Senior Citizen Health Insurance Plan

MediSenior – Senior Citizen Health Insurance Plan

 
UIN: IRDA/NL-HLT/TAGI/P-H/V.I/98/13-14

Good Health is a must for all, as it becomes a major concern once age advances. A major reason for this is that once a person crosses retirement age steady income stops and any expenses due to health problems eats into the savings. Tata AIG General Insurance Company Limited understands this need and brings to you MediSenior, an open, transparent and comprehensive medical insurance especially for senior citizens so after retirement you can focus on your good health without any financial worry

 
 

Salient Features of Medisenior

 
  • In – patient hospitalization including room rent, ICU, nursing, medicines drugs & consumables covered.
  • Pre and Post Hospitalization medical expenses: Expenses incurred upto 30 days immediately before hospitalization and upto 60 days immediately after discharge are covered.
  • Day Care Procedures: The policy covers medical expenses for 140 different day care treatments which do not require 24 hours hospitalization.
  • Domiciliary Treatment: The policy covers for the medical expenses incurred for availing medical treatment at home which would otherwise have required Hospitalisation. This is applicable only when attending medical practioner advises that insured person could not be transferred to hospital of hospital bed was unavailable .
  • Organ Donor The policy covers inpatient medical expenses incurred on the insured (i.e recipient) and the organ donor for harvesting.
  • Emergency Ambulance: Actual expenses incurred or Rs. 2000/- whichever is lower per hospitalisation for utilizing ambulance service for transporting insured person from a hospital to the nearest hospital.which is prepared to provide necessary services .
  • Portability: If you are insured continuously and without interruption under any individual health insurance policy of an Indian non-life insurance company and you want to shift to us on renewal, MediSenior Policy offers you transfer of the accrued benefits and make due allowances for waiting periods etc. If the Insured person transfers from any other insurer and increases the Sum Insured, then the portability benefits will be offered only in respect to the previous sum insured.
  • Settlement of your claims :We settle your claims hassle free and quickly so that you can focus on quality and timely recovery rather than managing the funding of the treatment ,subject to submission of all required documents .
  • Network of Hospitals: We are equipped to offer you quality health care in your city with our strong network of 3000+ hospitals across India. Kindly carry original photo identity proof along with cashless card to avail cashless hospitalization in network hospitals .
    Click here to view the list of network
  • Lifelong Renewal :We offer you a lifelong renewal for your policy provided premium is paid prior to policy expiry or within grace period . Your renewal premium will be basis the age and coverage Your renewal premium will be basis your revised age band and there will no extra loadings based on your individual claim .
  • Tax savings - If one purchases a health insurance policy for self /spouse/children, he/she can claim a tax deduction of upto Rs. 25000. When one purchases a health insurance policy for parents (a senior citizen), he/she is eligible for an additional tax deduction benefit upto Rs. 30,000. These benefits are covered under section 80D of Income Tax Act 1961. Tax benefits are subject to changes in tax laws.
  • No Claims Discount :5% non cumulative discount will be offered on the premium payable at each renewal after every claim free policy year provided policy is renewed by us without any break .
 
 
What is not covered under Tata AIG General Insurance Company Limited MediSenior cover?
 
  • War or any act of war, invasion, act of foreign enemy, war like operations (whether war be declared or not or caused during service in the armed forces of any country), civil war, public defence, rebellion, revolution, insurrection, military or usurped acts, nuclear weapons/materials, chemical and biological weapons, radiation of any kind.
  • Any Insured Person committing or attempting to commit a breach of law with criminal intent, or intentional self injury or attempted suicide while sane or insane.
  • Any Insured Person’s participation or involvement in naval, military or air force operation, racing, diving, aviation, scuba diving, parachuting, hang-gliding, rock or mountain climbing.
  • The abuse or the consequences of the abuse of intoxicants or hallucinogenic substances such as intoxicating drugs and alcohol, including smoking cessation programs and the treatment of nicotine addiction or any other substance abuse treatment or services, or supplies.
  • Treatment of Obesity and any weight control program.
  • Psychiatric, mental disorders (including mental health treatments); Parkinson and Alzheimer’s disease; general debility or exhaustion (“run-down condition”); congenital internal or external diseases(known /unknown), defects or anomalies; genetic disorders; stem celltherapy or surgery; or growth hormone therapy; sleep-apnoea.
  • Venereal disease, sexually transmitted disease or illness; “AIDS” (Acquired Immune Deficiency Syndrome) and/or infection with HIV (Human immunodeficiency virus) including but not limited to conditions related to or arising out of HIV/AIDS such as ARC (AIDS related complex), Lymphomas in brain, Kaposi’s sarcoma, tuberculosis.
  • Pregnancy (including voluntary termination), miscarriage (except as a result of an Accident or Illness), maternity or birth (including caesarean section) except in the case of ectopic pregnancy in relation to Inpatient Treatment only.
  • Sterility, treatment whether to effect or to treat infertility; any fertility, sub-fertility or assisted conception procedure; surrogate or vicarious pregnancy; birth control, contraceptive supplies or services including complications arising due to supplying services.
  • Dental treatment and surgery of any kind, other than accident and requiring Hospitalisation
  • Expenses for donor screening, or, save as and to the extent provided for in Organ Donor benefit, the treatment of the donor (including surgery to remove organs from a donor in the case of transplant surgery).
  • Treatment and supplies for analysis and adjustments of spinal subluxation; diagnosis and treatment by manipulation of the skeletal structure; muscle stimulation by any means except for treatment of fractures (excluding hairline fractures) and dislocations of the mandible and extremities.
  • circumcisions (unless necessitated by illness or injury and forming part of treatment); laser treatment for correction of eye due to refractive error; aesthetic or change-of-life treatments of any description such as sex transformation operations, treatments to do or undo changes in appearance or carried out in childhood or at any other times driven by cultural habits, fashion or the like or any procedures which improve physical appearance.
  • Plastic surgery or cosmetic surgery unless necessary as a part of medically necessary treatment certified by the attending Medical Practitioner for reconstruction following an Accident, Cancer or Burns.
  • Experimental, investigational or unproven treatment, devices and pharmacological regimens; measures primarily for diagnostic, X-ray or laboratory examinations or other diagnostic studies which are not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any Illness for which confinement is required at a Hospital.
  • Measures primarily for diagnostic, X-ray or laboratory examinations or other diagnostic studies which are not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any Illness for which confinement is required at a Hospital.
  • Convalescence, cure, rest cure, sanatorium treatment, rehabilitation measures, private duty nursing, respite care, long-term nursing care or custodial care.
  • Any non allopathic treatment.
  • All preventive care, vaccination including inoculation and immunisations unless certified to be required by the attending Medical Practitioner as part of in-patient treatment as a direct consequence of an otherwise covered claim; any physical, psychiatric or psychological examinations or testing; enteral feedings (infusion formulae via a tube into the upper gastrointestinal tract) and other nutritional and electrolyte supplements, unless certified to be required by the attending Medical Practitioner as a direct consequence of an otherwise covered claim.
  • Charges related to a Hospital stay not expressly mentioned as being covered, including but not limited to charges for admission, discharge, administration, registration, documentation and filing.
  • Items of personal comfort and convenience including but not limited to television (wherever specifically charged for), charges for access to telephone and telephone calls (wherever specifically charged for), internet, foodstuffs (except patient’s diet), cosmetics, hygiene articles, body care products and bath additive, barber or beauty service, guest service as well as similar incidental services and supplies, and vitamins and tonics unless vitamins and tonics are certified to be required by the attending Medical Practitioner as a direct consequence of an otherwise covered claim.
  • Treatment rendered by a Medical Practitioner which is outside his discipline or the discipline for which he is licensed; treatments rendered by a Medical Practitioner who shares the same residence as an Insured Person or who is a member of an Insured Person's family, however proven material costs are eligible for reimbursement in accordance with the applicable cover.
  • Provision or fitting of hearing aids, spectacles or contact lenses including optometric therapy, any treatment and associated expenses for alopecia, baldness, wigs, or toupees, medical supplies including elastic stockings, diabetic test strips, and similar products.
  • Any treatment or part of a treatment that is not of a reasonable charge, not medically necessary; drugs or treatments which are not supported by a prescription.
  • Artificial limbs, crutches or any other external appliance and/or device used for diagnosis or treatment (except when used intra-operatively).
  • Any specific time bound or lifetime exclusion(s) applied by us and mentioned in the Schedule and accepted by the insured as per Our underwriting guidelines.
  • Non medical expenses as per Annexure II of the policy wordings
Frequently Asked Questions
 

Q1. What is the Entry Age applicable for Medisenior ?

The minimum entry age under this policy is 61 years and above.

Q2. What are the Policy Term Options available in Medisenior ?

The policy will be issued either for a period of 1 year or 2 years.

Q3. What is the waiting period applicable for Medisenior ?

 

  • 30 days for all illnesses (except accident) in the first year and is not applicable in Section 3 C b) subsequent renewals.
  • 24 months for specific illness and treatments in the first two years and is not applicable in subsequent renewals Section 3 C c)
  • Pre-existing Diseases will be covered after a waiting period 48 months and it will get reduced by 1 year on every continuous renewal of your policy Payout. Please refer Section 3 C d) for detailed information.
  • We offer life-long renewal subject to application for renewal and the renewal premium in full has been received by the due dates and realisation of premium, unless the Insured Person or any one acting on behalf of an Insured Person has acted in an improper, dishonest or fraudulent manner or any misrepresentation or non cooperation under or in relation to this policy or the policy poses a moral hazard.

 

Q4. What are the renewal conditions in the policy

 

    Terms of Renewal:
  • We offer life-long renewal unless the Insured Person or any one acting on behalf of an Insured Person has acted in an improper, dishonest or fraudulent manner or any misrepresentation under or in relation to this policy or the policy poses a moral hazard.
  • Grace Period - Grace Period of 30 days for renewing the policy is provided under this policy.
  • Maximum Age – There is no maximum cover ceasing age in this policy.
  • Waiting Period - The Waiting Periods mentioned in the policy wording will get reduced by 1 year on every continuous renewal of your MediSenior policy.
  • Renewal Premium –. Your renewal premium for this policy will not change unless we have revised the premium and obtained due approval from IRDA.. Any change in benefits or premium (other than due to change in Age) will be done with the approval of the Insurance Regulatory and Development Authority and will be intimated atleast 3 months in advance.
     
  • Premium at renewal will also change if you move into a higher age group, opt for a higher sum insured, change the term or change the plan
  • Sum Insured Enhancement – Sum insured can be enhanced only at the time of renewal subject to no claim have been lodged/ paid under the policy. If the insured enhances the basic sum insured one grid up, no fresh medicals shall be required. In cases where the basic sum insured enhanced is more than one grid up, the case shall be subject to medicals. In case of enhancement in the basic sum insured waiting period will apply afresh in relation to the amount by which the basic sum insured has been enhanced. However the quantum of enhancement shall be at our sole discretion. Option to Migrate – There is an option to migrate to similar indemnity health insurance Policy with Us provided that:
    • Insured Person has been insured with Us.
    • This option for migration to similar Indemnity health insurance policy shall be exercised by the Insured Person only at the time of renewal only.
    • Insured Person will be offered continuity of coverage & suitable credits, if any, for all the previous policy years, provided the policy has been maintained without a break
  • In the likelihood of this policy being withdrawn in future, we will intimate you about the same 3months prior to expiry of the policy. You will have the option to migrate to similar indemnity health insurance policy available with us at the time of renewal with all the accrued continuity benefits such as cumulative bonus, waiver of waiting period etc. provided the policy has been maintained without a break as per portability guidelines issued by IRDA.

     

    Q5. What are the In-Patient (Hospitalization) Related Benefits offered in Medisenior

    The Medical Expenses for:

  • Room rent, boarding expenses,
  • Nursing,
  • Intensive care unit,
  • Medical Practitioner(s),
  • Anaesthesia, blood, oxygen, operation theatre charges, surgical appliances,
  • Medicines, drugs and consumables,
  • Diagnostic procedures, The Cost of prosthetic and other devices or equipment if implanted internally during a Surgical Procedure

     

    Q6. What are the renewal benefits provided in the policy ?

    No Claim Discount - A 5% non cumulative discount will be offered on the renewal premium payable under the Policy after every CLAIM FREE Policy Year, provided that the Policy is renewed with Us and without a break.

    Q7. What are the List of Documents for Claims Filing?

    (1) Signed Claim Form (2) First consultation letter and subsequent prescription (3) Original detailed discharge card (4) Day care summary from the hospital (5) Original Bills / Receipts from Hospital / Medicines / Investigations / Implants and any other document as required for processing claim (6)Original Photo identify proof along with the cashless card.

    Q8. What are the timeliness for claim settlement ?

    We shall make the payment of claim that has been admitted as payable by Us under the Policy terms and conditions within 30 days of submission of all necessary documents / information and any other additional information required for the settlement of the claim. All claims will be settled in accordance with the applicable regulatory guidelines, including IRDA (Protection of Policyholders Regulation), 2002. In case of delay in payment of any claim that has been admitted as payable by Us under the Policy terms and condition, beyond the time period as prescribed under IRDA (Protection of Policyholders Regulation), 2002, we shall pay interest at a rate which is 2% above the bank rate prevalent at the beginning of the financial year in which the claim is reviewed by Us. For the purpose of this clause, ‘bank rate’ shall mean the existing bank rate as notified by Reserve Bank of India, unless the extent regulation requires payment based on some other prescribed interest rate

    Q9. How can I claim

    Intimation & Assistance – Please contact our designated TPA atleast 48 hours prior to an event which might give rise to a claim. For any emergency situations, kindly contact our TPA within 24 hours of the event.
    Contact details for claims - Family Health Plan (TPA) Ltd. Claims Department, Tata AIG General Insurance Company Limited , Ground Floor, Srinilaya – Cyber Spazio, Road No: 2, Banjara Hills, Hyderabad Pin : 500 034.· FHPL Toll Free Number: 1800 425 4090 Toll Free: 1800-425-4033, Fax: +91-40-23541400 / 1800 22 9966 (Only for Senior Citizens)
    NOTE - Specified Third Party Administrator (TPA) licensed by IRDA will process all claims under this policy on behalf of Tata-AIG General Company Limited. The final decision on any claim solely rests with Tata-AIG General Insurance Company Limited.

    Q10. Is Pre-Policy checkup required before the policy issuance ?

    Pre-Policy Check-up at our network will be required. We will reimburse 50% of the expenses incurred per insured person on the acceptance of the proposal. The medical reports are valid for a period of 90 days from the date of Pre-Policy Check-up.

    Q11. Is co-payment applicable in the Medisenior policy ?

    a) Co-Payment applicable on accommodation type

    • Shared Accommodation or any lower accommodation type – 15%
    • Single occupancy or any higher accommodation type- 30%
    A Co-payment of 15% shall be applicable to all enlisted Day Care Procedures;

    b) Co-Payment applicable on specified Illnesses/surgeries

    If a claim has been admitted under Section I in respect of the specified illnesses/Surgeries mentioned in the policy schedule then a co pay of 30% would apply and claim payment, if any, shall only be in excess of that sum

     

    Note- If we accept a claim for above mentioned specified illnesses/surgeries then no additional Copayment shall be applicable for the same claim i.e at any given point of time , no two different Co-payment will be applied for a single claim.

    Q12. What are the timelines for Notification of Claims to Tata AIG or our Claims TPA

    Please contact our designated TPA atleast 48 hours prior to an event which might give rise to a claim.

    For any emergency situations, kindly contact our TPA within 24 hours of the event.

    Our TPA can be contacted through:

    - 24 x 7 Toll free line at:1-800-425-4033 / 040- 23552899 (for Senior Citizens)
    - E-mail at:info@fhpl.net / seniorcitizensdesk@fhpl.net (for Senior Citizens)
    - Fax at:040-23541400
    Post/ Courier to:
    Claims Department
    Family Health Plan Ltd
    Plot No. 25
    MCH No. 8-2-334
    Road No.-3, Azam Colony
    Banjara Hills,Hyderabad-500034
Track your Claims
 
How can I Claim?
 
  • Intimation & Assistance – Please contact our designated TPA atleast 48 hours prior to an event which might give rise to a claim. For any emergency situations, kindly contact our TPA within 24 hours of the event.
  • Contact details for claims - Family Health Plan (TPA) Ltd. Claims Department, Tata AIG General Insurance Company Limited , Ground Floor, Srinilaya – Cyber Spazio, Road No: 2, Banjara Hills, Hyderabad Pin : 500 034.
  • FHPL Toll Free Number: 1800 425 4090 Toll Free: 1800-425-4033,
    Fax: +91-40-23541400 / 1800 22 9966 (Only for Senior Citizens)
  • NOTE - Specified Third Party Administrator (TPA) licensed by IRDA will process all claims under this policy on behalf of Tata-AIG General Company Limited. The final decision on any claim solely rests with Tata-AIG General Insurance Company Limited.

Download Claim Form

Watch Claims Video

View & Download :Policy Wordings, Customer Information Sheet & Premium Table
 

 

 
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