MediPlus – Top-up Medical Health Insurance Plan

• 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 cell implantation 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 1)a) 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.
• 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, 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.
• The 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 specified in the Schedule and accepted by the insured as per Our underwriting guidelines
• Any non medical expenses as per Annexure II of the policy document

Q1. What is the Entry Age applicable for Mediplus ?

Entry age for Enrollment ins form 91 days to 65 year. Dependant child aged between 91 days and 21 years if they are unmarried are covered.Child between 91 days to 5 years can be insured only when either parent is getting insured under this policy Policy is however renewable for life upon payment of premium provided the cover is maintained with us without a break unless cancelled due to fraud or misrepresentation or non-cooperation.

Q2 What is the waiting period applicable for Mediplus?

• 30 days for all illnesses (except accident) in the first year and is not applicable in Section 2 b) subsequent renewals.
• 24 months for specific illness and treatments in the first two years and is not applicable in subsequent renewals Section 2 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 2 d) for detailed information.

Q3 What are the Policy Term Options available in Mediplus?

• The policy will be issued for 1 year /2 years period

Q4 What are the In-Patient (Hospitalization) Related Benefits offered in Mediplus

• 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
• cost of prosthetic & other devices or equipments if implanted internally during a surgical procedure.

  Q5 What are the timelines for Notification of Claims to Tata AIG General Insurance Company Limited 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
  

  Q 6 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.

  Q7 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 Interest Regulation), 2002. In case of any delay in payment as stated herein, We will pay you interest at the prevalent bank rate plus 2 % at the beginning of the financial year in which claim is settled. 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

  Q8 What are the renewal conditions applicable in the policy ?

  1. 30 days Grace Period (For renewals only).

  2. Policy coverage, terms, conditions and premium is subject to modification/revision from time to time. In the event of such a change you will be informed 3 months before the expiry of the policy. You will have the option to either continue with such modified product or migrate to similar 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.

  3. Option to Migrate- There is an option to migrate to similar health insurance Policy with Us provided that:
  i) Insured Person has been insured with Us for first time under this Policy as a dependant.
  This option for migration to similar health insurance policy shall be exercised by the Insured Person only when he / she is at the end of specified exit age, and certainly at the time of renewal only.
  ii) 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 all other cases, No benefits shall accrue to any Insured Person by virtue of continuity of coverage in the event of discontinuation of this Policy at any point of time or shifting to any other Health Insurance Policy with Us.

  4. The renewal premium for this policy will not change unless We have revised the premium and obtained due approval from IRDA Premium at renewal will also change if you move into a higher age group, opt for change of deductible or, change the term

  5. 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

Track your claims

• 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.

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