NICHLIP21113 V032021 I

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National Insurance Company Limited

CIN - U10200WB1906GOI001713 IRDAI Regn. No. - 58

Vidyarthi Mediclaim for Students


POLICY

Recital clause
Whereas the insured person designated in the schedule hereto has by a proposal and declaration, dated as stated in the schedule,
which shall be the basis of this contract and is deemed to be incorporated herein, has applied to National Insurance Company
Ltd., (herein after called the company) for the insurance herein after set forth in respect of insured person(s) named in the
schedule hereto (herein after called the insured person) and has paid premium as consideration for such insurance.

Section-I - Hospitalisation expenses of the student

1 Operative clause
Now the policy witnesses that, subject to the terms, definition, exclusions and conditions contained herein or endorsed or
otherwise expressed hereon, the company undertakes that if during the policy period stated in the schedule or during the
continuance of the policy by renewal, any insured person shall suffer from any illness or disease (hereinafter called disease) or
sustain any bodily injury due to an accident (hereinafter called injury) and if such disease or injury shall require any such
insured person upon the advice of a duly qualified medical practitioner to be hospitalised for treatment at any nursing home/
hospital (herein after called hospital) in India as an in-patient, the company shall pay to the hospital or reimburse the Insured
person the amount of such reasonable, customary and medically necessary expenses described below, incurred in respect thereof
by or on behalf of such insured person but not exceeding the sum insured for the insured person in respect of all such claims,
during the policy period.

Coverage
The Company shall indemnify the Hospital or the Insured,
1.1 Room charges, Intensive Care Unit charges

1.2 Nursing expenses by qualified nurse

1.3 Surgeon, anesthetist, medical practitioner, consultants, specialist’s fees

1.4 Anesthesia, blood, oxygen, OT charges, surgical appliances (any disposable surgical consumables subject to upper limit of
10% of Sum insured), medicines & drugs, diagnostic material & X-ray, dialysis, chemotherapy, cadiotherapy, cost of
pacemaker, artificial limbs, cost of stents & implants, expenses for organ donor’s treatment.

1.5 Pre and post hospitalisation – Expenses related to medical diagnosis or procedure that resulted in hospitalisation and
incurred during the period up to 30 days prior to hospitalisation and up to 60 days after discharge from hospital and will be
considered as part of hospitalisation claim

1.6 Following Modern Treatments (wherever medically indicated) either as In patient or as part of Day Care Treatment in a
Hospital, subject to Maximum amount admissible for any one Modern Treatment shall be 25% of Sum Insured
A. Uterine Artery Embolization and HIFU (High intensity focused ultrasound)
B. Balloon Sinuplasty
C. Deep Brain stimulation
D. Oral chemotherapy
E. Immunotherapy- Monoclonal Antibody to be given as injection
F. Intra vitreal injections
G. Robotic surgeries
H. Stereotactic radio surgeries
I. Bronchical Thermoplasty
J. Vaporisation of the prostrate (Green laser treatment or holmium laser treatment)
K. IONM - (Intra Operative Neuro Monitoring)
L. Stem cell therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered.

1.7 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 25% of Sum Insured

1.8 Morbid Obesity Treatment


Medical Expenses (including Pre and Post Hospitalisation Expenses) incurred for surgical treatment of obesity that fulfils all the
following conditions and subject to Waiting Period of two (04) years as per Section 4.2.f.iii:
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

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Regd. & Head Office: 3, Middleton Street, (UIN: NICHLIP21113V032021)
Kolkata 700071
4. Body Mass Index (BMI) is;
b) greater than or equal to 40 or
c) 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

1.9 Correction of Refractive Error


Medical Expenses (including Pre 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.ii

1.10 HIV/ AIDS Cover


Medical Expenses (including Pre and Post Hospitalisation Expenses) related to following stages of HIV infection:
i. Acute HIV infection – acute flu-like symptoms
ii. Clinical latency – usually asymptomatic or mild symptoms
iii. AIDS – full-blown disease; CD4 < 200

1.11 Mental Illness Cover


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 (as
defined in Definition 3.27).

Exclusions
Any kind of Psychological counselling, cognitive/ family/ group/ behavior/ palliative therapy or other kinds of psychotherapy for
which Hospitalisation is not necessary shall not be covered.

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

2.1 Cumulative Bonus/ Discount in premium


At the time of renewal, cumulative bonus allowed shall be an amount equal to 5% (five percent) of sum insured (excluding CB) of
the expiring policy in respect of an insured person, provided no claims were reported under the expiring policy.
In the event of a claim being reported under the expiring policy the cumulative bonus with respect to the insured person shall be
reduced by an amount equal to 5% (five percent) of sum insured (excluding CB) of the expiring policy.
Cumulative bonus shall be aggregated over the years and available, subject to maximum of 50% (fifty percent) of the sum insured
(excluding CB) of the expiring policy.
Insured person has the option either to avail cumulative bonus or claim 5% discount in renewal premium in respect of each claim
free year of insurance subject to maximum of 10 (ten) claim free years of insurance.

3 Definition

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

3.2 Any One Illness means continuous period of illness and it includes relapse within 45 (forty five) days from the date of last
consultation with the Hospital where treatment has been taken.

3.3 Cashless Facility means a facility extended by the Company to the Insured where the payments, of the costs of treatment
undergone by the Insured in accordance with the Policy terms and conditions, are directly made to the Network Provider by the
Company to the extent pre-authorization approved

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

3.5 Congenital Anomaly means a condition which is present since birth, and which is abnormal with reference to form,
structure or position.
a) Internal Congenital Anomaly
Congenital Anomaly which is not in the visible and accessible parts of the body.
b) External Congenital Anomaly
Congenital Anomaly which is in the visible and accessible parts of the body

3.6 Cumulative Bonus means any increase or addition in the Sum Insured granted by the Company without an associated
increase in premium.
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Regd. & Head Office: 3, Middleton Street, (UIN: NICHLIP21113V032021)
Kolkata 700071
3.7 Day Care Treatment means medical treatment, and/or surgical procedure which is:
i. undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 (twenty four) hrs because of
technological advancement, and
ii. which would have otherwise required a hospitalisation of more than 24 (twenty four) hours.
Treatment normally taken on an out-patient basis is not included in the scope of this definition.

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

3.9 Grace period means 30 (thirty) days immediately following the premium due date during which a payment can be made to
renew or continue the policy in force without loss of continuity benefits such as waiting period and coverage of pre-existing
disease. Coverage is not available for the period for which no premium is received.

3.10 Hospital means any Institution established for In-Patient Care and Day Care Treatment of Illness/ Injuries and which has
been registered as a Hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act,
2010 or under the enactments specified under Schedule of Section 56(1) of the said Act, OR complies with all minimum criteria
as under:
i. has qualified nursing staff under its employment round the clock;
ii. has at least ten (10)In-Patient beds, in those towns having a population of less than ten lacs and fifteen (15) inpatient beds in
all other places;
iii. has qualified Medical Practitioner (s) in charge round the clock;
iv. has a fully equipped operation theatre of its own where surgical procedures are carried out
v. maintains daily records of patients and shall make these accessible to the Company’s authorized personnel.

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

3.12 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 a disease, 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 disease/ illness/ injury which leads to full recovery.
ii. Chronic condition means a disease, illness, or injury that has one or more of the following characteristics
a) it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and / or tests
b) it needs ongoing or long-term control or relief o f symptoms
c) it requires your rehabilitation or for you to be specially trained to cope with it
d) it continues indefinitely
e) it comes back or is likely to come back.

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

3.14 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.

3.15 ICU (Intensive Care Unit) Charges means the amount charged by a Hospital towards ICU expenses which shall include
the expenses for ICU bed, general medical support services provided to any ICU patient including monitoring devices, critical
care nursing and intentivist charges.

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

3.17 Medical Practitioner means a person who holds a valid registration from the medical council of any state or Medical Council
of India or Council for Indian Medicine or for Homeopathy set up by the Government of India or a State Government and is
thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of the licence.

3.18 Network Provider means hospitals or health care providers enlisted by an insurer or by a TPA and insurer together to
provide medical services to an insured person on payment by a cashless facility.

3.19 Non- Network means any hospital, day care centre or other provider that is not part of the network.

3.20 Notification of Claim means the process of intimating a claim to the Company or TPA through any of the recognized modes
of communication.
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Regd. & Head Office: 3, Middleton Street, (UIN: NICHLIP21113V032021)
Kolkata 700071
3.21 OPD (Out-Patient) Treatment means the one in which the Insured Person visits a clinic / Hospital or associated facility like
a consultation room for Diagnosis and treatment based on the advice of a Medical Practitioner. The Insured is not admitted as a
Day Care or In-Patient.

3.22 Policy Period means period of one year as mentioned in the schedule for which the policy is issued.

3.23 Preferred Provider Network (PPN) means a network of hospitals which have agreed to a cashless packaged pricing for
certain procedures for the insured person. The list is available with the company/TPA and subject to amendment from time to
time. Reimbursement of expenses incurred in PPN for the procedures (as listed under PPN package) shall be subject to the rates
applicable to PPN package pricing.

3.24 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.

3.25 Post hospitalisation Medical Expenses means Medical Expenses incurred during predefined number of days immediately
after the Insured Person is discharged from the Hospital provided that:
i. Such Medical Expenses are for the same condition for which the Insured Person’s Hospitalisation was required, and
ii. The inpatient hospitalisation claim for such hospitalisation is admissible by the Company.

3.26 Pre existing disease means any condition, ailment, injury or disease
a. That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the Company or
b. For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the
effective date of the policy or its reinstatement.

3.27 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.

3.28 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.

3.29 Room Rent means the amount charged by a hospital for the occupancy of a bed on per day (24 hours) basis and shall include
associated medical expenses.

3.30 Sum Insured means the sum insured (excluding CB) as mentioned in the schedule against Section I.

3.31 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.

3.32 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 .

3.33 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.

3.34 Waiting Period means a period from the inception of this Policy during which specified Illness/treatments are not covered.
On completion of the Waiting Period, Illness/treatments shall be covered provided the Policy has been continuously renewed
without any break.

4 Exclusions
The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any
person in connection with or in respect of:

4.1 Pre-Existing Disease (Excl 01)


a) Expenses related to the treatment of a Pre-Existing Disease (PED) and its direct complications shall be excluded until the
expiry of 36 (thirty six) 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.
National Insurance Co. Ltd. Page | 4 Vidyarthi Mediclaim for Students
Regd. & Head Office: 3, Middleton Street, (UIN: NICHLIP21113V032021)
Kolkata 700071
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 36 (thirty six) months for any pre-existing disease is subject to the same being
declared at the time of application and accepted by us.

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/
two year/four years (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. Two years Waiting Period
a. Cataract k. Pilonidal sinus
b. Benign prostatic hypertrophy l. Calculus diseases
c. Hernia m. Hysterectomy for menorrhagia or fibromyoma
d. Hydrocele n. Joints replacements of any kind unless arising out of
e. Internal congenital anomaly accident
f. Fissure/Fistula in anus o. Surgical treatment of tonsils, adenoids and deviated
g. Piles (Haemorrhoids) nasal septum and related disorders
h. Sinusitis p. Refractive error of the eye more than 7.5 dioptres.
i. CSOM (Chronic Suppurative Otitis Media) q. Internal Congenital Anomaly
j. Benign lumps/growths in any part of the body
If these diseases are pre-existing at the time of proposal, they will be covered only after 36 (thirty six) months of continuous
coverage as mentioned in 4.1 above.
iii. Four years Waiting Period
a. Morbid Obesity and its complications
b. Stem Cell Therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered
Following diseases even if pre-existing shall be covered after four years of continuous cover from the inception of the Policy.

4.3 First 30 days waiting period (Excl 03)


a) Expenses related to the treatment of any illness within 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 12 (twelve) months.
The within referred waiting period is made applicable to the enhanced sum insured in the event of granting higher sum insured
subsequently

4.4 Non Medical Admissions


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)

4.5 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 Birth control, Sterility and Infertility (Excl 17)


Expenses related to sterility and infertility. This includes:
i. Any type of sterilization
ii. Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT,
GIFT, ICSI
iii. Gestational Surrogacy
iv. Reversal of sterilization

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Regd. & Head Office: 3, Middleton Street, (UIN: NICHLIP21113V032021)
Kolkata 700071
4.7 Maternity (Excl 18)
i. Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during
hospitalization) except ectopic pregnancy;
ii. Expenses towards miscarriage (unless due to an accident) and lawful medical termination of pregnancy during the policy period

4.8 Self Inflicted Injury:


Treatment for intentional self-inflicted injury, attempted suicide.

4.9 Drug/alcohol abuse:


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

4.10 General Debility, Congenital External Anomaly


General debility, Congenital external anomaly.

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

4.12 Vaccination or Inoculation.


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

4.13 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.

4.14 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.

4.15 Naturopathy treatment

4.16 Dental treatment


Dental treatment, unless necessitated due to an Injury.

4.17 Vitamins, tonics:


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 (Excl 14)

4.18 lnvestigation & Evaluation (Excl 04):


a) Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.
b) Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.

4.19 Spectacles, contact lens, hearing aid, cochlear implants

4.20 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.

4.21 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.

4.22 Treatment taken outside the geographical limits of India

4.23 Permanently Excluded Diseases


In respect of the existing diseases, disclosed by the insured and mentioned in the policy schedule (based on insured's
consent), policyholder is not entitled to get the coverage for specified ICD codes.

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Regd. & Head Office: 3, Middleton Street, (UIN: NICHLIP21113V032021)
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5 Conditions

5.1 Physical examination


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

5.2 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 even if the sum insured is not exhausted. 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.

5.3 Territorial limit


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

5.4 Claim procedure


Claims under Section I of the policy will be serviced by TPA.
Claim will be paid to the guardian.

5.4.1 Notification of claim


In case of a claim, the insured person/insured person’s representative shall intimate the TPA 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.

Claim notification in case of cashless facility TPA must be informed:


In case of planned hospitalization At least 72 (seventy two) hours prior to the insured person’s
admission to network provider/PPN
In case of emergency hospitalization Within 24 (twenty four) hours of the insured person’s
admission to network provider/PPN

Claim notification in case of reimbursement TPA must be informed:


In case of planned hospitalization At least 72 (seventy two) hours prior to the insured person’s
admission to hospital
In case of emergency hospitalization Within 24 (twenty four) hours of the insured person’s
admission to hospital

5.4.2 Procedure for cashless claims


i. Treatment may be taken in a network provider/PPN and is subject to pre authorization by the TPA.
ii. Cashless request form available with the network provider/PPN and TPA shall be completed and sent to the TPA for
authorization.
iii. The TPA upon getting cashless request form and related medical information from the insured person/ network
provider/PPN will issue pre-authorization letter to the hospital after verification.
iv. At the time of discharge, the insured person has to verify and sign the discharge papers, pay for non-medical and
inadmissible expenses.
v. The TPA reserves the right to deny pre-authorization in case the insured person is unable to provide the relevant medical
details.
vi. In case of denial of cashless access, the insured person may obtain the treatment as per treating doctor’s advice and
submit the claim documents to the TPA for reimbursement.

5.4.3 Procedure for reimbursement of claims


For reimbursement of claims the insured person may submit the necessary documents to TPA within the prescribed time limit.

5.4.4 Documents
The claim is to be supported with the following documents and submitted within the prescribed time limit.
i. Completed claim form
ii. Original bills, payment receipts, medical history of the patient recorded, discharge certificate/ summary from the hospital
etc.
iii. Original cash-memo from the hospital (s)/chemist (s) supported by proper prescription
iv. Original payment receipt, investigation test reports etc. supported by the prescription from attending medical practitioner
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Regd. & Head Office: 3, Middleton Street, (UIN: NICHLIP21113V032021)
Kolkata 700071
v. Attending medical practitioner’s certificate regarding diagnosis and bill receipts etc.
vi. Surgeon’s original certificate stating diagnosis and nature of operation performed along with bills/receipts etc.
vii. Any other document required by company/TPA

Note
In the event of a claim lodged as per clause 5.2 of the policy and the original documents having been submitted to the other
insurer, the company may accept the documents listed under clause 5.4.4 of the policy and claim settlement advice duly certified
by the other insurer subject to satisfaction of the company.

Type of claim Time limit for submission of documents to TPA


Reimbursement of hospitalisation and pre Within 15 (fifteen) days of date of discharge from hospital
hospitalisation expenses
Reimbursement of post hospitalisation expenses Within 15 (fifteen) days from completion of post
hospitalisation treatment

5.4.5 Claim settlement


i. The Company shall settle or reject a claim, as the case may be, within 30 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)

5.4.6 Services offered by a TPA


The TPA shall render health care services covered under the policy like issuance of ID cards & guide book, hospitalization & pre-
authorization services, call centre, acceptance of claim related documents, claim processing and other related services
The services offered by a TPA shall not include
i. Claim settlement and rejection with respect to the policy; However, TPA may handle claims admission and recommend
to the company for the payment of the claim settlement
ii. Any services directly to the 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 claim notification and submission of documents may be waived in cases where it is proved to the satisfaction of the
company, that the circumstances under which insured person was placed, it was not possible to intimate the claim/submit the
documents within the prescribed time limit.

5.5 Moratorium Period


After completion of eight continuous years under this policy no look back would be applied. This period of eight years is called as
moratorium period. The moratorium would be applicable for the sums insured of the first policy and subsequently completion of
eight continuous years would be applicable from date of enhancement of sums insured only on the enhanced limits. After the
expiry of Moratorium Period no claim under this policy shall be contestable except for proven fraud and permanent exclusions
specified in the policy contract. The policies would however be subject to all limits, sub limits, co-payments as per the policy.

5.6 Migration
The insured person will have the option to migrate the policy to other health insurance products/plans offered by the company
by applying for migration of the policyatleast30 days before the policy renewal date as per IRDAI guidelines on Migration. If
such person is presently covered and has been continuously covered without any lapses under any health insurance product/plan
offered by the company, the insured person will get the accrued continuity benefits in waiting periods as per IRDAI guidelines
on migration.

5.7 Portability
The insured person will have the option to port the policy to other insurers by applying to such insurer to port the entire policy
along with all the members of the family, if any, at least 45 days before, but not earlier than 60 days from the policy renewal
date as per IRDAI guidelines related to portability. If such person is presently covered and has been continuously covered
without any lapses under any health insurance policy with an Indian General/Health insurer, the proposed insured person will
get the accrued continuity benefits in waiting periods as per IRDAI guidelines on portability.

National Insurance Co. Ltd. Page | 8 Vidyarthi Mediclaim for Students


Regd. & Head Office: 3, Middleton Street, (UIN: NICHLIP21113V032021)
Kolkata 700071
Section-II – Personal Accident of the guardian and Section-III – Personal Accident of the student

1 Personal accident cover


Now the policy witnesses that, subject to the terms, definition, exclusions and conditions contained herein or endorsed or otherwise
expressed hereon, the company undertakes that if during the policy period stated in the schedule or during the continuance of the
policy by renewal the insured person shall sustain any bodily injury resulting solely and directly from accident then the company
shall pay to the insured person the sum hereinafter set forth that is to say

1.1 If such injury shall within twelve calendar months of its occurrence be the sole and direct cause of the death of the Insured
persons the Capital Sum Insured stated in the Schedule.
1.2 If such injury shall within twelve calendar months of its occurrence be the sole and direct cause of the total and irrecoverable
loss of sight of both eyes or total and irrecoverable loss of use of two hands or two feet, or of one hand and one foot or of such
loss of sight of one eye and such loss of use of one hand or one foot, the capital sum insured stated in the schedule hereto.
1.3 If such injury shall within twelve calendar months of its occurrence be the sole and direct cause of the total and irrecoverable
loss of sight of one eye or total and irrecoverable loss of use of a hand or foot, fifty percent to the capital sum insured stated in the
schedule hereto.
1.4 If such injury shall within twelve calendar months of its occurrence be the sole and direct cause of permanently totally and
absolutely disabling the Insured persons from engaging in being occupied with or giving attention to any employment or
occupation of any description whatsoever the Sum Insured stated in the Schedule.

1.2 Additional cover for Section I and Section II


Transportation cost of insured’s dead body (death due to accident only) to the place of residence subject to a maximum of 2% of
the Capital Sum Insured or Rs.1,000/- (one thousand) whichever is lower. This cover is applicable both for Section II & III.

2 Definitions

2.1 Capital sum insured means the sum insured as mentioned in the schedule against Section II and Section III of the policy. The
sum insured represents maximum liability for each insured person, for any and all benefits claimed during the policy period.

2.2 Standard type of aircraft means any aircraft duly licensed to carry passengers (for hire or otherwise) by appropriate authority
irrespective of whether such an aircraft is privately owned OR chartered OR operated by a regular airline OR whether such an
aircraft has a single engine or multiple engines.

3 Exclusions
The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any
person in connection with or in respect of:

3.1 Compensation under more than one of the aforesaid sub-clauses 1.1, 1.2, 1.3 or 1.4 in respect of the same injury or disablement
under Section II and Section III of the policy.

3.1 Any payment in excess of Capital Sum Insured under Section II and Section III of the Policy during any one period of Insurance.

3.3 Any payment in respect of injury or disablement directly or indirectly arising out of or contributed to be or traceable to any
disability existing on the date of issue of this policy.

3.4 Any payment in respect of death of the insured (a) from intentional self injury, suicide or attempted suicide (b)whilst under
influence of intoxicating liquor or drugs (c) whilst engaging in Aviation or Ballooning, whilst Mounting into, Dismounting from
or Travelling in any aircraft other than as a passenger (fare paying or otherwise) in any duly licensed standard type of aircraft
anywhere in the world (d) directly or indirectly caused by venereal disease or insanity, (e) arising or resulting from the insured
committing any breach of the law with criminal intent.

3.5 Any payment in respect of death of the insured due to or arising out of directly or indirectly connected with or traceable to
war, invasion, Act of foreign enemy, Hostilities (Whether war be declared or not) Civil War, Rebellion, Revolution, Insurrection,
Mutiny, Military or Usurped Power, Seizure, Capture, Arrests, restraints and Detainment of all kings, princes and people of
whatsoever nation, condition or quality.

3.6 Any payment in respect of death of the insured:


a Directly or indirectly caused by or contributed to by or arising from ionising radiations or contamination by radioactivity from
any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel. For the purpose of this exception, combustion
shall include any self-sustaining process of nuclear fission.
b Directly or indirectly caused by or contributed to by or arising from nuclear weapon material.

3.7 Any payment in respect of death or disablement resulting directly or indirectly caused by or contributed to by or aggravated to
prolonged by childbirth or pregnancy or in consequence thereof.

National Insurance Co. Ltd. Page | 9 Vidyarthi Mediclaim for Students


Regd. & Head Office: 3, Middleton Street, (UIN: NICHLIP21113V032021)
Kolkata 700071
4. Claim procedure
Claims under Section II and Section II of the policy will be serviced by the company.

4.1 Notification of claim


Upon the happening of any event which may give rise to a claim under this policy written notice with full particulars must be
given to the company within 72 (seventy two) hrs of occurrence of the accident. Written notice also of the death must, unless
reasonable cause is shown, be so given before interment/ cremation and in any case, within one calendar month (30 days), after
the death.

4.2 Documents
Documents to be submitted within 14 (fourteen) days from the date of notification:
a. FIR
b. Death Certificate
c. Post Mortem Certificate, if required
d. Any other Documents required by Company

Conditions applicable to Section-I, Section-II & Section-III:

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,
misdescription 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)

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.

3 Communication
i. All communication should be in writing.
ii. For claim serviced by TPA, ID card, PPN/network provider related issues to be communicated to the TPA at the address
mentioned in the schedule. For claim serviced by the company, the policy related issues, change in address to be
communicated to the policy issuing office at the address mentioned in the schedule.
iii. The company or TPA will communicate to the insured person at the address mentioned in the schedule.

4 Payment of premium
The Policy will commence from the date and time the premium is received by the company and issue a receipt for the same by a
duly authorized official of company. The due payment of premium and the observance and fulfillment of the terms, provisions,
conditions and endorsements of this Policy by the Insured Persons in so far as they relate to anything to be done or complied with
by the Insured Person shall be a condition precedent to any liability of the Company to make any payment under this policy. No
waiver of any terms, provisions, conditions and endorsements of this policy shall be valid unless made in writing and signed by an
authorized official of the Company.

5 Payment of claim
All claims under this policy shall be payable in Indian currency through NEFT/ RTGS only.

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

7 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.
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.
National Insurance Co. Ltd. Page | 10 Vidyarthi Mediclaim for Students
Regd. & Head Office: 3, Middleton Street, (UIN: NICHLIP21113V032021)
Kolkata 700071
8 Cancellation
i. The Company may cancel the policy at any time on grounds of misrepresentation non-disclosure of material facts, fraud by
the insured person by giving 15 days’ written notice. There would be no refund of premium on cancellation on grounds of
misrepresentation, non-disclosure of material facts or fraud
ii. The policyholder may cancel this policy by giving 15days’ written notice and in such an event, the Company shall refund
premium for the unexpired policy period as detailed below.

Period of Risk Rate of premium to be charged


Up to 1 month 1/4th of the annual rate
Up to 3 month 1/2 of the annual rate
Up to 6 month 3/4th of the annual rate
Exceeding 6 month Full annual rate

9 The Company shall not be bound to take notice or be affected by any notice of any trust, charge, lien, assignment or other
dealings with or relating to this policy but the receipt of the insured or his legal personal representative(s) shall in all cases be an
effective discharge to the Company.

10 Disclaimer
It is also hereby further expressly agreed and declared that if the Company/TPA shall disclaim liability to the insured for any
claim hereunder and such claims shall not within 12 (twelve) calendar months from the date of such disclaimer have been made
the subject matter of a suit in court of law, then the claim shall for all purposes be deemed to have been abandoned and shall not
thereafter be recoverable hereunder.

11 Territorial jurisdiction
All disputes or differences under or in relation to the policy shall be determined by the Indian court and according to Indian law.

12 Arbitration
If any dispute or difference shall arise as to the quantum to be paid under 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 or if they cannot agree upon a single arbitrator within 30 (thirty) days of any party invoking arbitration, the same shall
be referred to a panel of three arbitrators, comprising of 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/in accordance
with the provisions of the Arbitration and Conciliation Act 1996.
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 this Policy.

It is hereby expressly stipulated and declared that it shall be condition precedent to any right of action or suit upon this Policy that
award by such arbitrator/arbitrators of the amount of the loss or damage shall be first obtained.

13 Renewal
The policy shall ordinarily be renewable except on grounds of fraud, misrepresentation by the insured person.
i. The Company shall endeavor to give notice for renewal. However, the Company is not under obligation to give any notice
for renewal.
ii. Renewal shall not be denied on the ground that the insured person had made a claim or claims in the preceding policy years.
iii. Request for renewal along with requisite premium shall be received by the Company before the end of the policy period.
iv. 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.
v. No loading shall apply on renewals based on individual claims experience.

14 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.

15 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 three months before the changes are effected.

16 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 fifteen days from date of receipt of the policy document to review the
terms and conditions of the policy, and to return the same if not acceptable.
National Insurance Co. Ltd. Page | 11 Vidyarthi Mediclaim for Students
Regd. & Head Office: 3, Middleton Street, (UIN: NICHLIP21113V032021)
Kolkata 700071
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;

17 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
finaldischarge of its liability under the policy.

18 Redressal of grievance
In case of any grievance the insured person may contact the company through
Website: http://nationalinsurance.nic.co.in/ Courier: National Insurance Co. Ltd.,
Toll free: 1800 345 0330 6A Middleton Street, 7th Floor,
E-mail: customer.relations@nic.co.in CRM Dept.,
Phn : (033) 2283 1742 Kolkata - 700 071
Insured person may also approach the grievance cell at any of the company’s branches with the details of grievance.
If Insured person is not satisfied with the redressal of grievance through one of the above methods, insured person may contact the
grievance officer (Office in-Charge) at that location.
For updated details of grievance officer, kindly refer the link: http://nationalinsurance.nic.co.in/
If Insured person is not satisfied with the redressal of grievance through above methods, the insured person may also approach the
office of Insurance Ombudsman of the respective area/region for redressal of grievance as per Insurance Ombudsman Rules 2017.
Grievance may also be lodged at IRDAI Integrated Grievance Management System - https://igms.irda.gov.in/

National Insurance Co. Ltd. Page | 12 Vidyarthi Mediclaim for Students


Regd. & Head Office: 3, Middleton Street, (UIN: NICHLIP21113V032021)
Kolkata 700071
Appendix I
List I – List of which coverage is not available in the policy 61 OUNCE GLASS
Sl Item 62 OXYGEN MASK
1 BABY FOOD 63 PELVIC TRACTION BELT
2 BABY UTILITIES CHARGES 64 PAN CAN
3 BEAUTY SERVICES 65 TROLLY COVER
4 BELTS/ BRACES 66 UROMETER, URINE JUG
5 BUDS 67 AMBULANCE
6 COLD PACK/HOT PACK 68 VASOFIX SAFETY
7 CARRY BAGS List II – Items that are to be subsumed into Room Charges
8 EMAIL / INTERNET CHARGES Sl Item
9 FOOD CHARGES (OTHER THAN PATIENT's DIET 1 BABY CHARGES (UNLESS SPECIFIED/INDICATED)
PROVIDED BY HOSPITAL) 2 HAND WASH
10 LEGGINGS 3 SHOE COVER
11 LAUNDRY CHARGES 4 CAPS
12 MINERAL WATER 5 CRADLE CHARGES
13 SANITARY PAD 6 COMB
14 TELEPHONE CHARGES 7 EAU-DE-COLOGNE / ROOM FRESHNERS
15 GUEST SERVICES 8 FOOT COVER
16 CREPE BANDAGE 9 GOWN
17 DIAPER OF ANY TYPE 10 SLIPPERS
18 EYELET COLLAR 11 TISSUE PAPER
19 SLINGS 12 TOOTH PASTE
20 BLOOD GROUPING AND CROSS MATCHING OF 13 TOOTH BRUSH
DONORS SAMPLES 14 BED PAN
21 SERVICE CHARGES WHERE NURSING CHARGE ALSO 15 FACE MASK
CHARGED 16 FLEXI MASK
22 Television Charges 17 HAND HOLDER
23 SURCHARGES 18 SPUTUM CUP
24 ATTENDANT CHARGES 19 DISINFECTANT LOTIONS
25 EXTRA DIET OF PATIENT (OTHER THAN THAT 20 LUXURY TAX
WHICH FORMS PART OF BED CHARGE) 21 HVAC
26 BIRTH CERTIFICATE 22 HOUSE KEEPING CHARGES
27 CERTIFICATE CHARGES 23 AIR CONDITIONER CHARGES
28 COURIER CHARGES 24 IM IV INJECTION CHARGES
29 CONVEYANCE CHARGES 25 CLEAN SHEET
30 MEDICAL CERTIFICATE 26 BLANKET/WARMER BLANKET
31 MEDICAL RECORDS 27 ADMISSION KIT
32 PHOTOCOPIES CHARGES 28 DIABETIC CHART CHARGES
33 MORTUARY CHARGES 29 DOCUMENTATION CHARGES / ADMINISTRATIVE
34 WALKING AIDS CHARGES EXPENSES
35 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE 30 DISCHARGE PROCEDURE CHARGES
HOSPITAL) 31 DAILY CHART CHARGES
36 SPACER 32 ENTRANCE PASS / VISITORS PASS CHARGES
37 SPIROMETRE 33 EXPENSES RELATED TO PRESCRIPTION ON
38 NEBULIZER KIT DISCHARGE
39 STEAM INHALER 34 FILE OPENING CHARGES
40 ARMSLING 35 INCIDENTAL EXPENSES / MISC. CHARGES (NOT
41 THERMOMETER EXPLAINED)
42 CERVICAL COLLAR 36 PATIENT IDENTIFICATION BAND / NAME TAG
43 SPLINT 37 PULSEOXYMETER CHARGES
44 DIABETIC FOOT WEAR List III – Items that are to be subsumed into Procedure Charges
45 KNEE BRACES (LONG/ SHORT/ HINGED) Sl Item
46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER 1 HAIR REMOVAL CREAM
47 LUMBO SACRAL BELT 2 DISPOSABLES RAZORS CHARGES (for site preparations)
48 NIMBUS BED OR WATER OR AIR BED CHARGES 3 EYE PAD
49 AMBULANCE COLLAR 4 EYE SHEILD
50 AMBULANCE EQUIPMENT 5 CAMERA COVER
51 ABDOMINAL BINDER 6 DVD, CD CHARGES
52 PRIVATE NURSES CHARGES- SPECIAL NURSING 7 GAUSE SOFT
CHARGES 8 GAUZE
53 SUGAR FREE Tablets 9 WARD AND THEATRE BOOKING CHARGES
54 CREAMS POWDERS LOTIONS (Toiletries are not payable, 10 ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS
only prescribed medical pharmaceuticals payable) 11 MICROSCOPE COVER
55 ECG ELECTRODES 12 SURGICAL BLADES, HARMONICSCALPEL,SHAVER
56 GLOVES 13 SURGICAL DRILL
57 NEBULISATION KIT 14 EYE KIT
58 ANY KIT WITH NO DETAILS MENTIONED [DELIVERY 15 EYE DRAPE
KIT, ORTHOKIT, RECOVERY KIT, ETC] 16 X-RAY FILM
59 KIDNEY TRAY 17 BOYLES APPARATUS CHARGES
60 MASK 18 COTTON
19 COTTON BANDAGE 6 CPAP/ CAPD EQUIPMENTS
20 SURGICAL TAPE 7 INFUSION PUMP– COST
21 APRON 8 HYDROGEN PEROXIDE\SPIRIT\ DISINFECTANTS ETC
22 TORNIQUET 9 NUTRITION PLANNING CHARGES - DIETICIAN
23 ORTHOBUNDLE, GYNAEC BUNDLE CHARGES- DIET CHARGES
List IV – Items that are to be subsumed into costs of treatment 10 HIV KIT
Sl Item 11 ANTISEPTIC MOUTHWASH
1 ADMISSION/REGISTRATION CHARGES 12 LOZENGES
2 HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC 13 MOUTH PAINT
PURPOSE 14 VACCINATION CHARGES
3 URINE CONTAINER 15 ALCOHOL SWABES
4 BLOOD RESERVATION CHARGES AND ANTE NATAL 16 SCRUB SOLUTION/STERILLIUM
BOOKING CHARGES 17 Glucometer & Strips
5 BIPAP MACHINE 18 URINE BAG

National Insurance Co. Ltd. Page | 14 Vidyarthi Mediclaim for Students


Regd. & Head Office: 3, Middleton Street, (UIN: NICHLIP21113V032021)
Kolkata 700071
Appendix II
List of illnesses permanently excluded if existing at the time of taking the Policy
Sl Existing Disease ICD Code Excluded
1 Sarcoidosis D86.0-D86.9
2 Malignant Neoplasms C00-C14 Malignant neoplasms of lip, oral cavity and pharynx, • C15-C26 Malignant neoplasms of digestive
organs, • C30-C39 Malignant neoplasms of respiratory and intrathoracic organs• C40-C41 Malignant neoplasms
of bone and articular cartilage• C43-C44 Melanoma and other malignant neoplasms of skin • C45-C49 Malignant
neoplasms of mesothelial and soft tissue • C50-C50 Malignant neoplasms of breast • C51-C58 Malignant
neoplasms of female genital organs • C60-C63 Malignant neoplasms of male genital organs • C64-C68
Malignant neoplasms of urinary tract • C69-C72 Malignant neoplasms of eye, brain and other parts of central
nervous system • C73-C75 Malignant neoplasms of thyroid and other endocrine glands • C76-C80 Malignant
neoplasms of ill-defined, other secondary and unspecified sites • C7A-C7A Malignant neuroendocrine tumours •
C7B-C7B Secondary neuroendocrine tumours • C81-C96 Malignant neoplasms of lymphoid, hematopoietic and
related tissue• D00-D09 In situ neoplasms • D10-D36 Benign neoplasms, except benign neuroendocrine tumours
• D37-D48 Neoplasms of uncertain behaviour, polycythaemiavera and myelodysplastic syndromes • D3A-D3A
Benign neuroendocrine tumours • D49-D49 Neoplasms of unspecified behaviour
3 Epilepsy G40 Epilepsy
4 Heart Ailment Congenital I49 Other cardiac arrhythmias, (I20-I25)Ischemic heart diseases, I50 Heart failure, I42Cardiomyopathy; I05-I09 -
heart disease and valvular Chronic rheumaticheart diseases. • Q20 Congenital malformations of cardiac chambers and connections • Q21
heart disease Congenital malformations of cardiac septa • Q22 Congenital malformations of pulmonary and tricuspid valves •
Q23 Congenital malformations of aortic and mitral valves • Q24 Other congenital malformations of heart • Q25
Congenital malformations of great arteries • Q26 Congenital malformations of great veins • Q27 Other congenital
malformations of peripheral vascular system• Q28 Other congenital malformations of circulatory system • I00-
I02 Acute rheumatic fever • I05-I09 • Chronic rheumatic heart diseases Nonrheumatic mitral valve disorders
mitral (valve): • disease (I05.9) • failure (I05.8) • stenosis (I05.0). When of unspecified cause but with mention
of: • diseases of aortic valve (I08.0), • mitral stenosis or obstruction (I05.0) when specified as congenital (Q23.2,
Q23.3) when specified as rheumatic (I05), I34.0Mitral (valve) insufficiency • Mitral (valve): incompetence /
regurgitation - • NOS or of specified cause, except rheumatic, I 34.1to I34.9 - Valvular heart disease.
5 Cerebrovascular disease I67 Other cerebrovascular diseases, (I60-I69) Cerebrovascular diseases
(Stroke)
6 Inflammatory Bowel K 50.0 to K 50.9 (including Crohn's and Ulcerative colitis)
Diseases K50.0 - Crohn's disease of small intestine; K50.1 -Crohn's disease of large intestine; K50.8 - Other
Crohn's disease; K50.9 - Crohn's disease,
unspecified. K51.0 - Ulcerative (chronic) enterocolitis; K51.8 -Other ulcerative colitis; K51.9 - Ulcerative
colitis,unspecified.
7 Chronic Liver diseases K70.0 To K74.6 Fibrosis and cirrhosis of liver; K71.7 - Toxic liver disease with fibrosis and
cirrhosis of liver; K70.3 - Alcoholic cirrhosis of liver; I98.2 - K70.-Alcoholic liver disease; Oesophagealvarices
in diseases classified elsewhere. K 70 to K 74.6 (Fibrosis, cirrhosis, alcoholic liver disease, CLD)
8 Pancreatic diseases K85-Acute pancreatitis; (Q 45.0 to Q 45.1) Congenital conditions of pancreas, K 86.1 to K 86.8 - Chronic
pancreatitis
9 Chronic Kidney disease N17-N19) Renal failure; I12.0 - Hypertensive renal disease with renal failure; I12.9 Hypertensive renal disease
without renal failure; I13.1 - Hypertensive heart and renal disease with renal failure; I13.2 - Hypertensive heart
and renal disease with both (congestive) heart failure and renal failure; N99.0 - Post procedural renal failure;
O08.4 - Renal failure following abortion and ectopic and molar pregnancy; O90.4 - Postpartum acute renal
failure; P96.0 - Congenital renal failure. Congenital malformations of the urinary system (Q 60 to Q64), diabetic
nephropathy E14.2, N.083
10 Hepatitis B B16.0 - Acute hepatitis B with delta-agent (coinfection) with hepatic coma; B16.1 – Acute hepatitis B with delta-
agent (coinfection) without hepatic coma; B16.2 - Acute hepatitis B without delta-agent with hepatic coma;
B16.9 –Acute hepatitis B without delta-agent and without hepatic coma; B17.0 - Acute delta-(super) infection of
hepatitis B carrier; B18.0 -Chronic viral hepatitis B with delta-agent; B18.1 -Chronic viral hepatitis B without
delta-agent;
11 Alzheimer's Disease, G30.9 - Alzheimer's disease, unspecified; F00.9 -G30.9Dementia in Alzheimer's disease, unspecified, G20 -
Parkinson's Disease Parkinson's disease.
12 Demyelinating disease G.35 to G 37
13 HIV & AIDS B20.0 - HIV disease resulting in mycobacterial infection; B20.1 - HIV disease resulting in other bacterial
infections; B20.2 - HIV disease resulting in cytomegaloviral disease; B20.3 - HIV disease resulting in other viral
infections; B20.4 - HIV disease resulting in candidiasis; B20.5 - HIV disease resulting in other mycoses; B20.6 -
HIV disease resulting in Pneumocystis carinii pneumonia; B20.7 - HIV disease resulting in multiple infections;
B20.8 - HIV disease resulting in other infectious and parasitic diseases; B20.9 - HIV disease resulting in
unspecified infectious or parasitic disease; B23.0 - Acute HIV infection syndrome; B24 - Unspecified human
immunodeficiency virus [HIV] disease
14 Loss of Hearing H90.0 - Conductive hearing loss, bilateral; H90.1 - Conductive hearing loss, unilateral with unrestricted hearing
on the contralateral side; H90.2 - Conductive hearing loss, unspecified; H90.3 - Sensorineural hearing loss,
bilateral; H90.4 - Sensorineural hearing loss, unilateral with unrestricted hearing on the contralateral side; H90.6
- Mixed conductive and sensorineural hearing loss, bilateral; H90.7 - Mixed conductive and sensorineural
hearing loss, unilateral with unrestricted hearing on the contralateral side; H90.8 - Mixed conductive and
sensorineural hearing loss, unspecified; H91.0 - Ototoxic hearing loss; H91.9 - Hearing loss, unspecified
15 Papulosquamous disorder L40 - L45 Papulosquamous disorder of the skin including psoriasis lichen planus
of the skin
16 Avascular necrosis
M 87 to M 87.9
. (osteonecrosis)

National Insurance Co. Ltd. Page | 15 Vidyarthi Mediclaim for Students


Regd. & Head Office: 3, Middleton Street, (UIN: NICHLIP21113V032021)
Kolkata 700071
Appendix III
The contact details of the Insurance Ombudsman offices are as below-
Office of the Insurance Ombudsman, Jaipur - 302 005.
Gujarat , UT of Dadra and Nagar
Jeevan Prakash Building, 6th Floor, Tel.: 0141 - 2740363
Haveli, Daman and Diu
Tilak Marg, Relief Road, Email: Bimalokpal.jaipur@ecoi.co.in
Ahmedabad-380001 Kerala , UT of(a) Lakshadweep, Office of the Insurance Ombudsman,
Tel: 079 -25501201/ 02/ 05/ 06 (b) Mahe – a part of UT of 2nd Floor, Pulinat Bldg.,
Email: Pondicherry Opp. Cochin Shipyard, M. G. Road,
bimalokpal.ahmedabad@ecoi.co.in Ernakulam - 682 015.
Office of the Insurance Ombudsman, Tel.: 0484 - 2358759 / 2359338
Karnataka
JeevanSoudhaBuilding,PID No. 57- Fax: 0484 - 2359336
27-N-19 Email:
Ground Floor, 19/19, 24th Main bimalokpal.ernakulam@ecoi.co.in
Road, West Bengal, UT of Andaman Office of the Insurance Ombudsman,
JP Nagar, Ist Phase, and Nicobar Islands, Sikkim Hindustan Bldg. Annexe, 4th Floor,
Bengaluru – 560 078. 4, C.R. Avenue,
Tel.: 080 - 26652048 / 26652049 KOLKATA - 700 072.
Email: Tel.: 033 - 22124339 / 22124340
bimalokpal.bengaluru@ecoi.co.in Fax : 033 - 22124341
Madhya Pradesh and Office of the Insurance Ombudsman, Email: bimalokpal.kolkata@ecoi.co.in
Chhattisgarh JanakVihar Complex, 2nd Floor, Districts of Uttar Pradesh : Office of the Insurance Ombudsman,
6, Malviya Nagar, Opp. Airtel Office, Laitpur, Jhansi, Mahoba, 6th Floor, JeevanBhawan, Phase-II,
Near New Market, Hamirpur, Banda, Chitrakoot, Nawal Kishore Road, Hazratganj,
Bhopal – 462 003. Allahabad, Mirzapur, Lucknow - 226 001.
Tel.: 0755 - 2769201 / 2769202 Sonbhabdra, Fatehpur, Tel.: 0522 - 2231330 / 2231331
Fax: 0755 - 2769203 Pratapgarh, Jaunpur,Varanasi, Fax: 0522 - 2231310
Email: bimalokpal.bhopal@ecoi.co.in Gazipur, Jalaun, Kanpur, Email:
Odisha Office of the Insurance Ombudsman, Lucknow, Unnao, Sitapur, bimalokpal.lucknow@ecoi.co.in
62, Forest park, Lakhimpur, Bahraich, Barabanki,
Bhubneshwar – 751 009. Raebareli, Sravasti, Gonda,
Tel.: 0674 - 2596461 /2596455 Faizabad, Amethi, Kaushambi,
Fax: 0674 - 2596429 Balrampur, Basti,
Email: Ambedkarnagar, Sultanpur,
bimalokpal.bhubaneswar@ecoi.co.in Maharajgang, Santkabirnagar,
Punjab , Haryana, Himachal Office of the Insurance Ombudsman, Azamgarh, Kushinagar,
Pradesh, Jammu and Kashmir, S.C.O. No. 101, 102 & 103, 2nd Gorkhpur, Deoria, Mau,
UT of Chandigarh Floor, Ghazipur, Chandauli, Ballia,
Batra Building, Sector 17 – D, Sidharathnagar.
Chandigarh – 160 017. Goa, Office of the Insurance Ombudsman,
Tel.: 0172 - 2706196 / 2706468 Mumbai Metropolitan Region 3rd Floor, JeevanSevaAnnexe,
Fax: 0172 - 2708274 excluding Navi Mumbai & Thane S. V. Road, Santacruz (W),
Email: Mumbai - 400 054.
bimalokpal.chandigarh@ecoi.co.in Tel.: 022 - 26106552 / 26106960
Tamil Nadu, UT–Pondicherry Office of the Insurance Ombudsman, Fax: 022 - 26106052
Town and Karaikal (which are Fatima Akhtar Court, 4th Floor, 453, Email:
part of UT of Pondicherry) Anna Salai, Teynampet, bimalokpal.mumbai@ecoi.co.in
CHENNAI – 600 018. State of Uttaranchal and the Office of the Insurance Ombudsman,
Tel.: 044 - 24333668 / 24335284 following Districts of Uttar BhagwanSahai Palace
Fax: 044 - 24333664 Pradesh: 4th Floor, Main Road,
Email: Agra, Aligarh, Bagpat, Bareilly, Naya Bans, Sector 15,
bimalokpal.chennai@ecoi.co.in Bijnor, Budaun, Bulandshehar, Distt: GautamBuddh Nagar,
Delhi Office of the Insurance Ombudsman, Etah, Kanooj, Mainpuri, Mathura, U.P-201301.
2/2 A, Universal Insurance Building, Meerut, Moradabad, Tel.: 0120-2514250 / 2514251 /
Asaf Ali Road, Muzaffarnagar, Oraiyya, Pilibhit, 2514253
New Delhi – 110 002. Etawah, Farrukhabad, Firozbad, Email: bimalokpal.noida@ecoi.co.in
Tel.: 011 - 23232481 / 23213504 Gautambodhanagar, Ghaziabad,
Email: bimalokpal.delhi@ecoi.co.in Hardoi, Shahjahanpur, Hapur,
Assam , Meghalaya, Manipur, Office of the Insurance Ombudsman, Shamli, Rampur, Kashganj,
Mizoram, Arunachal Pradesh, JeevanNivesh, 5th Floor, Sambhal, Amroha, Hathras,
Nagaland and Tripura Nr. Panbazar over bridge, S.S. Road, Kanshiramnagar, Saharanpur
Guwahati – 781001(ASSAM). Bihar, Office of the Insurance Ombudsman,
Tel.: 0361 - 2132204 / 2132205 Jharkhand. 1st Floor,Kalpana Arcade Building,,
Fax: 0361 - 2732937 Bazar Samiti Road,
Email: Bahadurpur,
bimalokpal.guwahati@ecoi.co.in Patna 800 006.
Andhra Pradesh, Telangana and Office of the Insurance Ombudsman, Tel: 0612-2680952
UT of Yanam – a part of the UT 6-2-46, 1st floor, "Moin Court", Email: bimalokpal.patna@ecoi.co.in
of Pondicherry Lane Opp. Saleem Function Palace, Maharashtra, Office of the Insurance Ombudsman,
A. C. Guards, Lakdi-Ka-Pool, Area of Navi Mumbai and Thane JeevanDarshan Bldg., 3rd Floor,
Hyderabad - 500 004. excluding Mumbai Metropolitan C.T.S. No.s. 195 to 198,
Tel.: 040 - 65504123 / 23312122 Region N.C. Kelkar Road, Narayan Peth,
Fax: 040 - 23376599 Pune – 411 030.
Email: Tel.: 020 - 32341320
bimalokpal.hyderabad@ecoi.co.in Email: bimalokpal.pune@ecoi.co.in
Rajasthan Office of the Insurance Ombudsman,
JeevanNidhi – II Bldg., Gr. Floor,
Bhawani Singh Marg,

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