health insurance product shall be subject to the Underwriting Guidelines of the said product,
including Pre Policy Health Checkup (if applicable).
2. This option can be exercised by the Insured Person at the time of renewal only.
3. On migration, terms and rates of the migrated policy shall apply.

1.5 Good Health Incentive

1.5.1 Cumulative Bonus (CB)
For each claim free Policy Year (i.e., no claims are reported and admitted by the Company), Cumulative Bonus allowed shall be
an amount equal to 5% of the Basic Sum Insured (excluding CB) of the expiring Policy Year.
If a claim is made in any particular Policy Year, the CB accrued shall be reduced at the same rate at which it has accrued.
However, Basic Sum Insured will be maintained and will not be reduced.
CB shall be accumulated and available on renewal. Maximum CB shall not exceed 50% of the Basic Sum Insured of the renewed
Policy. Wherever, due to reduction in Basic Sum Insured on renewal, if the accumulated CB exceeds 50% of the reduced Basic
Sum Insured, then CB shall be restricted to 50% of the reduced Basic Sum Insured.
In case there is no claim in a particular Policy Year, Cumulative Bonus shall be accumulated and available on renewal to the
subsequent Policy year, even in case of long term Policies for two years/ three years, as opted by the Insured.

Notes:
i. In case where the Policy is on Individual Basis, the Cumulative Bonus shall be added and available individually to the
Insured Person if no claim has been reported. Cumulative Bonus shall reduce only in case of claim from the same Insured
Person.
ii. In case where the Policy is on floater Basis, the Cumulative Bonus shall be added and available to the family on floater
basis, provided no claim has been reported from any Insured Person. Cumulative Bonus shall reduce in case of claim from
any of the Insured Persons.
iii. Any Cumulative Bonus that has accrued for a Policy Year will be credited at the end of the Policy Period if the policy is
renewed with the Company within Grace Period and will be available for any claims made in the subsequent Policy Period.
iv. If the Insured Persons in the expiring policy are covered on an Individual Basis as specified in the Policy Schedule and
there is an accumulated Cumulative Bonus for each Insured Person under the expiring policy, and such expiring policy has
been renewed on Floater Basis as specified in the Policy Schedule then the Cumulative Bonus to be carried forward for
credit in such renewed Policy shall be the one that is applicable to the lowest among all the Insured Persons.
v. In case of floater policies where Insured Persons renew their expiring policy by splitting the Sum Insured in to two or more
floater Policies/ individual Policies, or in cases where the Policy is split due to the child attaining the age of 25 years, the
Cumulative Bonus of the expiring Policy shall be apportioned to such renewed Policies in the proportion of the Sum
Insured of each renewed Policy.
vi. If a claim is made in the expiring Policy Year, and is notified to the Company after the acceptance of Renewal premium
any awarded Cumulative Bonus shall be withdrawn.
vii. Revision in Sum Insured: If the Basic Sum Insured under the Policy has been increased/decreased at the time of Renewal,
the Cumulative Bonus shall be calculated on the Sum Insured of the last completed Policy Period.
viii. The Cumulative Bonus will not be accumulated in excess of 50% of the Basic Sum Insured under the current Policy with
the Company under any circumstances.
ix. Splitting of policies or Migration from Floater to Individual Policy: If the Insured Persons in the expiring Policy are
covered on a Family Floater basis and such Insured Persons Renew their expiring Policy with the Company by splitting the
Sum Insured in to two or more Family Floater/Individual policies then the Cumulative Bonus shall be apportioned to such
Renewed Policies in the proportion of the Sum Insured of each Renewed Policy.

2 Salient Features:
2.1 Eligibility
i. Policy can be opted on individual and floater basis. On floater basis, at least two family members, as defined below, shall
be covered.

National Insurance Co. Ltd.

National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 4
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
 ii. Policy can be opted with or without a Base Policy (i.e., any Indemnity Based Health Insurance Product offered by any
General Insurance Company covering the same members).
iii. Entry age of Proposer should be between eighteen years and sixty five years.
iv. Maximum entry age of any family member is sixty five years.
v. Children above the entry age of three months may be covered for the first time subject to maximum entry age as
mentioned below, provided parent(s) is/are covered at the same time.
a. Dependent male child up to twenty five (25) years of age or till the person is employed, whichever is earlier
b. Dependent female child, till the person is employed or married
vi. Family members allowed under same policy.
a. Proposer
b. Spouse
c. Dependent legitimate or legally adopted children
d. Parents/ Parents-in law
vii. Renewal terms are as per Section 2.10 below.
viii. Midterm inclusion of family members at pro-rata premium is allowed only in case of
a. newborn between the age of three months and six months
b. spouse within sixty days of marriage
(Members other than above may be included only at renewal. On inclusion of a new member, waiting period of 4.1, 4.2,
4.3 shall apply for the new member.)

2.2 Policy Period

The Policy can be issued for a period of one year/ two years/ three years, as opted by the Insured.

2.3 Sum Insured (SI) and Threshold

i. The Policy is available with following combinations of Threshold and Sum Insured (in ₹):
Threshold Sum Insured (above Threshold)
2 Lakhs 3,5,7 Lakhs
3 Lakhs 3,5,7,10 Lakhs
5 Lakhs 5,7,10,15 Lakhs
8 Lakhs 8,10,15,20 Lakhs
10 Lakhs 10,15,20,30 Lakhs
20 Lakhs 20,30,50,80 Lakhs

ii. For Policy issued on individual basis, both Threshold and sum insured shall apply on individual basis on each insured
person.
iii. For Policy issued on floater basis, both Threshold and sum insured shall apply on floater basis to all the insured persons.

2.3.1 Enhancement of Sum Insured, Threshold

i. Sum insured may be enhanced only at the time of renewal. Sum insured may be enhanced subject to availability of higher
Sum Insured and at the discretion of the Company.
ii. For the incremental portion of the sum insured, the waiting periods and conditions as mentioned in exclusion 4.1, 4.2, 4.3
shall apply. Coverage on enhanced sum insured shall be available after the completion of waiting periods.

2.4 Discounts:
2.4.1 Early Entry Discount (EED)
In case where an insured person has entered the policy before the age 42 (completed years) and renewed the policy for a
continuous period of 3 years, an EED of 5% on individual premium will be allowed starting from the fourth policy period and
continue in subsequent renewals during the life time of the Policy.
Illustration
Scenario I Scenario II Scenario III
Age at inception of Policy 1 41 yrs 6 months 25 yrs 2 months 43 yrs 0 months
Age at inception of Policy 2 42 yrs 6 months 26 yrs 2 months 44 yrs 0 months
Age at inception of Policy 3 43 yrs 6 months 27 yrs 2 months 45 yrs 0 months
Age at inception of Policy 4 44 yrs 6 months 28 yrs 2 months 46 yrs 0 months
EED from Policy 4 Applicable Applicable Not applicable

2.4.2 Family Discount (applicable only to Policy issued on individual basis)

In case one or more of the family members are covered along with the proposer - Discount of 5% shall be allowed on the total
family premium for new and renewal policies.

2.4.3 Discount for Online, Direct

For Policy bought online, by walk in customer (where no intermediary is involved) - Discount of 10% shall be allowed on the
final payable premium for new and renewal policies.

2.4.4 Long Term Discount

For Long Term Policies – Discount of 3% for a 2- year policy and 5% for a 3-year policy, shall be allowed on the final payable
premium.
National Insurance Co. Ltd.
National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 5
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
2.5 Tax Rebate
The insured can avail tax benefits for the premium paid, under Section 80D of Income Tax Act 1961.

2.6 Buying the Policy

The Policy can be bought from the channels mentioned below.
i. online from portal, for policies where Pre Policy Checkup is not required.
ii. from our operating offices
iii. from our agents
iv. from self service kiosks
v. from Office on Wheels (office on mobile van)
vi. Any other channel introduced by the Regulator from time to time

2.7 Completion of Proposal Form

i. The proposal form is to be completed in all respects (including personal details, medical history of insured person) and to
be submitted to the office or to the agent.
ii. Identity and address of the proposer must be supported by documentary proof.
iii. Details of Base Policy must be supported by documentary proof (for Policy issued with Base Policy)
iv. Person insured covered by any similar health insurance policy of any other general insurance Company and wishing to port
(switch) to National Super Top Up Mediclaim Policy, will have to submit the proposal form and portability form to the
office or to the agent.
v. If opting for Waiver of Threshold (Section 1.4), fresh Proposal Form applicable to new product shall be submitted.

2.8 Pre Policy Checkup

i. Pre Policy checkup is required for all individual family members aged fifty years and above
ii. The Company shall reimburse 50% of the expenses incurred for pre Policy checkup, if the proposal is accepted and the
premium has been realized.
iii. No pre policy health check-up shall be required for existing policyholders of the Company, covered under any retail
indemnity health insurance policy for a continuous period 3 years or more as on date of opting for National Super Top Up
Mediclaim Policy.
iv. The Pre Policy checkup reports required are –
a) Physical examination (report to be signed by the Doctor with minimum MD (Medicine) qualification)
b) Blood sugar (fasting/ post prandial)
c) Lipid profile
d) Serum creatinine
e) Urine routine and microscopic examination
f) ECG
g) Any other investigation required by the Company
Note: The date of medical reports should not exceed thirty days prior to the date of proposal.

2.9 Payment of Premium

i. For Policy issued on individual basis, premium depends on the SI opted and age of the member.
ii. For Policy issued on floater basis, premium depends SI opted, age of the senior most member and age of family members.
iii. The proposer has the option of claims being serviced by TPA (in which case cashless facility/reimbursement of expenses
will be available) or the Company (in which case expenses will be reimbursed). If cashless facility is to be availed, the
premium payable is inclusive of TPA charges. If cashless facility is not required, the premium payable is without TPA
charges.
iv. PAN details must be submitted to the Company.
v. In case PAN is not available, Form 60 or Form 61 as per Rule 114B of the Income-tax Rule,1962 must be submitted

2.10 Renewal of Policy

i. The Policy can be renewed throughout the lifetime of all the insured persons, except the following:
 Dependent male child only up to twenty five years, shall be allowed renewal if not employed.
 Dependent female child if not employed, shall only be allowed renewal till marriage.
ii. Insured Children have the option to port to similar health insurance product on completion of the specified exit age as
mentioned in 2.10.i.
iii. The Policy may be renewed by mutual consent before the expiry of the Policy.
iv. The Company is not bound to send renewal notice.
v. Renewal of Policy can be denied on grounds of fraud, moral hazard, misrepresentation or noncooperation.
vi. In the event of break in the Policy a grace period of thirty days is allowed. Coverage is not available during the grace
period.
vii. In case of non-continuance of the Policy by the insured (due to death or any other valid and acceptable reason)
 The Policy may be renewed by any insured person above eighteen years of age, as the insured
 Where only children (less than eighteen years of age) are covered, the Policy shall be allowed till the expiry of the
policy period. The legal guardian may be allowed to renew the Policy as insured, covering the children.
viii. In case of death of the eldest insured person in a Policy issued on floater basis,
 The premium to be charged shall be based on the age of the next eldest insured person.

National Insurance Co. Ltd.

National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 6
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
 ix. If during the policy period, the number of members covered in a floater policy reduces to a single member, then on renewal
the Policy shall automatically be converted to individual basis.

3. DEFINITION

3.1 Accident means a sudden, unforeseen and involuntary event caused by external, violent and visible means.

3.2 Age / Aged means completed years on last birthday as on Commencement Date.

3.3 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.

3.4 Any One Illness means continuous period of illness and it includes relapse within forty five days from the date of last
consultation with the Hospital where treatment has been taken.

3.5 AYUSH Day Care Centre means and includes Community Health Centre (CHC), Primary Health Centre (PHC), Dispensary,
Clinic, Polyclinic or any such health centre which is registered with the local authorities, wherever applicable and having
facilities for carrying out treatment procedures and medical or surgical / para-surgical interventions or both under the
supervision of registered AYUSH Medical Practitioner(s) on day care basis without in-patient services and must comply with
all the following criterion:
i. Having qualified registered AYUSH Medical Practitioner in charge round the clock;
ii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures
are to be carried out;
iii. Maintaining daily records of the patients and making them accessible to the insurance company’s authorized
representative.

3.6 AYUSH Hospital means any health care institution wherein medical/surgical/para-surgical treatment procedures and
interventions are carried out by AYUSH Medical Practitioner(s) comprising of any of the following:
a. Central or State Government AYUSH Hospital or
b. Teaching hospital attached to AYUSH College recognised by the Central Government/ Central Council of Indian
Medicine/ Central Council for Homeopathy; or
c. AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any recognised system of medicine,
registered with the local authorities, wherever applicable, and is under the supervision of a qualified registered AYUSH
Medical Practitioner and must comply with all the following criteria:
i. Having at least 5 in-patient beds;
ii. Having a qualified AYUSH Medical Practitioner in charge round the clock;
iii. Having dedicated AYUSH therapy sections as required; and
iv. Maintaining daily records of the patients and making them accessible to the Company’s authorised representative.

3.7 AYUSH Treatment refers to the medical and / or Hospitalisation treatment given under Ayurveda, Yoga and Naturopathy,
Unani, Siddha and Homeopathy systems.

3.8 Body Mass Index (BMI) is defined as the body mass (weight) divided by the square of the height of an individual, and is
universally expressed in units of kg/m2, resulting from mass in kilograms and height in metres.

3.9 Break in policy means the period of gap that occurs at the end of the existing Policy Period, when the premium due for
renewal on a given policy is not paid on or before the premium renewal date or Grace Period.

3.10 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 or
a Non Network Provider to the extent pre-authorization approved.

3.11 Condition Precedent means a Policy term or condition upon which the Company’s liability under the Policy is conditional
upon.

3.12 Congenital Anomaly refers to a condition(s) 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.

3.13 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.

3.14 Cumulative Bonus means any increase or addition in the Sum Insured granted by the Company without an associated
increase in premium.
National Insurance Co. Ltd.
National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 7
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
3.15 Cumulative Medical Expenses means the aggregate of Medical Expenses incurred during the Policy Year of the Policy
Period of this Policy towards one or more out of the Coverage mentioned in Section 3.1 of the Policy (i.e. under the heads
of 3.1.1. In-patient Treatment, 3.1.2. Pre-Hospitalisation, 3.1.3. Post-Hospitalisation, 3.1.4. Day Care Procedure, 3.1.5.
AYUSH Treatment, 3.1.6. Organ Donor’s Medical Expenses, 3.1.7. HIV Treatment, 3.1.8. Morbid Obesity Treatment,
3.1.9. Maternity, 3.1.10 Modern Treatment, 3.1.11 Mental Illness Cover & 3.1.12 Correction of Refractive Error) in respect
of:
a) Individual Plan
The Insured Person for one or more Hospitalisation during the Policy Year of the Policy Period.
b) Floater Plan
One or more Insured Persons for one or more Hospitalisation during the Policy Year of the Policy Period.

3.16 Day Care Centre means any institution established for day care treatment of disease/ injuries or a medical setup within 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 Nurses under its employment;
ii. has Medical Practitioner(s) in charge;
iii. has a fully equipped operation theatre of its own where surgical procedures are carried out; and
iv. maintains daily records of patients and shall make these accessible to the Company’s authorised personnel.

3.17 Day Care Treatment means medical treatment, and/or surgical procedure (as listed in Annexure I) which is:
i. undertaken under general or local anesthesia in a Hospital/ Day Care Centre in less than twenty four hours because of
technological advancement, and
ii. which would have otherwise required a Hospitalisation of more than twenty four hours.
Treatment normally taken on an out-patient basis is not included in the scope of this definition.

3.18 Dental Treatment means a treatment carried out by a dental practitioner including examinations, fillings (where
appropriate), crowns, extractions and surgery.

3.19 Diagnosis means diagnosis by a Medical Practitioner, supported by clinical, radiological, histological and laboratory
evidence, acceptable to the Company.

3.20 Family Members means spouse, children and parents/ in-laws of the Insured, covered under the Policy.

3.21 Floater means the Threshold/ Sum Insured, as mentioned in the Schedule, applicable to all the Insured Persons, for any
and all claims made in aggregate during the Policy Period.

3.22 Grace Period means the specified period of time, immediately following the premium due date during which premium
payment can be made to renew or continue a policy in force without loss of continuity benefits pertaining to Waiting
Periods and coverage of Pre-Existing Diseases. The Grace Period for payment of the premium shall be thirty days.
In case of Renewal, Coverage shall not be available during the period for which no premium is received.

3.23 Hospital means any institution including a nursing home established for in-patient care and day care treatment of disease/
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:
i. has Qualified Nurses under its employment round the clock;
ii. has at least ten inpatient beds, in those towns having a population of less than ten lakh and fifteen inpatient beds in all
other places;
iii. has Medical Practitioner(s) in charge round the clock;
iv. has a fully equipped operation theatre of its own where surgical procedures are carried out; and
v. maintains daily records of patients and shall make these accessible to the Company’s authorised personnel.

3.24 Hospitalisation means admission in a Hospital for a minimum period of twenty four (24) consecutive ‘Inpatient care’
hours except for procedures/ treatments, where such admission could be for a period of less than twenty four (24)
consecutive hours.

3.25 ID Card means the card issued to the Insured Person by the TPA for availing cashless facility.

3.26 Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function
which manifests itself during the policy period and requires medical treatment.
i. Acute Condition means an Illness or Injury that is likely to response quickly to treatment which aims to return the
person to his or her state of health immediately before suffering the Illness/ Injury which leads to full recovery.
ii. Chronic Condition means an 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 specially trained to cope with it,
d) it continues indefinitely, or
e) it recurs or is likely recur.
National Insurance Co. Ltd.
National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 8
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
3.27 Injury means accidental physical bodily harm excluding Illness solely and directly caused by external, violent and visible
and evident means which is verified and certified by a Medical Practitioner.

3.28 In-Patient Care means treatment for which the Insured Person has to stay in a Hospital for more than 24 hours for a
covered event.

3.29 Insured/ Insured Person means person(s) named in the Schedule of the Policy.

3.30 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.

3.31 ICU (Intensive Care Unit) Charges means the amount charged by a Hospital towards ICU expenses on a per day basis
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.

3.32 Medical Advice means any consultation or advice from a Medical Practitioner including the issue of any prescription or
follow up prescription.

3.33 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.

3.34 Medically Necessary 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;
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; and
iv. must conform to the professional standards widely accepted in international medical practice or by the medical
community in India.

3.35 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 practise medicine within its jurisdiction; and is acting within the scope and
jurisdiction of the licence.

3.36 Migration means a facility provided to policyholders (including all members under family cover and group policies), to
transfer the credits gained for pre-existing diseases and specific waiting periods from one health insurance policy to
another with the same insurer.

3.37 Morbid Obesity is a medical term describing people who have a Body Mass Index (BMI) of at least 40 and with
significant medical problems caused by or made worse by their mass (weight).

3.38 Network Provider means Hospitals or Day Care Centers enlisted by the Company, TPA or jointly by the Company and
TPA to provide medical services to an Insured by a Cashless Facility.

3.39 Non- Network Provider means any Hospital, Day Care Centre that is not part of the network.

3.40 Notification of Claim means the process of intimating a claim to the Insurer or TPA through any of the recognised modes
of communication.

3.41 Out-Patient Treatment means treatment in which the Insured 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.

3.42 Policy Period means period of one year, two years or three years as mentioned in the Schedule for which the Policy is
issued.

3.43 Policy Year means a period of twelve months beginning from the date of commencement of the Policy Period and ending
on the last day of such twelve month period. For the purpose of subsequent years, Policy Year shall mean a period of
twelve months commencing from the end of the previous Policy Year and lapsing on the last day of such twelve-month
period, till the Policy Period, as mentioned in the Schedule.

3.44 Pre-Existing Disease means any condition, ailment, Injury or disease:

National Insurance Co. Ltd.

National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 9
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
 a) That is/are diagnosed by a physician within 36 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 36 months prior to
the effective date of the Policy issued by the Company or its reinstatement.

3.45 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.

3.46 Portability means a facility provided to the policyholders (including all members under family cover), to transfer the
credits gained for, Pre-Existing Diseases and Specific Waiting Periods from one insurer to another insurer.

3.47 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 In-patient Hospitalisation claim for such Hospitalisation is admissible by the Company.

3.48 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.

3.49 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.

3.50 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.

3.51 Room Rent means the amount charged by a Hospital towards room and boarding expenses and shall include the associated
charges.
3.52 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.

3.53 Schedule means a document forming part of the Policy, containing details including name of the Insured Person, age,
relation of the Insured Person, Sum Insured, premium paid and the policy period.

3.54 Sum Insured means the Basic Sum Insured and the Cumulative Bonus (CB) accrued in respect of the Insured Person (for
policies issued on individual basis)/ one or more Insured Persons (for policies issued on floater basis) as mentioned in the
schedule. The Sum Insured represents maximum liability of the Company for any and all claims during each Policy Year
of the Policy Period.

3.55 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.

3.56 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.

3.57 Threshold means the amount of Cumulative Medical Expenses (as per Definition 2.41), as chosen by the Insured and
mentioned in the Schedule, up to which no amount can be claimed under this Policy.

3.58 Unproven/ Experimental Treatment means treatment, including drug experimental therapy, which is not based on
established medical practice in India, and is experimental or unproven.

3.59 Waiting Period means a period from the inception of this Policy during which specified diseases/treatment is not covered.
On completion of the period, diseases/treatment shall be covered provided the Policy has been continuously renewed
without any break.

4 EXCLUSIONS
The Company shall not be liable to make any payment under the Policy, in respect of any expenses incurred in connection with or
in respect of:

4.1 Pre-Existing Diseases (Excl 01)

National Insurance Co. Ltd.
National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 10
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
a) Expenses related to the treatment of a Pre-Existing Disease (PED) and its direct complications shall be excluded until the
expiry of twelve (12) months of continuous coverage after the date of inception of the first policy with us.
b) In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
c) If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI
(Health Insurance) Regulations then waiting period for the same would be reduced to the extent of prior coverage.
d) Coverage under the policy after the expiry of twelve (12) months for any pre-existing disease is subject to the same being
declared at the time of application and accepted by us and as per the table given below.
Months from inception Limit of claim
13-24 months 50% of the admissible claim
25-36 months 75% of the admissible claim
After 36 months 100% of the admissible claim

4.2 Specified disease/procedure waiting period (Excl 02)

a) Expenses related to the treatment of the listed Conditions, surgeries/treatments shall be excluded until the expiry of 90 days/
one year/ two year (as specified against specific disease/ procedure) of continuous coverage after the date of inception of the
first policy with us. This exclusion shall not be applicable for claims arising due to an accident
b) In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
c) If any of the specified disease/procedure falls under the waiting period specified for Pre-Existing Diseases, then the longer
of the two waiting periods shall apply.
d) The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a
specific exclusion.
e) If the Insured Person is continuously covered without any break as defined under the applicable norms on portability
stipulated by IRDAI, then waiting period for the same would be reduced to the extent of prior coverage.
f) List of specific diseases/procedures
i. 90 Days Waiting Period (Life style conditions)
a. Hypertension and related complications
b. Diabetes and related complications
c. Cardiac conditions
ii. One year waiting period
a. Benign ENT disorders n.Non-infective arthritis
b. Tonsillectomy o.Pilonidal sinus
c. Adenoidectomy p.Gout and Rheumatism
d. Mastoidectomy q.Calculus diseases
e. Tympanoplasty r. Surgery of gall bladder and bile duct excluding
f. Cataract malignancy
g. Benign prostatic hypertrophy s. Surgery of genito-urinary system excluding
h.Hernia malignancy
i. Hydrocele t. Surgery for prolapsed intervertebral disc unless
j. Fissure/Fistula in anus arising from accident
k.Piles (Haemorrhoids) u.Surgery of varicose vein
l. Sinusitis and related disorders v.Hysterectomy excluding malignancy.
m. Polycystic ovarian disease

Above diseases/treatments under 4.2.f).i, ii shall be covered after the specified Waiting Period up to 100% of the admissible
claim, provided they are not Pre Existing Diseases.

iii. Two years waiting period

Following diseases even if pre-existing shall be covered after two years of continuous cover from the inception of the Policy.
a. Treatment for joint replacement unless arising from accident
b.Osteoarthritis and osteoporosis
c. Refractive error of the eye more than 7.5 dioptres.
d.Internal Congenital Anomaly (not applicable for new born baby)
e. Stem Cell Therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered.
After expiry of twenty four months any claim arising out of the above conditions or complications thereof will be paid as per the
table given below
Months from inception Limit of claim
25-36 months 75% of the admissible claim
After 36 months 100% of the admissible claim

4.3 First 30 days waiting period (Excl 03)

a) Expenses related to the treatment of any illness within thirty (30) days from the first policy commencement date shall be
excluded except claims arising due to an accident, provided the same are covered.
b) This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve (12) months.
c) The within referred waiting period is made applicable to the enhanced sum insured in the event of granting higher sum
insured subsequently.

4.4. Investigation & Evaluation (Excl 04)

National Insurance Co. Ltd.
National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 11
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
a) Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.
Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.

4.5. Rest Cure, Rehabilitation and Respite Care (Excl 05)

a) Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:
i. Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing,
dressing, moving around either by skilled nurses or assistant or non-skilled persons.
ii. Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.

4.6. Obesity/ Weight Control (Excl 06)

Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:
1) Surgery to be conducted is upon the advice of the Doctor
2) The surgery/Procedure conducted should be supported by clinical protocols
3) The member has to be 18 years of age or older and
4) Body Mass Index (BMI);
a. greater than or equal to 40 or
b. greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive
methods of weight loss:
i. Obesity-related cardiomyopathy
ii. Coronary heart disease
iii. Severe Sleep Apnea
iv. Uncontrolled Type2 Diabetes

4.7. Change-of-Gender Treatments (Excl 07)

Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite
sex.

4.8. Cosmetic or Plastic Surgery (Excl 08)

Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident,
Burn(s) or Cancer or as part of medically necessary treatment to remove a direct and immediate health risk to the insured. For this
to be considered a medical necessity, it must be certified by the attending Medical Practitioner.

4.9. Hazardous or Adventure Sports (Excl 09)

Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports, including
but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding,
sky diving, deep-sea diving.

4.10. Breach of Law (Excl 10)

Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach
of law with criminal intent.

4.11. Excluded Providers (Excl 11)

Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by
the Company and disclosed in its website / notified to the policyholders are not admissible. However, in case of life threatening
situations following an accident, expenses up to the stage of stabilization are payable but not the complete claim.

4.12. Drug/Alcohol Abuse (Excl 12)

Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof (Excl 12)

4.13. Non Medical Admissions (Excl 13)

Treatments received in health hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing
home attached to such establishments or where admission is arranged wholly or partly for domestic reasons (Excl 13)

4.14. Vitamins, Tonics (Excl 14)

Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals
and organic substances unless prescribed by a medical practitioners part of hospitalization claim or day care procedure

4.15. Refractive Error (Excl 15)

Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres.

4.16. Unproven Treatments (Excl16)

Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments
are treatments, procedures or supplies that lack significant medical documentation to support their effectiveness.

4.17. Birth control, Sterility and Infertility (Excl 17)

Expenses related to sterility and infertility. This includes:
i. Any type of sterilization
National Insurance Co. Ltd.
National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 12
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
ii. Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT,
GIFT, ICSI
iii. Gestational Surrogacy
iv. Reversal of sterilization

4. GENERAL EXCLUSIONS
The Company shall not be liable to make any payment under the Policy in respect of any expenses incurred in connection with or
in respect of:

5.1. Hormone Replacement Therapy

Expenses for hormone replacement therapy, unless part of Medically Necessary Treatment, except for Puberty and Menopause
related Disorders

5.2. General Debility, Congenital External Anomaly

General debility, Congenital external anomaly.

5.3. Self Inflicted Injury

Treatment for intentional self-inflicted injury, attempted suicide.

5.4. Stem Cell Surgery

Stem Cell Surgery (except Hematopoietic stem cells for bone marrow transplant for hematological conditions).

5.5. Circumcision
Circumcision unless necessary for treatment of a disease (if not excluded otherwise) or necessitated due to an accident.

5.6. Vaccination or Inoculation.

Vaccination or inoculation unless forming part of treatment and requires Hospitalisation.

5.7. Massages, Steam Bath, Alternative Treatment (Other than AYUSH)

Massages, steam bath, expenses for alternative treatments (other than AYUSH), acupuncture, acupressure, magneto-therapy and
similar treatment.

5.8. Dental treatment

Dental treatment, unless necessitated due to an Injury.

5.9. Out Patient Department (OPD) or Domiciliary treatment

Any expenses incurred on OPD or Domiciliary treatment.

5.10. Stay in Hospital which is not Medically Necessary.

Stay in hospital which is not medically necessary.

5.11. Spectacles, Contact Lens, Hearing Aid, Cochlear Implants

Spectacles, contact lens, hearing aid, cochlear implants.

5.12. Non Prescription Drug

Drugs not supported by a prescription, private nursing charges, referral fee to family physician, outstation
doctor/surgeon/consultants’ fees and similar expenses (as listed in respective Appendix-II).

5.13. Treatment not Related to Disease for which Claim is Made

Treatment which the insured person was on before Hospitalisation for the Illness/Injury, different from the one for which claim for
Hospitalisation has been made.

5.14. 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.

5.15. Items of personal comfort

Items of personal comfort and convenience (as listed in respective Appendix-II) including telephone, television, aya, barber,
beauty services, baby food, cosmetics, napkins, toiletries, guest services.

5.16. Service charge/ registration fee

Any kind of service charges including surcharges, admission fees, registration charges and similar charges (as listed in respective
Appendix-II) levied by the hospital.

5.17. Home visit charges

National Insurance Co. Ltd.
National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 13
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
Home visit charges during Pre and Post Hospitalisation of doctor, attendant and nurse, except as and to the extent provided for
under Section 1.3.2 (Doctor’s Home Visit/ Aya/ Nurse/ Attendant charges during Post Hospitalisation).

5.18. 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.

5.19. 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.

5.20. Treatment taken outside the geographical limits of India

6 CONDITIONS
General Terms and Conditions
6.1 Disclosure of Information
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.
(Explanation: "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)

6.2 Condition Precedent to Admission of Liability

The terms and conditions of the policy must be fulfilled by the insured person for the Company to make any payment for claim(s)
arising under the policy.

6.3 Claim Settlement

i. 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.
ii. 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.
iii. 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.
iv. 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.
(Explanation: “Bank rate” shall mean the rate fixed by the Reserve Bank of India (RBI) at the beginning of the financial year in
which claim has fallen due)

6.4 Multiple Policies

i. In case of multiple policies taken by an insured person during a period from one or more insurers to indemnify treatment costs,
the insured person shall have the right to require a settlement of his/her claim in terms of any of his/her policies. In all such
cases the insurer chosen by the insured person shall be obliged to settle the claim as long as the claim is within the limits of
and according to the terms of the chosen policy.
ii. Insured person having multiple policies shall also have the right to prefer claims under this policy for the amounts disallowed
under any other policy / policies. Then the insurer shall independently settle the claim subject to the terms and conditions of
this policy.
iii. If the amount to be claimed exceeds the sum insured under a single policy, the insured person shall have the right to choose
insurer from whom he/she wants to claim the balance amount.
iv. Where an insured person has policies from more than one insurer to cover the same risk on indemnity basis, the insured person
shall only be indemnified the treatment costs in accordance with the terms and conditions of the chosen policy.

6.5 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.
Any amount already paid against claims made under this policy but which are found fraudulent later shall be repaid by all
recipient(s)/policyholder(s), who has made that particular claim, who shall be jointly and severally liable for such repayment to
the insurer.
National Insurance Co. Ltd.
National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 14
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
For the purpose of this clause, the expression "fraud" means any of the following acts committed by the insured person or by his
agent or the hospital/doctor/any other party acting on behalf of the insured person, with intent to deceive the insurer or to induce
the insurer to issue an insurance policy:
a) the suggestion, as a fact of that which is not true and which the insured person does not believe to be true;
b) the active concealment of a fact by the insured person having knowledge or belief of the fact;
c) any other act fitted to deceive; and
d) any such act or omission as the law specially declares to be fraudulent
The Company shall not repudiate the claim and / or forfeit the policy benefits on the ground of Fraud, if the insured person /
beneficiary can prove that the misstatement was true to the best of his knowledge and there was no deliberate intention to suppress
the fact or that such misstatement of or suppression of material fact are within the knowledge of the insurer.

6.6 Cancellation
i. The Company may cancel the policy, on grounds of misrepresentation, non-disclosure of material facts by the insured
person by giving 15 days’ written notice. The Company may cancel the policy at any time on grounds of established 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 his/her policy at any time during the term, by giving 7 days notice in writing. The Company
shall refund proportionate premium for unexpired policy period, if there is no claim(s) made during the policy period.
Notwithstanding anything contained herein or otherwise, no refunds of premium shall be made in respect of Cancellation where,
any claim has been admitted or has been lodged or any Benefit has been availed under the Policy.

6.7 Migration
The Insured Person will have the option to migrate the Policy to an alternative health insurance product offered by the Company
by applying for Migration of the policy at least 30 days before the policy renewal date as per extant Guidelines related to
Migration. If such person is presently covered and has been continuously covered without any lapses under this Policy offered by
the Company:
i. The Insured Person will get all the accrued continuity benefits for credits gained to the extent of the specific waiting periods,
waiting period for pre-existing diseases and Moratorium period of the Insured Person.
ii. Migration benefit will be offered to the extent of Sum Insured and accrued Cumulative Bonus (as part of the sum insured) of
the previous policy. Migration benefit shall not apply to any other additional increased Sum Insured.
The Proposal may be subject to fresh Underwriting as per terms of conditions of the migrated product, if the insured is not
continuously covered for at least 36 months under the previous product.

6.8 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 15 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 this Policy offered by the Company,
i. The proposed Insured Person will get all the accrued continuity benefits for specific waiting periods, waiting period for pre-
existing diseases and Moratorium period of the Insured Person under the previous health insurance Policy.
ii. Portability benefit will be offered to the extent of Sum Insured and accrued Cumulative Bonus (as part of the sum insured) of
the previous policy. Portability benefit shall not apply to any other additional increased Sum Insured.

6.9 Renewal of Policy

i. A health insurance policy shall be renewable provided the product is not withdrawn, except in case of established fraud or
non-disclosure or misrepresentation by the Insured. If the product is withdrawn, the policyholder shall be provided with
suitable options to migrate to other similar health insurance products/plans offered by the Company.
ii. The Company shall endeavor to give notice for renewal. However, the Company is not under obligation to give any notice
for renewal.
iii. Renewal shall not be denied on the ground that the insured person had made a claim or claims in the preceding policy years.
iv. Request for renewal along with requisite premium shall be received by the Company before the end of the policy period.
v. At the end of the policy period, the policy shall terminate and can be renewed within the Grace Period of 30 days to maintain
continuity of benefits without break in policy. Coverage is not available during the grace period.
vi. No loading shall apply on renewals based on individual claims experience.
vii. In case of non-continuance of the Policy by the Insured (due to death or any other valid and acceptable reason):
 The Policy may be renewed by any Insured Person above eighteen (18) years of age, as the Insured.
 Where only children (less than eighteen years of age) are covered, the Policy shall be allowed till the expiry of the Policy
period. The legal guardian may be allowed to renew the Policy as Insured, covering the children.

6.10 Withdrawal of Product

i. In the likelihood of this product being withdrawn in future, the Company will intimate the insured person about the same 90
days prior to expiry of the policy.
ii. Insured Person will have the option to migrate to similar health insurance product available with the Company at the time of
renewal with all the accrued continuity benefits such as cumulative bonus, waiver of waiting period as per IRDAI guidelines,
provided the policy has been maintained without a break.

National Insurance Co. Ltd.

National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 15
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
6.11 Moratorium Period
After completion of sixty continuous months of coverage (including Portability and Migration), no claim shall be contestable by
the Company on grounds of non-disclosure, misrepresentation, except on grounds of established fraud. This period of sixty
continuous months is called as Moratorium Period. The moratorium would be applicable for the Basic Sums Insured of the first
policy. Wherever, the Basic Sum Insured is enhanced, completion of sixty continuous months would be applicable from the date
of enhancement of Basic Sums Insured only on the enhanced limits.

6.12 Revision of Terms of the Policy Including the Premium Rates

The Company, with prior approval of IRDAI, may revise or modify the terms of the policy including the premium rates. The
insured person shall be notified before the changes are effected.

6.13 Free Look Period

The Free Look Period shall be applicable on new individual health insurance policies and not on renewals or at the time of
porting/migrating the policy.
The Insured Person shall be allowed Free Look Period of thirty (30) days from date of receipt of the Policy document to review
the terms and conditions of the Policy. If he/she is not satisfied with any of the terms and conditions, he/she has the option to
cancel his/her policy. This option is available in case of policies with a term of one year or more.
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.

6.14 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.

Specific General Terms and Conditions

6.15 Communication
i. All communication should be made in writing.
ii. For Policies serviced by TPA, ID card, 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.

6.16 Physical examination

Any medical practitioner authorised by the Company shall be allowed to examine the insured person in the event of any alleged
injury or disease requiring hospitalisation when and as often as the same may reasonably be required on behalf of the Company.

6.17 Claim Procedure

6.17.1 Condition Precedent to Claim
1. Claim shall be admissible for the hospitalisation during which the cumulative medical expenses as per Section 1.2 of this
Policy in respect of hospitalisation(s) of any insured person (individual plan) or one or more insured person (floater plan) in
a policy period exceeds the threshold as per Section 1.2 of this Policy and for all subsequent hospitalisation(s) during the
policy period.
2. Admissible claim amount for hospitalisation(s) mentioned above shall be calculated as per Section 1.2 and Section 1.3 of
the Policy.

6.17.2 Notification of Claim

In order to lodge a claim under the Policy for any hospitalisation during the policy period, the insured person/insured person’s
representative shall notify the TPA (if claim is processed by TPA)/Company (if claim is processed by the Company) in writing by
letter, e-mail, fax providing all relevant information relating to claim including plan of treatment, policy number etc. within the
prescribed time limit.

Notification of claim for Cashless facility TPA must be informed:

In the event of planned hospitalisation At least seventy two hours prior to the insured person’s
admission to network provider
In the event of emergency hospitalisation Within twenty four hours of the insured person’s admission to

National Insurance Co. Ltd.

National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 16
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
 network provider

Notification of claim for Reimbursement Company/TPA must be informed:

In the event of planned hospitalisation At least seventy two hours prior to the insured person’s
admission to hospital
In the event of emergency hospitalisation Within twenty four hours of the insured person’s admission to
hospital
Note:
i. In case of hospitalisation where the cumulative medical expenses are likely to exceed the threshold, notification of claim shall
be sent to the TPA mentioned in the schedule/ Company.
ii. In case of hospitalisation where initially the cumulative medical expenses are not foreseen to exceed the threshold but
subsequently exceeds, notification of claim shall be sent to the TPA mentioned in the schedule/ Company, immediately.

6.17.3 Procedure for Cashless Claims

i. For the first claim under the Policy (i.e., the claim in which cumulative medical expenses exceeds the threshold) cashless
facility shall be available provided all evidences and documents are produced prior to cashless authorization, to substantiate
that the Cumulative Medical Expenses (CME) exceeds the Threshold. For all subsequent claims under the Policy cashless
facility shall be available as usual, subject to sl. no ii to viii below.
ii. Cashless facility for treatment can be availed, if TPA service is opted.
iii. Treatment may be taken in a network provider and is subject to pre authorization by the TPA. Updated list of network
provider is available on website of the Company and the TPA mentioned in the schedule.
iv. Cashless request form available with the network provider and TPA shall be completed and sent to the TPA for authorization.
v. The TPA upon getting cashless request form and related medical information from the insured person/ network provider shall
issue pre-authorization letter within an hour to the hospital after verification.
vi. At the time of discharge, the insured person has to verify and sign the discharge papers, pay for non-medical and inadmissible
expenses.
vii. The TPA shall grant the final authorization within three hours of the receipt of discharge authorization request from the
Hospital.
viii. The TPA reserves the right to deny pre-authorization in case the insured person is unable to provide the relevant medical
details.
ix. In case of denial of cashless access, the insured person may obtain the treatment as per treating medical practitioner’s advice
and submit the claim documents to the TPA for processing.

6.17.4 Procedure for Reimbursement of Claims

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.

6.17.5 Documents
The claim is to be supported by the following documents in original and submitted within the prescribed time limit.
i. Completed claim form
ii. Medical practitioner’s prescription advising admission for inpatient treatment.
iii. Bills, receipt from the hospital(s)/ chemist(s) supported by prescription from attending medical practitioner for period of pre
hospitalization, hospitalization and post hospitalization (if applicable)
iv. Bills, receipt, investigation test reports etc. supported by prescription from attending medical practitioner for period of pre
hospitalization, hospitalization and post hospitalization (if applicable)
v. Attending medical practitioner’s certificate regarding diagnosis along with date of diagnosis and bill, receipts etc.
vi. Certificate from the surgeon regarding diagnosis and nature of operation and bills, receipts etc.
vii. Bills, receipt, Sticker of the Implants.
viii. Bills, payment receipts, medical history of the patient recorded, indoor case papers, discharge certificate/ summary, break up
of final bill from the hospital etc.
ix. Documents as listed under Sl. No (ii) to (viii) relating to previous hospitalisation(s) in the Policy Year during the Policy
Period along with claim settlement advice (if any), in original or certified copy.
x. Any other document required by Company/TPA

Note
1. The insured shall preserve and submit all original documents and/ or certified copies of documents related to all
hospitalisation(s) during the policy period to enable the Company to calculate the cumulative medical expenses and
threshold, for determining admissibility and payment of claims.
2. 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 and claim settlement advice, duly certified by the other insurer subject to
satisfaction of the Company. In all such cases, any amount payable under this Policy for any covered expense shall be
reduced by any amount paid/ payable by the other insurer for the same expense during the same hospitalisation.

Type of claim Time limit for submission of documents to Company/TPA

Reimbursement of hospitalisation, pre hospitalisation Within fifteen days from date of discharge from hospital
expenses and ambulance charges (by road only)
National Insurance Co. Ltd.
National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 17
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
Reimbursement of post hospitalisation expenses Within fifteen days from completion of post hospitalisation
treatment

6.17.7 Services Offered by TPA

Servicing of claims under health insurance policies by way of pre-authorization of cashless treatment or settlement of claims other
than cashless claims or both, as per the underlying terms and conditions of the respective policy and within the framework of the
guidelines issued by the insurers for settlement of claims.
The services offered by a TPA shall not include
i. Claim settlement and claim rejection; however, TPA may handle claims admission and recommend to the Company for
settlement of the claim
ii. Any services directly to any insured person or to any other person unless such service is in accordance with the terms and
conditions of the Agreement entered into with the Company.

Waiver
Time limit for notification of claim and submission of documents may be waived in cases where it is proved to the satisfaction of
the Company, that the physical circumstances under which insured person was placed, it was not possible to intimate the
claim/submit the documents within the prescribed time limit.

6.18 Payment of Claim

All claims by the Policy shall be payable in Indian currency and through NEFT/ RTGS only.

6.19 Territorial Limit

All medical treatment for the purpose of this insurance will have to be taken in India only.

6.20 Territorial Jurisdiction

All disputes or differences under or in relation to the Policy shall be determined by an Indian court in accordance to Indian law.

6.21 Disclaimer
If the Company shall disclaim liability for a claim hereunder and if the insured person shall not within twelve calendar months
from the date of receipt of the notice of such disclaimer notify the Company in writing that he/ she does not accept such
disclaimer and intends to recover his/ her claim from the Company, then the claim shall for all purposes be deemed to have been
abandoned and shall not thereafter be recoverable hereunder.

6.22 Enhancement of Sum Insured, Threshold

Sum insured and/ or threshold can be enhanced only at the time of renewal. Sum insured may be enhanced to the next three higher
available slab subject to the discretion of the Company. For the incremental portion of the sum insured, the waiting periods and
conditions as mentioned in exclusion 4.1, 4.2, 4.3 shall apply. Coverage on enhanced sum insured shall be available after the
completion of waiting periods.

6.23 Adjustment of Premium for Overseas Travel Insurance Policy

If during the policy period any of the insured person is also covered by an Overseas Travel Insurance Policy of any general
insurance company, the Policy shall be inoperative in respect of the insured persons for the number of days the Overseas Travel
Insurance Policy is in force and proportionate premium for such number of days shall be adjusted against the renewal premium.
The insured person must inform the Company in writing before leaving India and may submit an application, stating the details of
visit(s) abroad, along with copies of the Overseas Travel Insurance Policy, within seven days of return or expiry of the Policy,
whichever is earlier.

6.24 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 to the decision of a sole arbitrator to be appointed in writing
by the parties here to or if they cannot agree upon a single arbitrator within thirty days of any party invoking arbitration, the
same shall be referred to a panel of three arbitrators, comprising two arbitrators, one to be appointed by each of the parties to
the dispute/difference and the third arbitrator to be appointed by such two arbitrators and arbitration shall be conducted under
and in accordance with the provisions of the Arbitration and Conciliation Act 1996, as amended by Arbitration and
Conciliation (Amendment) Act, 2015 (No. 3 of 2016).
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.

7. Redressal of Grievance
In case of any grievance related to the Policy, the insured person may submit in writing to the Policy Issuing Office or Grievance
cell at Regional Office of the Company for redressal. If the grievance remains unaddressed, the insured person may contact:
Customer Relationship Management Dept., National Insurance Company Limited, Premises No. 18-0374, Plot no. CBD-81, New
Town, Kolkata - 700156, email: customer.relations@nic.co.in, griho@nic.co.in

National Insurance Co. Ltd.

National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 18
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
For more information on grievance mechanism, and to download grievance form, visit our website
https://nationalinsurance.nic.co.in
Bima Bharosa (an Integrated Grievance Management System earlier known as IGMS) - https://bimabharosa.irdai.gov.in/
Insurance Ombudsman – The Insured person can also approach the office of Insurance Ombudsman of the respective
area/region for redressal of grievance as listed in Appendix -IV. The updated list of Office of Insurance Ombudsman are available
on IRDAI website: https://irdai.gov.in/ and on the website of Council for Insurance Ombudsman: https://www.cioins.co.in/

Helpline Number: 1800 345 0330

Dedicated Email ID for Senior Citizens: health.srcitizens@nic.co.in

8. Disclaimer
The prospectus contains salient features of the Policy. For details reference is to be made to the Policy. In case of any difference
between the prospectus and the Policy, the terms and conditions of the Policy shall prevail.
The prospectus and proposal form are part of the Policy. Hence please read the prospectus carefully and sign the same. The
proposal form is to be completed in all respects for each insured person. Both the prospectus and the proposal form are to be
submitted to the office or to the agent.

Place Signature

Date Name

Insurance is the subject matter of solicitation.

No loading shall apply on renewals based on individual claims experience

National Insurance Co. Ltd.

National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 19
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
Table of Benefits:
Name National Super Top Up Mediclaim Policy
Plan Individual Floater
Threshold – Sum Insured (in ₹) Threshold Sum Insured
2 Lakhs 3,5,7 Lakhs
3 Lakhs 3,5,7,10 Lakhs
5 Lakhs 5,7,10,15 Lakhs
8 Lakhs 8,10,15,20 Lakhs
10 Lakhs 10,15,20,30 Lakhs
20 Lakhs 20,30,50,80 Lakhs
Coverage* .
In patient Treatment Up to Sum Insured, No sub limits
System of Medicine Allopathy and AYUSH
Pre-hospitalisation 30 days immediately before hospitalisation
Post-hospitalisation 60 days immediately after discharge
Day Care Procedures 140+ day care procedures
AYUSH Treatment Up to Sum Insured
Organ Donor’s Medical Expenses Medical expenses, Pre-hospitalisation & Post-hospitalisation expenses up to Sum Insured
AIDS Treatment Medical Expenses for treatment of AIDS (any stage)
Maternity Expenses Covered up to Sum Insured after waiting period of 3 years, No Sub Limit
Modern Treatment (12 nos) Up to 25% of SI for each treatment
Treatment due to participation in Up to 25% of SI
hazardous or adventure sports
(non-professionals)
Morbid Obesity Covered after waiting period of 3 years
Refractive Error (min 7.5D) Covered after waiting period of 2 years
Additional Benefits**
Hospital Cash (in excess of initial  Up to Sum Insured 10 Lakh, ₹ 1,000 per day for 5 days per individual
3 days) Above Sum Insured 10 Lakh, ₹ 2,000 per day for 5 days per individual
Doctor's Home Visit/ Aya/ Nurse/  Up to Sum Insured Limit 10 Lakh, ₹ 1,000 per day for 10 days per individual
Attendant Charges post Above Sum Insured Limit 10 Lakh, ₹ 2,000 per day for 10 days per individual
hospitalisation
Ambulance Charges (by road Actual charges
only)
Others
Migration to Policy without Option available
Threshold
Pre-existing Disease (PED) 12 months – PED claim not payable
waiting period (Only PEDs 13-24 months - 50% of PED claim
declared in the Proposal Form and 25-36 months - 75% of PED claim
accepted for coverage by the After 36 months - 100% of PED claim
Company shall be covered)
Renewal Benefit
Cumulative Bonus (CB)  CB at 5% of Sum Insured Limit for each claim free year
In case of claim, CB to be reduced at 5% per year
Discounts
Early Entry Discount 5% on individual premium (In case where an insured person has entered the policy before
the age 42 (completed years) and renewed the policy for a continuous period of 3 years)
Family Discount 5 % (in individual policy only) Not Applicable for Floater Policies
Online/ Direct Discount 10% (for new and renewal, where no intermediary is involved)
Long Term Discount 3% for a 2- year policy and 5% for a 3-year policy
* Aggregate of all the benefits under ‘Coverage’ in a policy period are subject to the Threshold.
** Aggregate of all the benefits under ‘Coverage’ and ‘Additional Benefits’ for admissible claims in a policy period are subject to the Sum Insured opted.

National Insurance Co. Ltd.

National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 20
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
Rate Chart (in ₹)

Premium (₹) per Individual (for individual policy)/ Senior most member (for floater policy)
Threshold 2 lakhs 3 lakhs 5 lakhs
Sum Insured 3 lakhs 5 lakhs 7 lakhs 3 lakhs 5 lakhs 7 lakhs 10 lakhs 5 lakhs 7 lakhs 10 lakhs 15 lakhs
Age Group
0 – 5* 868 1180 1311 748 1016 1128 1423 695 852 1174 1465
6 - 17* 868 1180 1311 748 1016 1128 1423 695 852 1174 1465
18 - 25 1844 2324 2542 1362 1764 1930 2471 1028 1260 1734 2164
26 - 35 1900 2382 2602 1389 1791 1956 2508 1028 1260 1735 2166
36 - 40 2396 3009 3289 1758 2272 2483 3177 1312 1608 2215 2768
41 - 45 2396 3009 3289 1758 2272 2483 3177 1312 1608 2215 2768
46 - 50 3771 4846 5325 2903 3810 4187 5329 2333 2860 3938 4919
51 - 55 4623 6005 6611 3637 4808 5294 6733 3015 3696 5089 6362
56 - 60 4893 6482 7164 4006 5362 5926 7504 3501 4292 5909 7388
61 - 65 7658 10243 11343 6392 8608 9531 12051 5725 7019 9664 12076
66 - 70 9637 12958 14361 8127 10979 12168 15369 7372 9038 12443 15549
71 - 75 12660 17069 18925 10731 14519 16098 20324 9792 12006 16530 20669
76 - 80 12920 17421 19316 10955 14823 16435 20754 10000 12260 16880 21105
81 - 85 12920 17421 19316 10955 14823 16435 20754 10000 12260 16880 21105
>=86 12920 17421 19316 10955 14823 16435 20754 10000 12260 16880 21105
* 0-5 & 6-17 age groups not applicable in Floater option

Threshold 8 lakhs 10 lakhs 20 lakhs

Sum 8 10 15 20 10 15 20 30 20 30 50 80
Insured Lakhs lakhs lakhs lakhs lakhs lakhs lakhs lakhs lakhs lakhs lakhs lakhs
Age Group
0 – 5* 872 1058 1355 1616 682 852 1016 1193 613 720 828 929
6 - 17* 872 1058 1355 1616 682 852 1016 1193 614 721 830 931
18 - 25 1289 1564 2002 2388 1007 1258 1501 1762 906 1063 1223 1373
26 - 35 1289 1564 2002 2388 1007 1258 1501 1762 907 1065 1225 1375
36 - 40 1645 1997 2557 3051 1286 1607 1917 2251 1158 1360 1565 1756
41 - 45 1645 1997 2557 3051 1286 1607 1917 2251 1158 1360 1565 1756
46 - 50 2925 3552 4546 5424 2287 2858 3409 4004 2056 2414 2777 3117
51 - 55 3782 4592 5876 7009 2952 3694 4407 5174 2658 3121 3590 4029
56 - 60 4393 5333 6825 8142 3433 4291 5118 6010 3090 3628 4174 4684
61 - 65 7184 8722 11161 13315 5610 7016 8370 9828 5050 5930 6823 7657
66 - 70 9251 11231 14374 17147 7233 9035 10778 12656 6504 7637 8786 9860
71 - 75 12289 14920 19093 22778 9603 12002 14318 16813 8644 10150 11677 13104
76 - 80 12550 15236 19498 23261 9805 12257 14622 17170 8825 10362 11921 13379
81 - 85 12550 15236 19498 23261 9805 12257 14622 17170 8825 10362 11921 13379
>=86 12550 15236 19498 23261 9805 12257 14622 17170 8825 10362 11921 13379

Premium (₹) for Additional Family Member (For floater policy)

Threshold 2 lakhs 3 lakhs 5 lakhs
Sum 10 10 15
3 lakhs 5 lakhs 7 lakhs 3 lakhs 5 lakhs 7 lakhs 5 lakhs 7 lakhs
Insured lakhs lakhs lakhs
Age Group
0-5 116 158 176 100 136 151 190 93 114 158 197
6 - 17* 127 174 193 110 149 166 209 102 125 173 215
18 - 25 290 365 399 214 277 303 388 161 198 273 340
26 - 35 321 403 439 235 303 330 424 174 213 293 366
36 - 40 582 731 800 427 552 604 772 319 391 538 672
41 - 45 582 731 800 427 552 604 772 319 391 538 672
46 - 50 1316 1692 1858 1013 1330 1461 1860 814 998 1375 1717
51 - 55 1613 2095 2307 1269 1678 1848 2350 1053 1291 1776 2221
56 - 60 1973 2612 2887 1614 2161 2389 3025 1411 1730 2381 2977
61 - 65 3828 5122 5671 3195 4304 4765 6025 2862 3509 4832 6038
66 - 70 5001 6725 7454 4218 5698 6315 7976 3825 4691 6458 8070
71 - 75 6825 9200 10202 5784 7825 8677 10954 5278 6471 8909 11140
76 - 80 7235 9756 10817 6135 8301 9204 11622 5600 6866 9453 11819
81 - 85 7507 10122 11223 6365 8612 9549 12058 5809 7124 9808 12262

National Insurance Co. Ltd.

National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 21
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156
 >=86 8398 11324 12555 7121 9635 10683 13490 6500 7969 10973 13719
Threshold 8 lakhs 10 lakhs 20 lakhs
Sum 8 10 15 20 10 15 20 30 20 30
50 lakhs 80 lakhs
Insured Lakhs lakhs lakhs lakhs lakhs lakhs lakhs lakhs lakhs lakhs
Age Group
0 – 5* 117 142 181 216 91 114 136 160 82 96 111 125
6 - 17* 128 156 199 237 100 125 149 175 90 106 122 137
18 - 25 202 245 314 375 158 197 236 277 142 167 192 215
26 - 35 217 264 339 404 170 212 254 298 153 180 207 232
36 - 40 400 486 621 741 313 391 466 547 282 331 380 427
41 - 45 400 486 621 741 313 391 466 547 282 331 380 427
46 - 50 1021 1240 1587 1893 798 997 1190 1397 717 842 969 1088
51 - 55 1320 1603 2051 2446 1031 1290 1538 1806 928 1089 1253 1406
56 - 60 1770 2149 2751 3281 1384 1729 2062 2422 1245 1462 1682 1888
61 - 65 3593 4361 5581 6658 2805 3508 4185 4914 2526 2966 3412 3829
66 - 70 4802 5829 7459 8899 3753 4689 5594 6569 3375 3963 4559 5117
71 - 75 6624 8042 10292 12277 5176 6469 7718 9063 4659 5471 6294 7063
76 - 80 7028 8532 10919 13026 5491 6863 8188 9614 4942 5803 6675 7491
81 - 85 7291 8852 11328 13514 5697 7121 8495 9976 5127 6020 6926 7773
>=86 8158 9904 12674 15119 6374 7967 9504 11160 5736 6736 7749 8696
GST extra

The premiums rates given above are all exclusive of TPA charges.
For with TPA – 3.5% loading on the premiums tabulated above.

Discount:
 A discount of 10% for direct sales
 Family discount of 5% (Applicable for policies issued on an individual basis)
 Early Entry Discount-5% on individual premium (where an insured person has entered the policy before the age 42
(completed years) and renewed the policy for a continuous period of 3 years)
 Long term discount- 3% for a 2 year policy and 5% for a 3 year policy.

Capping on aggregate of Discounts:

Discount capping 23.5% (5% for family discount+5% early entry discount +5% for a 3 year policy+10% Direct Discount on
premium after adjustment for the other three discounts).

National Insurance Co. Ltd.

National Super Top Up Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Plot no. Page | 22
UIN: NICHLIP24154V042324
CBD-81, New Town, Kolkata - 700156