National Super Top Up Policy

• Policy covers commonly excluded diseases/conditions like HIV/AIDS, obesity- bariatric surgery and maternity up to the sum insured, subject to waiting periods.
• Waiting period of only one year in all pre-existing diseases. Waiting periods for specific diseases are limited to 90 days, one and two years instead of the usual one, two and four years.
• Medical expenses are reimbursed without any sub limits (for e.g. room rent per day, Doctor's fees & etc.)
• This policy can be taken with/without a base policy.
• Annual increase in SI by 5% for each claim free year up to maximum 50% of SI opted.
• Tax Rebate under Section 80D of Income Tax Act 1961 for premium paid.

National Super Top Up Mediclaim Policy is a high threshold 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. The policy provides the customer an option to choose a high sum insured at reasonable cost. This policy can be taken with/without a base policy. This policy provides unique features which address all health related concerns of our valued customers. The expenses incurred should be reasonable, customary and medically necessary.

Highlights of National Super Top Up Policy

• Sum Insured (SI) and Threshold

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

• Entry Age of proposer as 18 to 65 years
• Maximum entry age of any family member - 65 years.
• Who can be covered Spouse, Dependent legitimate or legally adopted children, Parents/Parents-in law, new-born new born 3 months or individual of 18 years.
• Lines of treatment covered Allopathy, Ayurveda and Homeopathy
• In-patient Treatment including Room Rent/ICU charges, Medical practitioners, surgeon, naesthetist, consultants, specialists fees and other charges are covered.
• Ambulance Charges on actuals but will be paid once for any one illness for each insured person.
• Organ Donors medical expenses, Pre & Post Hospitalisation expenses covered up to Sum Insured.
• Pre and Post Hospitalisation up to 30 days and 60 days respectively for the same for same disease/illness/injury for which Hospitalisation occurred.
• 12 Modern treatments like Robotic surgery, oral chemotherapies, immuno therapies and etc., are now covered in the policy.
• Treatment for morbid obesity is are now covered after specified waiting periods (refer policy for complete details).
• Correction of eyesight, i.e., refractive errors above -7.5 D are now covered after specified waiting periods.
• Treatment related to participation as a non-professional in hazardous or adventure sports subject sublimits.
• Mental illness, HIV/AIDS, Genetic disorders are now covered.
• Cashless Facility available at network Hospitals Only through TPA.
• Pre Negotiated Package rates for specific surgeries/procedure in network hospitals.
• Life Long Renewability.
• Portability (migration) allowed from/to similar products only as per IRDAI guidelines.

Pre Policy Check Up

For Whom - Proposers aged 50 years and above (including dependents) and availing the policy for the first time.
No pre policy health check-up shall be required for existing policy holders 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 this policy.

The Pre- Policy check-up reports required are

• Physical examination (report to be signed by the Doctor with minimum MD (Medicine qualification)
• Blood sugar (fasting/ post prandial)
• Lipid profile
• Serum creatinine
• Urine routine and microscopic examination
• ECG
• Any other investigation required by the Company

Note: The date of medical reports should not exceed 30 days prior to the date of proposal. 50% of the expenses incurred for pre-policypre policy check-up shall be reimbursed, if the proposal is accepted. Terms and conditions apply.

Exclusions

• Only claims arising out of accidents are payable for the first 30 days of iInception of the pPolicy
• All pre-existing diseases included after first 12 twelve months (12) of Policy and thereafter as follows:

• 90 days, 1 One, 2 Two and 3 Three Years waiting period for specific diseases
• Change-of-Gender Treatments, Cosmetic or Plastic Surgery, Excluded Providers
• Vitamins, Tonics Drug/alcohol abuse, Self-Inflicted Injury
• Non-prescription Drug, Home visit charges
• Dental treatment (unless arising out of accident and requiring hospitalisation) and Out Patient Department treatment (OPD treatment)

Claims procedure

How to report a claim?
Cashless Facility is available only for policies serviced by a Third Party Administrator (TPA)

• Check if the hospital falls under the networked hospitals (Preferred provider network/other network Hospitals), as cashless is available only for empanelled network hospitals of the Company/TPA.
• For planned hospitalisation, intimation is to be sent to the TPA/Company in advance (72 hours prior) with details of Name and address of the hospital and condition requiring hospitalisation.
• In case of an emergency hospitalisation, intimation is to be sent to the TPA/Company within 24 hours of admission.
• On admission, a Pre-authorisation Request for cashless will be sent to the TPA by the hospital – duly signed by the insured and Hospital Authorities giving the details of admission, illness, proposed line of treatment and the estimated expenses. Pre and post hospitalisation expenses can be claimed separately after treatment.
• 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 authorisation, 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.
• In case of hospitalizsation 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.
• In case of hospitalizsation 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.
• All documents in original are to be submitted within 15 days to TPA, after completion of Post Hospitalizsation treatment.
• The insured shall preserve and submit all original documents and/ or certified copies of documents related to all hospitalizsation during the policy period to enable the Company to calculate the cumulative medical expenses and threshold, for determining admissibility and payment of claims.

For Reimbursement Claims

• Written intimation/mail/fax about hospitalisation is to be sent to TPA /Company within 72 hours of hospitalizsation in the case of emergency hospitalisation and 72 hours prior in case of planned admission.
• Before leaving the hospital, Discharge Summary, investigation report and other relevant documents (Claim form Part A & Part B) may be obtained from the hospital authorities. All the documents in original are to be submitted to TPA / Office within 15 days from date of discharge.
• Pre and post hospitalizsation expenses can be claimed separately after treatment.
• All documents (as mentioned in the prospectus) in original, to be submitted within 15 days after completion of Post Hospitalisation treatment.

• Duly filled Claim form issued by insurer (Part A & Part B)
• Medical practitioners prescription advising admission for inpatient treatment.
• Bills, receipt from the hospital(s)/ chemist(s) supported by prescription from an attending from attending medical practitioner for period of pre hospitalisation, hospitalisation and post hospitalisation (if applicable).
• Bills, receipt, investigation test reports etc. supported by prescription from attending medical practitioner for period of pre hospitalisation, hospitalisation and post hospitalisation (if applicable).
• Attending a medical Attending medical practitioners certificate regarding diagnosis along with date of diagnosis and bill, receipts etc.
• Certificate from the surgeon regarding diagnosis and nature of operation and bills, receipts etc.
• Bills, receipt, Sticker of the Implants.
• Bills, payment receipts, medical history of the patient recorded, indoor case papers, discharge certificate/ summary, break up of final bill from the hospital etc.
• Any other document required by company/TPA
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