Group Hospitalisation & Surgical

 

	Group Hospitalisation & Surgical Coverage
	Policy Exclusions
	Exclusions
	Claims Procedures

 

 

Description

Group Hospitalisation & Surgical Coverage provides a tailor-made comprehensive health plan for any company/organisation who ensures that their employees are sufficiently protected. In certain instances, the Company may extend coverage to the employee's family for the benefit of the employees' welfare.

 

POLICY EXCLUSIONS

1) Pre-existing conditions shall mean :-

Disabilities that existed before the Effective date of Insurance of an Insured Person and for which the Insured is receiving treatment or shown manifestations/symptoms irrespective of whether the Insured was aware or should have reasonably been aware.

Consultation with a medical doctor for any sign or pain or discomfort shall constitute a manifestation or symptom of a disability.

2) SPECIFIED ILLNESSES shall mean the following disabilities and its related conditions, occuring within the first 12 months of Insurance of the Insured Person, irrespective of whether the Insured Person was aware or not;

i)	Stones in the urinary and biliary systems and cholecystitis
ii)	Hypertension and diabetes mellitus
iii)	Cardiovascular disease and varicose veins
iv)	Cataracts and pterygium
v)	Tumours of any kind, including cyst and malignant blood
vi)	All ear, nose (including sinuses) and throat (including tonsil and thyroid) conditions requiring surgery
vii)	Hernias, haemorrhoids, fistulae, hydrocele, varicocele
viii)	Systemic Lupus Erythematosus/Discoid Lupus Erythematosus, Epilepsy, Gastritis and peptic ulcer and erosion
ix)	Endometriosis including disease of the Reproductive System
x)	Prostate conditions requiring surgery
xi)	Vertebro_spinal disorders (including disc) and knee conditions; not accompanied by fractures but requiring surgery

EXCLUSIONS

The Policy shall not cover :

1. Pre-existing conditions.

2. Specified Illnesses for the first 12 months of continuous cover. After 12 months of continuous cover, the Insured shall be eligible for benefit provided such conditions has not occurred and Insured has not consulted any doctor for the purpose of medical treatment, medication (including drugs, medicines, special diet or injection) or advice for the condition or any related condition during the first 12 months of cover.

3. Any medical or physical conditions arising within the first 30 days of the Insured Person's cover except for accidental injuries.

4. Care or treatment for which payment is not required or to the extent which is payable by any other insurance or indemnity covering the Insured and Disabilities arising out of duties of employment or profession that is covered under a Workman's Compensation Insurance Contract.

5. Plastic/Cosmetic surgery, circumcision, eye examination, glasses and refraction or surgical correction of nearsightedness (Radial Keratotomy) and the use or acquisition of external prosthetic appliances or devices such as artificial limbs, hearing aids, implanted pacemakers and prescriptions thereof.

6. Dental conditions including dental treatment or oral surgery except as necessitated by Accidental Injuries to sound natural teeth occurring wholly during the Period of Insurance.

7. Private nursing, rest cures or sanitaria care, illegal drugs, intoxication, sterilisation, venereal disease and its sequelae, AIDS (Acquired Immune Deficiency Syndrome) or ARC (AIDS Related Complex) and HIV related diseases.

8. Any treatment or surgical operation for congenital abnormalities or deformities including hereditary conditions.

9. Pregnancy, child birth (including surgical delivery), miscarriage, abortion and prenatal or postnatal care and surgical, mechanical or chemical contraceptive methods of birth control or treatment pertaining to infertility. Erectile dysfunction and tests or treatment related to impotence or sterilisation.

10. Psychotic, mental or nervous disorders, (including any neuroses and their physiological or psychosomatic manifestations).

11. Hospitalisation primarily for investigatory purposes, diagnosis, X-ray examinations, general physical or medical examinations, not incidental to treatment or diagnosis of a covered Disability or any treatment which is not Medically Necessary and any preventive treatments, preventive medicines or examinations carried out by a Physician, and treatments specifically for weight reduction or gain.

12. Costs/expenses of services of a non-medical nature, such as television, telephones, telex services, radios or similar facilities.

13. Sickness or Injury arising from racing of any kind (except foot racing), skydiving, water skiing, underwater activities requiring breathing apparatus, winter sports, professional sport and illegal activities.

14. Suicide, attempted suicide or intentionally self-inflicted injury while sane or insane.

15. Private flying other than as a fare-paying passenger in any commercial scheduled airlines licensed to carry passengers over established routes.

16. War or any act of war, declared or undeclared, criminal or terrorist activities, active duty in any armed forces, direct participation in strikes, riots and civil commotion or insurrection.

17. Ionising radiation or contamination by radioactivity from any nuclear fuel or nuclear waste from process of nuclear fission or from any nuclear weapons material.

18. Expenses incurred for donation of any body organ by an Insured Person and costs of acquisition of the organ including all costs incurred by the donor during organ transplant.

19. Expenses incurred for sex change.

20. Investigation and treatment of sleep disorders, and hormone replacement therapy for menopausal conditions.

WAR AND TERRORISM EXCLUSION CLAUSE

It is hereby declared and agreed that this policy shall not cover hospitalisation and incurred medical expenses or any other loss caused directly or indirectly occasioned by happening through or consequence of:-

(1) War, invasion, acts of foreign enemies, hostilities or warlike operations (whether war be declared or not), civil war, rebellion, revolution, insurrection, riot strike civil commotion assuming the proportions of or amounting to an uprising, military or usurped power; or

(2) any act of terrorism
For the purpose of this exclusion and act of terrorism means an act, including but not limited to the use of force or violence and/or the threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organisation(s) or government(s), committed for political, religious, ideological or similar purposes including the intention to influence any government and/or to put the public, or any section of the public, in fear.

This exclusion also excludes hospitalisation and incurred medical expenses whatsoever nature directly or indirectly caused by resulting from or in connection with any action taken in controlling, preventing, suppressing or in any way relating to (1) and/or (2) above.

If the Company alleges that by reason of this exclusion any hospitalisation and incurred medical expenses is not covered by this insurance, the burden of proving the contrary shall be upon the Insurred.
In the event any portion of this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect.

Subject otherwise to the terms exceptions and conditions of this policy.

RIOT STRIKE AND CIVIL COMMOTION CLAUSE
Notwithstanding anything contained herein to the contrary it is hereby declared and agreed that this Policy is hereby extended to cover hospitalisation and incurred eligible medical expenses as herein defined due to :-

1. Riot Strike and Civil Commotion provided the Insurred Person is not directly or indirectly participating in such activities.

2. Riot Strike and Civil Commotion for the purpose of this Clause

i) The act of any person taking part together with others in any disturbance of the public peace (whether in connection with a strike or lock-out or not).

ii) The action of any lawfully constituted authority in suppressing or attempting to suppress any such disturbance or in minimizing the consequence of any such disturbance.

iii) The wilful act of any striker or locked-out worker done in furtherance of a strike or in resistance to a lock-out.

iv) The action of any lawfully constituted authority in preventing or attempting to prevent any such act or in minimizing the consequences of any such act.


3.Provided this Clause shall not apply to any Hospitalisation and incurred medical expenses or any other loss directly or indirectly proximately or remotely occasioned by contributed to by or traceable to or arising out of or in connection with:-

i) war, invasion, acts of foreign enemies, hostilities or warlike operations (whether war be declared or not), civil war, rebellion, revolution, insurrection, civil commution assuming the proportions of or amounting to an uprising, military or usurped power; or

ii) any act of terrorism.

Subject otherwise to the terms exceptions and conditions of this policy.

CLAIMS PROCEDURES

Notification of Loss

In the event of claims, you are to give notification in writing within 30 days of a Disability and to provide the policy number and the name of the insured/claimant.

Documentation to be provided to expedite the claim process:

1. Claim Form
2. Original bills and receipts
3. Medical report
4. Any other relevant documents