National Insurance Company Limited

CIN - U10200WB1906GOI001713 IRDAI Regn. No. – 58

National Mediclaim Plus Policy

PROSPECTUS
1.1 Product
The policy covers expenses for inpatient treatment (cashless/reimbursement) reasonably and customarily incurred for treatment of
illness/disease or injury contracted/sustained during the policy period. The policy covers medical expenses for 30 (thirty) days of
pre hospitalisation, 60 (sixty) days of post hospitalization, 140+ day care procedures/surgeries, ayurveda and homeopathy
treatment, organ donor’s medical expenses, maternity, hospital cash ambulance, air ambulance, medical emergency reunion,
vaccination for children and medical second opinion.
The policy also provides optional covers for Critical Illness and Out-patient Treatment.

1.2 Coverage
The coverage depends on the plan opted as shown in the Table of Benefits.

1.2.1 In-patient Treatment

The company shall pay to the hospital or reimburse the insured, in respect of the medical expenses for:
i. Room charges and intensive care unit charges (including diet charges, nursing care by qualified nurse, RMO charges,
administration charges for IV fluids/blood transfusion/injection), subject to limit as mentioned in Section 1.2.1.1
ii. Medical practitioner(s)
iii. Anaesthesia, blood, oxygen, operation theatre charges, surgical appliances
iv. Medicines and drugs
v. Diagnostic procedures
vi. Prosthetics and other devices or equipment if implanted internally during a surgical procedure.

1.2.1.1 Limit for Room Charges and Intensive Care Unit Charges
Room charges and intensive care unit charges payable shall be up to the limit mentioned in the Table of Benefits. The limit shall
not apply if treatment is taken in a Preferred Provider Network (PPN) as a package.

1.2.1.2 Limit for Cataract Surgery

Company’s liability for cataract surgery shall be up to the limit mentioned in the Table of Benefits. The limit shall not apply if
treatment is taken in a Preferred Provider Network (PPN) as a package.

1.2.1.3 Treatment related to Participation as a Non-Professional in Hazardous or Adventure Sports

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 lower of 25% of Sum Insured.

1.2.2 Pre Hospitalisation

The company shall reimburse the insured in respect of the medical expenses incurred up to 30 (thirty) days immediately before the
insured person is hospitalised, 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
Pre hospitalisation shall be considered as part of hospitalisation claim.

1.2.3 Post Hospitalisation

The company shall reimburse the insured in respect of the medical expenses incurred up to 60 (sixty) days immediately after the
insured person is discharged from hospital, 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
Post hospitalisation shall be considered as part of hospitalisation claim.

1.2.4 Day Care Procedure

The company shall pay to the hospital in respect of the medical expenses or reimburse the insured in respect of the medical
expenses and pre and post hospitalisation expenses, for day care procedures which require hospitalisation for less than 24 (twenty
four) hours provided that
i. day care procedures/surgeries where such treatment is taken by an insured person in a hospital/day care centre (but not the
outpatient department of a hospital)
ii. any other surgeries/procedures which due to advancement of medical science require hospitalisation for less than 24 (twenty
four) hours and for which prior approval from company/TPA is mandatory.

1.2.5 Ayurveda and Homeopathy

The company shall pay to the hospital in respect of the medical expenses or reimburse the insured in respect of the medical
expenses pre and post hospitalisation expenses, incurred for Ayurveda and Homeopathy treatment up to the limit as mentioned in
the Table of Benefits provided treatment is taken in an Ayush Hospital.

National Insurance Co. Ltd.

National Mediclaim Plus Policy
Regd. & Head Office: 3, Middleton Street, Page | 1
(UIN: NICHLIP21150V022021)
Kolkata 700071
1.2.6 Organ Donor’s Medical Expenses
The company shall reimburse the insured in respect of expenses of hospitalisation of organ donor during the course of organ
transplant of the insured person provided that
i. the donation conforms to ‘The Transplantation of Human Organs Act 1994’ and the organ is for the use of the insured person
ii. the insured person has been medically advised to undergo an organ transplant.

Exclusions
The company shall not be liable to make any payment in respect of any expenses incurred in connection with or in respect of
1. Cost of the organ to be transplanted.
2. Organ donor’s pre and post hospitalisation expenses, as per Section 1.2.2 and Section 1.2.3.

1.2.7 Maternity
The company shall pay to the hospital or reimburse the insured in respect of medical expenses, incurred as an in-patient, with
respect to delivery or termination up to first two deliveries or terminations of pregnancy, after the policy has been continuously in
force for 24 (twenty four) months, during the lifetime of the insured or the spouse of the insured, if covered under the policy, as
described below, up to the limit mentioned in the Table of Benefits.
i. Medical expense for delivery (normal or caesarean).
ii. Medical expense for lawful medical termination of pregnancy.
iii. Medical expenses for pre natal medically necessary hospitalisation, up to 30 (thirty) days and post natal medically necessary
hospitalisation, up to 60 (sixty) days, per delivery or lawful termination of pregnancy, if incurred as an in-patient.
iv. Medical expenses of the new born baby, including expenses with respect to vaccination. Hospitalisation is not required for
vaccination of new born baby.

Exclusions
The company shall not be liable to make any payment in respect of any expenses incurred in connection with or in respect of
1. Delivery or termination within 2 (two) years of continuous coverage from the inception of the policy, or from the date of
inclusion of insured person, whichever is later. However, this period can be waived only in the case of delivery, miscarriage
or abortion induced by accident or other medical emergency.
2. More than one delivery or termination in a policy period.
3. Ectopic pregnancy. However, ectopic pregnancy is covered under Section 1.2.1 provided it may be established by medical
reports.
4. Pre and post hospitalisation expenses as per Section 1.2.2 and Section 1.2.3, other than pre and post natal treatment.

1.2.8 Hospital Cash

The company shall pay the insured a daily hospital cash allowance up to the limit mentioned in the Table of Benefits for a
maximum of 5 (five) days, provided
i. hospitalisation exceeds 3 (three) days and starts within the policy period.
ii. a claim has been admitted under Section 1.2.1.

1.2.9 Ambulance
The company shall reimburse the insured in respect of expenses incurred for transportation of the insured person to the hospital by
ambulance up to the limit as mentioned in the Table of Benefits, provided a claim has been admitted under Section 1.2.1.

1.2.10 Air Ambulance

The company shall reimburse the insured in respect of expenses incurred for medical evacuation of the insured person by air
ambulance to the nearest hospital or from one hospital to another hospital following an emergency up to the limit mentioned in the
Table of Benefits, provided prior intimation is given to the company/TPA, and a claim has been admitted under Section 1.2.1.

1.2.11 Medical Emergency Reunion

In the event of the insured person being hospitalised in a place away from the place of residence for more than 5 (five) continuous
days in an intensive care unit for any life threatening condition, the company after obtaining confirmation from the attending
medical practitioner, of the need of a ‘family member’ to be present, shall reimburse the expenses of a round trip economy class
air ticket, or first class railway ticket up to the limit mentioned in the Table of Benefits in a policy period to allow a family
member.
For the purpose of the Section, ‘family member’ shall mean spouse, children and parents of the insured person.

1.2.12 Doctor’s Home Visit and Nursing Care during Post Hospitalisation
The company shall reimburse the insured, medically necessary expenses incurred for doctor’s home visit charges, nursing care by
qualified nurse during post hospitalisation up to the limit mentioned in the Table of Benefits.

1.2.13 Vaccination for Children

The company shall reimburse the insured, in respect to expenses incurred for vaccinations of children (up to 12 years), up to the
limit mentioned in the Table of Benefits, provided the children are covered under the policy. Hospitalisation is not required for
this benefit.

1.2.14 HIV/ AIDS Cover

The Company shall indemnify the Hospital or the Insured the Medical Expenses (including Pre and Post Hospitalisation
Expenses) related to following stages of HIV infection:
National Insurance Co. Ltd.
National Mediclaim Plus Policy
Regd. & Head Office: 3, Middleton Street, Page | 2
(UIN: NICHLIP21150V022021)
Kolkata 700071
i. Acute HIV infection – acute flu-like symptoms
ii. Clinical latency – usually asymptomatic or mild symptoms
iii. AIDS – full-blown disease; CD4 < 200

1.2.15 Mental Illness Cover

The Company shall indemnify the Hospital or the Insured the 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 or a professional having a post-graduate degree (Ayurveda)
in Mano Vigyan Avum Manas Roga or a post-graduate degree (Homoeopathy) in Psychiatry.

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.

1.2.16 Modern Treatment

The Company shall pay to the hospital or reimburse the insured the medical expenses for In-Patient Care (admissible as per
Section 1.2.1) or Day Care Procedure (admissible as per Section 1.2.4) along with pre hospitalisation expenses (admissible as per
Section 1.2.2) and post hospitalisation expenses (admissible as per Section 1.2.3) incurred for following Modern Treatments
(wherever medically indicated), subject to Maximum amount admissible for any one Modern Treatment shall be 25% of
Sum Insured
A. Uterine Artery Embolization and HIFU (High intensity H. Stereotactic radio surgeries
focused ultrasound) I. Bronchical Thermoplasty
B. Balloon Sinuplasty J. Vaporisation of the prostrate (Green laser treatment or
C. Deep Brain stimulation holmium laser treatment)
D. Oral chemotherapy K. IONM - (Intra Operative Neuro Monitoring)
E. Immunotherapy- Monoclonal Antibody to be given as L. Stem cell therapy: Hematopoietic stem cells for bone
injection marrow transplant for haematological conditions to be
F. Intra vitreal injections covered.
G. Robotic surgeries

1.2.17 Morbid Obesity Treatment

The Company shall indemnify the Hospital or the Insured the Medical Expenses, including pre hospitalisation expenses
(admissible as per Section 1.2.2) and post hospitalisation expenses (admissible as per Section 1.2.3), incurred for surgical
treatment of obesity that fulfils all the following conditions and subject to Waiting Period of four (04) years as per Section
4.2.f.iv:
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
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 Type 2 Diabetes

1.2.18 Correction of Refractive Error

The Company shall indemnify the Hospital or the Insured the Medical Expenses, including pre hospitalisation expenses
(admissible as per Section 1.2.2) and post hospitalisation expenses (admissible as per Section 1.2.3), 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.iii.

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

1.3 Medical Second Opinion

The company shall arrange for Medical Second Opinion from a panel of World Leading Medical Centers (WLMC), at insured
person’s request if the insured person is diagnosed with one of the major illness, during the policy period. The insured person can
avail one Medical Second Opinion for each major illness diagnosed during the policy period.
The insured person shall provide the medical records containing a diagnosis and a recommended course of treatment to the TPA.
The Medical Second Opinion shall be based only on the information and documentation provided to the medical practitioner of
WLMC by or on behalf of the insured person, and the second opinion and the recommended course of treatment shall be sent
directly to the insured/ insured person.

In opting for this service and deciding to obtain a Medical Second Opinion, each insured person expressly notes and agrees that:

National Insurance Co. Ltd.

National Mediclaim Plus Policy
Regd. & Head Office: 3, Middleton Street, Page | 3
(UIN: NICHLIP21150V022021)
Kolkata 700071
i. it is entirely for the insured person to choose whether or not to obtain a Medical Second Opinion from WLMC and if obtained
under this service then whether or not to act on it
ii. the company does not provide Medical Second Opinion or make any representation as to the adequacy or accuracy of the
same, the insured person’s or any other person’s reliance on the same, or the use to which the Medical Second Opinion is put
iii. the company assume no responsibility for and shall not be responsible for any actual or alleged errors, omissions or
representations made by any medical practitioner or in any Medical Second Opinion or for any consequences of any action
taken or not taken in reliance there on
iv. Medical Second Opinion provided under this service shall not be valid for any medico-legal purposes
v. Medical Second Opinion does not entitle the insured person to any consultations from or further opinions from that medical
practitioner.

Copayment
Claims under Section 1.2, except claims under Section 1.2.13 (Vaccination for children), shall be subject to a co payment of 20%
(twenty percent) of the admissible claim amount if treatment is taken in a non-network provider. Co payment shall not apply to
claims if treatment is undergone in a non-network provider in a place where the company/ TPA does not have tie-up with any
hospital.

1.4 Good Health Incentives

1.4.1 Cumulative Bonus (CB)

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. However, the reduction of
CB will not impact sum insured (excluding CB).
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.

1.4.2 Health Check Up

Expenses of health check up shall be reimbursed (irrespective of past claims) at the end of a block of two continuous policy
period, provided the policy has been continuously renewed with the company without a break. Expenses payable is subject to the
limit as stated in the Table of Benefits.

1.5 Hospitalisation Options

The policy provides for cashless facility and/ or reimbursement of hospitalisation expenses for treatment of disease or injury.
Cashless facility is available only in network providers, if opted for TPA service, subject to prior approval by the TPA. Preferred
Provider Network (PPN) is a hospital which has 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.

2.1 Other Benefits

2.1.1 Family Discount
Discount of 10% (ten percent) is allowed in the premium for eligible family members if policy is bought for family, comprising
the insured and any one or more of the family members as mentioned below
i. Spouse
ii. Dependent children
iii. Dependent parents
2.1.2 Youth Discount
Discount of 10% (ten percent) is allowed in the premium for eligible members if either or both of the insured and spouse of the
insured is aged between 18 (eighteen) to 25 (twenty five) years.

2.1.3 Online Discount

Discount of 5% (five percent) in the total premium is allowed if policy is bought online from http://niconline.in/.

Above discounts (as per Section 2.1.1, 2.1.2 and 2.1.3) are not applicable to the premium for optional covers.

2.1.4 Tax Rebate

The insured can avail tax benefits for the premium paid, under Section 80D of Income Tax Act 1961.

2.2 Eligibility
i. Policy can be issued to individuals on individual sum insured basis.
ii. Entry age of proposer is between 18 (eighteen) years and 65(sixty five) years.
iii. Maximum entry age of any individual is 65(sixty five) years.
iv. Children between the age of 3 (three) months and 18 (eighteen) years may be covered, provided parent(s) is/are covered
at the same time.
v. Policy can be availed for self and the following family members
a. Spouse
National Insurance Co. Ltd.
National Mediclaim Plus Policy
Regd. & Head Office: 3, Middleton Street, Page | 2
(UIN: NICHLIP21150V022021)
Kolkata 700071
 b. Dependent legitimate or legally adopted children
 Dependent child up to 18 (eighteen) years of age
 Dependent male child above 18 (eighteen) years and up to 25 (twenty five) years, if a bona-fide student and
not employed
 Dependent female child if not employed, till marriage
c. Parents
vi. Midterm inclusion of family members at pro-rata premium is allowed only in case of
a. newborn between the age of 3 (three) months and 6 (six) months
b. spouse within 60 (sixty) days of marriage
(Family members other than above may be included only at renewal)
vii. Dependent children have option to port to similar retail health insurance product of the company or of any other insurer
at the end of the specified exit age as mentioned.
2.3 Sum Insured (SI)
i. Plan A – 9 slabs, ₹ 2,00,000 to 10,00,000 in multiple of 1,00,000
Plan B – 3 slabs, ₹ 15,00,000/ 20,00,000/ 25,00,000
Plan C – 3 slabs, ₹ 30,00,000/ 40,00,000/ 50,00,000
ii. The proposer has the option of selecting same SI for each family member or separate SI for different members.

2.4 Enhancement of Sum Insured

i. Sum insured can be enhanced only at the time of renewal.
ii. Sum insured can be enhanced to the next slab subject to discretion of the company.
iii. For the incremental portion of the SI, the waiting periods and conditions as mentioned in exclusion 4.1, 4.2, 4.3 shall
apply. Coverage on enhanced sum insured shall be available after the completion of waiting periods.
iv. Change of plan is allowed only at the time of renewal, subject to 4 (four) years of continuous coverage with the company
and any insured person is not suffering from any chronic disease.
v. For change of plan, medical reports as per Section 2.8.iii are required to be submitted with respect to each insured person
aged 40 (forty) years and above.
vi. For individual aged 70 (seventy) years and above, SI can be enhanced only in Plan A and change of plan is not allowed.

2.5 Policy Period

The policy and the optional covers are issued for a period of one year.

2.6 Buying the Policy

The policy can be bought
i. online from portal
ii. from our offices
iii. from our agents
iv. from self service kiosks
v. from Office on Wheels (office on mobile van)

2.7 Completion of Proposal Form

i. The proposal form is to be completed in all respects (including personal details, medical history of insured person) and to
be submitted to the office or to the agent.
ii. Identity and address of the proposer must be supported by documentary proofs.
iii. If a person is insured under health insurance policy of any other non life insurance company and wants to port (switch) to
National Mediclaim Plus Policy, the portability and proposal form will have to be completed and submitted to the office
or to the agent.

2.8 Pre Policy Checkup

i. Pre policy checkup is required for individual
a. 40 (forty) years and above or
b. opting for SI ₹ 6,00,000 and above, irrespective of age of the individual
c. opting for Critical Illness optional cover, between the age of 18 (eighteen) years and 65 (sixty five) years
ii. The company shall reimburse 50% (fifty percent) of the expenses incurred for pre policy checkup, if the proposal is
accepted and the premium has been realised.
iii. The reports required are –
a) Physical examination (report to be signed by e) Urine routine and microscopic examination
the Doctor with minimum MD (Medicine) f) ECG
qualification) g) Eye checkup (including retinoscopy)
b) HbA1c h) Any other investigation required by the
c) Lipid profile company
d) Serum creatinine
The date of medical reports should not exceed 30 (thirty) days prior to the date of proposal.

National Insurance Co. Ltd.

National Mediclaim Plus Policy
Regd. & Head Office: 3, Middleton Street, Page | 3
(UIN: NICHLIP21150V022021)
Kolkata 700071
2.9 Payment of Premium
i. Premium is based on age, SI, and optional covers opted.
ii. The proposer has the option of claims being serviced by TPA (in which case cashless facility/reimbursement of expenses
will be available) or the company (in which case expenses will be reimbursed). If cashless facility is to be availed, the
premium payable is inclusive of TPA charges. If cashless facility is not required, the premium payable is without TPA
charges.
iii. Premium as per the premium table attached is to be paid in full before the commencement of the policy.
iv. Premium can be paid online for both, new policy and renewals.
v. No loadings shall apply on renewals based on individual claims experience.
vi. PAN details must be submitted by the insured.
vii. In case PAN is not available, Form 60 or Form 61 must be submitted

2.10 Renewal of Policy

i. The policy can be renewed annually throughout the lifetime of the insured person.
ii. The policy may be renewed by mutual consent before the expiry of the policy.
iii. The company is not bound to send renewal notice.
iv. Renewal of policy can be denied on grounds of fraud, moral hazard, misrepresentation or noncooperation.
v. In the event of break in the policy a grace period of 30 (thirty) days is allowed. Coverage is not available during the grace
period.

3 Policy Definition

3.1 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.

3.2 Diagnosis means diagnosis by a medical practitioner, supported by clinical, radiological, histological and laboratory evidence,
acceptable to the company.

3.3 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.

3.4 Hospitalisation means admission in a Hospital or mental health establishment for a minimum period of twenty four (24)
consecutive ‘Inpatient care’ hours except for specified procedures/ treatments, where such admission could be for a period of less
than twenty four (24) consecutive hours.

3.5 Network Provider means hospitals or health care providers enlisted by the Company or jointly by the Company and a TPA to
provide medical services to an insured person on payment by a cashless facility.

3.6 Out-Patient Treatment means treatment which the insured person visits a clinic / hospital or associated facility like a
consultation room for diagnosis and treatment based on the advise of a medical practitioner and the insured person is not admitted
as a day care patient or in-patient.

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

3.8 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.

3.9 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 its
reinstatement 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 issued by the Company or its reinstatement.

3.10 Schedule means a document forming part of the policy, containing details including name of the insured person, age, relation
of the insured person, sum insured, premium paid and the policy period

3.11 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.

4 Exclusions
The company shall not be liable to make any payment under the policy, in respect of any expenses incurred in connection with or
in respect of:

National Insurance Co. Ltd.

National Mediclaim Plus Policy
Regd. & Head Office: 3, Middleton Street, Page | 2
(UIN: NICHLIP21150V022021)
Kolkata 700071
4.1. Pre-Existing Diseases (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 thirty six (36) 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.
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 thirty six (36) 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/
one year/ 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. One year waiting period
a. Benign ENT disorders d. Mastoidectomy
b. Tonsillectomy e. Tympanoplast
c. Adenoidectomy
iii. Two years waiting period
a. Cataract l. Gout and Rheumatism
b. Benign prostatic hypertrophy m. Calculus diseases
c. Hernia n. Surgery of gall bladder and bile duct excluding
d. Hydrocele malignancy
e. Congenital internal anomaly o. Surgery of genito-urinary system excluding
f. Fissure/Fistula in anus malignancy
g. Piles (Haemorrhoids) p. Surgery for prolapsed intervertebral disc unless
h. Sinusitis and related disorders arising from accident
i. Polycystic ovarian disease q. Surgery of varicose vein
j. Non-infective arthritis r. Hysterectomy
k. Pilonidal sinus s. Refractive error of the eye more than 7.5 dioptres
Above diseases/treatments under 4.2.f).i, ii, iii shall be covered after the specified Waiting Period, provided they are not Pre
Existing Diseases.
iv. Four years waiting period
Following diseases even if pre-existing shall be covered after four years of continuous cover from the inception of the policy.
a. Treatment for joint replacement unless arising from accident
b. Osteoarthritis and osteoporosis
c. Morbid Obesity and its complications
d. Stem Cell Therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered.

4.3. First 30 days waiting period (Excl 03)

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

4.4. Investigation & 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.

4.5. 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.
National Insurance Co. Ltd.
National Mediclaim Plus Policy
Regd. & Head Office: 3, Middleton Street, Page | 3
(UIN: NICHLIP21150V022021)
Kolkata 700071
4.6. Obesity/ Weight Control (Excl 06)
Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:
1) Surgery to be conducted is upon the advice of the Doctor
2) The surgery/Procedure conducted should be supported by clinical protocols
3) The member has to be 18 years of age or older and
4) Body Mass Index (BMI);
a. greater than or equal to 40 or
b. 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

4.7. 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.

4.8. 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.

4.9. Hazardous or Adventure Sports (Excl 09)

Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports, including
but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding,
sky diving, deep-sea diving.

4.10. Breach of Law (Excl 10)

Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach
of law with criminal intent.

4.11. Excluded Providers (Excl 11)

Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by
the Company and disclosed in its website / notified to the policyholders are not admissible. However, in case of life threatening
situations following an accident, expenses up to the stage of stabilization are payable but not the complete claim.

4.12. Drug/Alcohol Abuse (Excl 12)

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

4.13. Non Medical Admissions (Excl 13)

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)

4.14. Vitamins, Tonics (Excl 14)

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

4.15. Refractive Error (Excl 15)

Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres.

4.16. Unproven Treatments (Excl16)

Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments
are treatments, procedures or supplies that lack significant medical documentation to support their effectiveness.

4.17. 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

4.18. Hormone Replacement Therapy

Expenses for hormone replacement therapy, unless part of Medically Necessary Treatment, except for Puberty and Menopause
related Disorders

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4.19. General Debility, Congenital External Anomaly
General debility, Congenital external anomaly.

4.20. Self Inflicted Injury

Treatment for intentional self-inflicted injury, attempted suicide.

4.21. Stem Cell Surgery

Stem Cell Surgery (except Hematopoietic stem cells for bone marrow transplant for haematological conditions).

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

4.23. Vaccination or Inoculation.

Vaccination or inoculation unless forming part of treatment and requires Hospitalisation, except as and to the extent provided for
under Section 1.2.7.iv and Section 1.2.13.

4.24. Massages, Steam Bath, Alternative Treatment (Other than Ayurveda and Homeopathy)
Massages, steam bath, expenses for alternative or AYUSH treatments (other than Ayurveda and Homeopathy), acupuncture,
acupressure, magneto-therapy and similar treatment.

4.25. Dental treatment

Dental treatment, unless necessitated due to an Injury.

4.26. Domiciliary Hospitalization & Out Patient Department (OPD) treatment

Any expenses incurred on Domiciliary Hospitalization and OPD treatment.

4.27. Stay in Hospital which is not Medically Necessary.

Stay in hospital which is not medically necessary.

4.28. Spectacles, Contact Lens, Hearing Aid, Cochlear Implants

Spectacles, contact lens, hearing aid, cochlear implants.

4.29. Non Prescription Drug

Drugs not supported by a prescription, private nursing charges, referral fee to family physician, outstation
doctor/surgeon/consultants’ fees and similar expenses.

4.30. Treatment not Related to Disease for which Claim is Made

Treatment which the insured person was on before Hospitalisation for the Illness/Injury, different from the one for which claim for
Hospitalisation has been made.

4.31. Equipments
External/durable medical/non-medical equipments/instruments of any kind used for diagnosis/ treatment including CPAP, CAPD,
infusion pump, ambulatory devices such as walker, crutches, belts, collars, caps, splints, slings, braces, stockings, diabetic foot-
wear, glucometer, thermometer and similar related items and any medical equipment which could be used at home subsequently.

4.32. Items of personal comfort

Items of personal comfort and convenience including telephone, television, aya, barber, beauty services, baby food, cosmetics,
napkins, toiletries, guest services.

4.33. Service charge/ registration fee

Any kind of service charges including surcharges, admission fees, registration charges and similar charges levied by the hospital.

4.34. Home visit charges

Home visit charges during Pre and Post Hospitalisation of doctor, attendant and nurse, except as and to the extent provided for
under 1.2.12.

4.35. 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.

4.36. 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

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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.

4.37. Treatment taken outside the geographical limits of India

4.38. 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 (as listed in Appendix).

5 Policy conditions
5.1 Disclosure of information
The policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of misrepresentation, mis
description 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)
5.2 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, 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 shall communicate to the insured person at the address mentioned in the schedule.
5.3 Claim Procedure

5.3.1 Notification of claim

In the event of a hospitalisation claim, the insured person/insured person’s representative shall notify the TPA (if claim is
processed by TPA)/company (if claim is processed by the company) 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.

Notification of claim in case of Cashless facility TPA must be informed:

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

Notification of claim in case of Reimbursement Company/TPA must be informed:

In the event of planned hospitalisation At least 72 (seventy two hours prior to the insured person’s
admission to hospital
In the event of emergency hospitalisation Within 24 (twenty four) hours of the insured person’s
admission to hospital
In case of a claim under Section 1.3, notification of claim is not required.

5.3.2 Procedure for Cashless claims

i. Cashless facility for treatment in network hospitals shall be available to insured if opted for claim processing by TPA.
ii. Treatment may be taken in a network provider/PPN and is subject to pre authorization by the TPA. Booklet containing list of
network provider/PPN shall be provided by the TPA. Updated list of network provider/PPN is available on website of the
company and the TPA mentioned in the schedule.
iii. Cashless request form available with the network provider/PPN and TPA shall be completed and sent to the TPA for
authorization.
iv. The TPA upon getting cashless request form and related medical information from the insured person/ network provider/PPN
shall issue pre-authorization letter to the hospital after verification.
v. At the time of discharge, the insured person has to verify and sign the discharge papers, pay for non-medical and inadmissible
expenses.
vi. The TPA reserves the right to deny pre-authorization in case the insured person is unable to provide the relevant medical
details.
vii. 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.

5.3.3 Procedure for reimbursement of claims

For reimbursement of claims the insured person may submit the necessary documents to TPA (if claim is processed by
TPA)/company (if claim is processed by the company) within the prescribed time limit.

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5.3.4 Documents
The claim is to be supported with the following original documents and submitted within the prescribed time limit.
i. Completed claim form
ii. Bills, payment receipts, medical history of the patient recorded, discharge certificate/ summary from the hospital etc.
iii. Cash-memo from the hospital (s)/chemist (s) supported by proper prescription
iv. Payment receipt, investigation test reports etc. supported by the prescription from attending medical practitioner
v. Attending medical practitioner’s certificate regarding diagnosis along with date of diagnosis and bill receipts etc.
vi. Surgeon’s original certificate stating diagnosis and nature of operation performed along with bills/receipts etc.
vii. In the event of claim under Section 1.2.11, confirmation of the need of family member from attending medical practitioner
viii. Any other document required by company/TPA

Note
In the event of a claim lodged as per contribution clause of the policy and the original documents having been submitted to the
other insurer, the company may accept the documents listed under condition 5.3.4 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 company/TPA

Reimbursement of hospitalisation and pre hospitalisation Within 15 (fifteen) days of date of discharge from hospital
expenses
Reimbursement of post hospitalisation expenses Within 15 (fifteen) days from completion of post
hospitalisation treatment
Reimbursement of health checkup expenses (as per Section At least 45 (forty five) days before the expiry of the third policy
1.3.2) period.
Vaccination for children Within 15 (fifteen) days from date of vaccination

5.3.5 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)

5.3.6 Services offered by 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 notification of claim and submission of documents may be waived in cases where it is proved to the satisfaction of
the company, that the physical circumstances under which insured person was placed, it was not possible to intimate the
claim/submit the documents within the prescribed time limit.

5.4 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.

5.5 Payment of claim

All medical treatments for the purpose of this insurance will have to be taken in India only. All claims under the policy shall be
payable in Indian currency only.

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5.6 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.

5.7 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 15 days’ 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 1month ¼ of the annual rate
Up to 3 months ½ of the annual rate
Up to 6 months ¾ of the annual rate
Exceeding 6 months Full annual rate

5.8 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 policy at least 30 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.

5.9 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.

5.10 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.

5.11 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.
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.

5.12 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

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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 final
discharge of its liability under the policy.

6 Redressal of grievance
In case of any grievance the insured person may contact the company through
Website: https://nationalinsurance.nic.co.in/ Post: National Insurance Co. Ltd.,
Toll free: 1800 345 0330 6A Middleton Street, 7th Floor,
E-mail: [email protected] 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: https://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/
7 Optional covers
Critical Illness and Outpatient Treatment are optional covers.

7.1 Critical illness

The company shall pay the benefit amount, as stated in the schedule, provided that
i. the insured person is first diagnosed as suffering from a critical illness (as defined) during the policy period, and
ii. the insured person survives for at least 30 (thirty) days following such diagnosis
iii. diagnosis of critical illness is supported by clinical, radiological, histological and laboratory evidence acceptable to the
company.

Eligibility (entry age)

The cover can be availed by persons between the age of 18 (eighteen) years and 65 (sixty five) years.

Benefit amount
Benefit amount available under Critical Illness cover shall be limited to the sum insured (excluding cumulative bonus) under the
policy.
Benefit amount available per individual are INR 2,00,000/ 3,00,000/ 5,00,000/ 10,00,000/ 15,00,000/ 20,00,000/ 25,00,000.

Enhancement of benefit amount

i. Benefit amount can be enhanced only at the time of renewal.
ii. Benefit amount can be enhanced to the next slab subject to discretion of the company.

Policy period
The policy period for the policy, and the cover should be identical, as mentioned in the schedule.

Pre policy checkup

Pre policy checkup reports (as per Section 2.8.iii) are required for individual opting for Critical illness cover between the age of
18 (eighteen) years and 65 (sixty five) years.

Tax rebate
No tax benefit is allowed on the premium paid under Critical Illness cover (if opted)

Renewal
The Critical Illness cover can be renewed annually throughout the lifetime of the insured person.

7.1.1 Definition
Critical illness means stroke resulting in permanent symptoms, cancer of specified severity, kidney failure requiring regular
dialysis, major organ/ bone marrow transplant, multiple sclerosis with persisting symptoms and open chest CABG (Coronary
Artery Bypass Graft), permanent paralysis of limbs and blindness.

I Stroke resulting in permanent symptoms

Any cerebrovascular incident producing permanent neurological sequelae. This includes infarction of brain tissue, thrombosis in
an intracranial vessel, haemorrhage and embolisation from an extracranial source. Diagnosis has to be confirmed by a specialist
medical practitioner and evidenced by typical clinical symptoms as well as typical findings in CT Scan or MRI of the brain.
Evidence of permanent neurological deficit lasting for at least 3 (three) months has to be produced.

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The following are not covered
i. transient ischemic attacks (TIA)
ii. traumatic injury of the brain
iii. vascular disease affecting only the eye or optic nerve or vestibular functions.

II Cancer of specified severity

A malignant tumour characterised by the uncontrolled growth and spread of malignant cells with invasion and destruction of
normal tissues. This diagnosis must be supported by histological evidence of malignancy and confirmed by a pathologist. The
term cancer includes leukemia, lymphoma and sarcoma.

The following are not covered

i. tumours showing the malignant changes of carcinoma in situ and tumours which are histologically described as premalignant
or non invasive, including but not limited to: Carcinoma in situ of breasts, Cervical dysplasia CIN-1, CIN -2 and CIN-3.
ii. any skin cancer other than invasive malignant melanoma
iii. all tumours of the prostate unless histologically classified as having a Gleason score greater than 6 (six) or having progressed
to at least clinical TNM classification T2N0M0.
iv. papillary micro – carcinoma of the thyroid less than 1 (one) cm in diameter
v. chronic lymphocyctic leukaemia less than RAI stage 3
vi. microcarcinoma of the bladder
vii. all tumours in the presence of HIV infection.

III Kidney failure requiring regular dialysis

End stage renal disease presenting as chronic irreversible failure of both kidneys to function, as a result of which either regular
renal dialysis (hemodialysis or peritoneal dialysis) is instituted or renal transplantation is carried out. Diagnosis has to be
confirmed by a specialist medical practitioner.

IV Major organ/ Bone marrow transplant

The actual undergoing of a transplant of:
i. one of the following human organs: heart, lung, liver, kidney, pancreas, that resulted from irreversible end-stage failure of the
relevant organ, or
ii. human bone marrow using haematopoietic stem cells. The undergoing of a transplant has to be confirmed by a specialist
medical practitioner.

The following are not covered

i. other stem-cell transplants
ii. where only islets of langerhans are transplanted

V Multiple sclerosis with persisting symptoms

The definite occurrence of multiple sclerosis. The diagnosis must be supported by all of the following:
i. investigations including typical MRI and CSF findings, which unequivocally confirm the diagnosis to be multiple sclerosis;
ii. there must be current clinical impairment of motor or sensory function, which must have persisted for a continuous period of
at least 6 months, and
iii. well documented clinical history of exacerbations and remissions of said symptoms or neurological deficits with at least two
clinically documented episodes at least one month apart.

The following are not covered

Other causes of neurological damage such as SLE (Systemic Lupus Erythematosus) and HIV (Human Immunodeficiency Virus).

VI Open chest CABG

The actual undergoing of open chest surgery for the correction of one or more coronary arteries, which is/are narrowed or blocked,
by coronary artery bypass graft (CABG). The diagnosis must be supported by a coronary angiography and the realization of
surgery has to be confirmed by a specialist medical practitioner.

The following are not covered

i. angioplasty and/or any other intra-arterial procedures
ii. any key-hole or laser surgery.

VII Permanent paralysis of limbs

Total and irreversible loss of use of two or more limbs as a result of injury or disease of the brain or spinal cord. A specialist
medical practitioner must be of the opinion that the paralysis will be permanent with no hope of recovery and must be present for
more than 3 (three) months.

VIII Blindness
The total and permanent loss of all sight in both eyes.

7.1.2 Exclusions
The company shall not be liable to make any payment under the policy if:

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i. any critical illness and/or its symptoms (and/or the treatment) which were present at any time before inception of the first
policy, or which manifest within a period of 90 (ninety) days from inception of the first policy, whether or not the insured
person had knowledge that the symptoms or treatment were related to such critical illness. In the event of break in the policy,
the terms of this exclusion shall apply as new from recommencement of cover
ii. the insured person smokes 40 (forty) or more cigarettes / cigars or equivalent tobacco intake in a day

7.1.3 Condition
Claim amount
i. Any amount payable under the optional covers will not affect the sum insured applicable to Section 1.2.
ii. Copayment shall not apply to claims under optional covers.
iii. Any amount payable under the optional covers shall not affect the entitlement to cumulative bonus.

Notification of claim
In the event of a claim, the insured person/insured person’s representative shall intimate the company in writing by letter, e-mail,
fax providing all relevant information relating to the critical illness within 15 (fifteen) days of critical illness diagnosis

Procedure for claims under critical illness

Claim documents supporting the diagnosis shall be submitted to the company after 30 (thirty) days and within 60 (sixty) days
from the date of diagnosis of the disease.

Documents
The claim is to be supported with the following original documents
i. Doctor’s certificate confirming diagnosis of the critical illness along with date of diagnosis.
ii. Pathological/other diagnostic test reports confirming the diagnosis of the critical illness.
iii. Any other documents required by the company

Cessation of cover
1 This cover shall cease upon payment of the benefit amount on the occurrence of a critical illness and no further claim shall be
paid for any other critical illness during the policy period.
2 On renewal, no claim shall be paid for any critical illness for which claim has already been made

Cancellation
In the event of cancellation of the policy by either insured or the company, the cover will also be cancelled as per cancellation
clause of the policy.

7.2 Out-patient treatment

Subject to Exclusions 4.7, 4.8, 4.18, 4.16, 4.24, 4.12, 4.9, 4.10, 4.35 and 4.36, the company shall pay up to the limit, as stated in
the schedule with respect of
i. Out-patient consultations by a medical practitioner
ii. Diagnostic tests prescribed by a medical practitioner
iii. Medicines/drugs prescribed by a medical practitioner
iv. Out-patient dental treatment

Eligibility
The cover can be availed by individuals of any age band.

Limit of cover
Limit of cover available per individual are INR 2,000/ 3,000/ 4,000/ 5,000/ 10,000.

Enhancement of limit of cover

i. Limit of cover can be enhanced only at the time of renewal.
ii. Benefit amount can be enhanced to the next slab subject to discretion of the company.

Policy period
The policy period for the policy, and the cover should be identical, as mentioned in the schedule.

Tax rebate
The insured person can avail tax benefits for the premium paid, under Section 80D of Income Tax Act 1961.

Renewal
The Outpatient Treatment cover can be renewed annually throughout the lifetime of the insured person.

7.2.1 Exclusions
The company shall not make any payment under the cover in respect of
i. Treatment other than Allopathy/ Modern medicine, Ayurveda and Homeopathy
ii. Cosmetic dental treatment to straighten lightens, reshape and repair teeth. Cosmetic treatments include veneers, crowns,
bridges, tooth-coloured fillings, implants and tooth whitening.
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7.2.2 Condition
Claim amount
i. Any amount payable under the optional covers will not affect the sum insured applicable to Section 1.2.
ii. Copayment shall not apply to claims under optional covers.
iii. Any amount payable under the optional covers shall not affect the entitlement to cumulative bonus.

Procedure for claims under outpatient treatment

Claim documents supporting all such outpatient treatments shall be submitted to the TPA/ company twice during the policy
period, within 30 (thirty) days of completion of 6 month period.

Documents
The claim is to be supported with the following original documents
i. All bills, prescriptions from medical practitioner
ii. Diagnostic test bills, copy of reports
iii. Any other documents required by the company

Cancellation
In the event of cancellation of the policy by either insured or the company, the cover will also be cancelled as per cancellation
clause of the policy.

8 Disclaimer
The prospectus contains salient features of the policy. For details reference is to be made to the Policy. In case of any difference
between the prospectus and the policy, the terms and conditions of the policy shall prevail.
The prospectus and proposal form are part of the policy. Hence please read the prospectus carefully and sign the same. The
proposal form is to be completed in all respects for each insured person. Both the prospectus and the proposal form are to be
submitted to the office or to the agent.
Place Signature

Date Name

National Insurance Co. Ltd.

National Mediclaim Plus Policy
Regd. & Head Office: 3, Middleton Street, Page | 10
(UIN: NICHLIP21150V022021)
Kolkata 700071
Table of Benefits
Features Plans
PLAN A PLAN B PLAN C
INR 2/ 3 /4 / 5/ 6/ 7/ 8/ 9 /10
Sum insured INR 15/ 20 /25 Lac INR 30/ 40/ 50 Lac
Lac
Coverage
Hospitalisation, Pre (30days) and Post (60
Covered Covered Covered
days) Hospitalisation, Daycare procedure
Pre existing disease (Only PEDs declared in
Covered after 36 months of Covered after 36 months of Covered after 36 months of
the Proposal Form and accepted for coverage
continuous coverage continuous coverage continuous coverage
by the Company shall be covered)
Room - Up to 1% of SI per
day
Room/ ICU charges ICU – Up to 2% of SI per Up to INR 15,000 per day Up to INR 20,000 per day
day subject to max. of INR
15,000 per day
For each eye – Up to 15% of
For each eye – Up to INR For each eye – Up to INR
Limit for cataract surgery sum insured or INR 60,000
80,000 1,00,000
whichever is lower
Ayurveda and Homeopathy Up to sum insured Up to sum insured Up to sum insured
Organ donor’s medical expenses Covered Covered Covered
Up to INR 30,000 for normal Up to INR 60,000 for normal Up to INR 80,000 for normal
Maternity delivery and INR 50,000 for delivery and INR 75,000 for delivery and INR 100,000 for
caesarean section caesarean section caesarean section
Hospital cash INR 500 per day, max. of 5 INR 800 per day, max. of 5 INR 1,000 per day, max. of 5
days days days
Up to INR 2,500 in a policy Up to INR 4,000 in a policy Up to INR 5,000 in a policy
Ambulance
period period period
Up to 5% of SI per policy Up to 5% of SI per policy
Air ambulance Not covered
period period
Up to INR 20,000 per policy Up to INR 20,000 per policy
Medical emergency reunion Not covered
period period
Doctor’s home visit and nursing care during INR 750 per day, max. of 10 INR 1,000 per day, max. of
Not covered
post hospitalisation days 10 days
Up to INR 1,000 in a policy Up to INR 1,000 in a policy Up to INR 1,000 in a policy
Vaccination for children (up to 12 years)
period period period
Modern Treatment (12 nos) Up to 25% of SI for each Up to 25% of SI for each Up to 25% of SI for each
treatment treatment treatment
Treatment due to participation in hazardous or Up to 25% of SI Up to 25% of SI Up to 25% of SI
adventure sports (non-professionals)
Morbid Obesity Covered after waiting period Covered after waiting period Covered after waiting period
of 4 years of 4 years of 4 years
Refractive Error (min 7.5D) Covered after waiting period Covered after waiting period Covered after waiting period
of 2 years of 2 years of 2 years
Other benefits
One MSO for each new One MSO for each new One MSO for each new
Medical Second Opinion (MSO) diagnosis of any of the major diagnosis of any of the major diagnosis of any of the major
illnesses, in a policy period illnesses, in a policy period illnesses, in a policy period
Good Health Incentives
Increase in SI by 5% of SI Increase in SI by 5% of SI Increase in SI by 5% of SI
Cumulative bonus (excluding CB) per year up (excluding CB) per year up (excluding CB) per year up
to 50% of SI (excluding CB) to 50% of SI (excluding CB) to 50% of SI (excluding CB)
Health checkup Every 2 yrs., up to INR 1,000 Every 2 yrs., up to INR 2,000 Every 2 yrs., up to INR 3,000
Copayment
Copayment of 20% of admissible claim if
treatment taken in non-network hospital (not Applicable Applicable Applicable
applicable to optional covers)
Optional covers
Benefit amount per individual - INR 2,00,000/ 3,00,000/ 5,00,000/ 10,00,000/ 15,00,000/
Critical Illness
20,00,000/ 25,00,000.
Outpatient Treatment Limit of cover per individual - INR 2,000/ 3,000/ 4,000/ 5,000/ 10,000.

National Insurance Co. Ltd.

National Mediclaim Plus Policy
Regd. & Head Office: 3, Middleton Street, Page | 11
(UIN: NICHLIP21150V022021)
Kolkata 700071
Premium rate
Rate with TPA charges (in ₹)
SI 3m-5 6 - 17 18 - 25 26-35 36-45 46-55 56-59 60-65 66-70 71-75 76-80 81-85 86 +
2,00,000 5,303 5,356 5,951 6,070 6,192 8,533 12,344 16,064 23,304 27,103 28,586 29,833 31,009
3,00,000 6,918 6,918 7,687 7,841 7,841 11,344 16,543 21,324 31,356 35,820 38,967 40,992 42,519
4,00,000 8,381 8,382 9,314 9,499 9,499 13,913 20,392 26,096 38,732 43,681 48,573 51,387 53,218
5,00,000 9,743 9,743 10,826 11,042 11,043 16,314 24,000 30,536 45,645 50,964 57,643 61,251 63,285
6,00,000 10,852 10,852 12,057 12,299 12,300 18,592 27,428 34,730 52,208 57,817 65,726 70,106 73,039
7,00,000 11,901 11,902 13,224 13,488 13,489 20,596 30,536 38,565 58,332 64,169 73,674 78,903 82,260
8,00,000 12,902 12,903 14,338 14,624 14,624 22,518 33,528 42,242 64,230 70,245 81,347 87,302 91,173
9,00,000 13,865 13,865 15,407 15,714 16,365 24,375 36,420 45,784 69,936 76,091 88,660 95,446 99,820
10,00,000 14,792 14,793 16,437 16,765 18,201 26,173 39,229 49,212 75,477 81,739 95,752 1,03,367 1,08,237
15,00,000 19,952 19,953 29,474 33,076 33,407 36,663 52,460 61,655 80,547 87,132 1,07,210 1,25,964 1,32,586
20,00,000 23,806 23,807 31,806 46,836 47,305 47,777 63,596 72,329 87,633 90,500 1,19,378 1,46,718 1,55,270
25,00,000 27,358 27,359 34,314 49,016 49,506 53,523 73,732 80,878 90,644 93,994 1,26,742 1,62,657 1,72,917
30,00,000 31,217 31,219 37,515 51,819 53,158 62,159 83,223 88,196 91,285 98,102 1,31,041 1,75,246 1,86,618
40,00,000 37,389 37,392 43,547 56,662 61,703 77,050 98,473 98,478 99,351 1,05,769 1,31,384 1,90,674 2,04,536
50,00,000 42,950 42,952 50,148 61,024 70,992 91,358 1,11,388 1,11,395 1,11,400 1,14,035 1,31,391 1,97,469 2,13,206
Service Tax extra

Rate without TPA charges (in ₹)

SI 3m-5 6 - 17 18 - 25 26-35 36-45 46-55 56-59 60-65 66-70 71-75 76-80 81-85 86 +
2,00,000 5,003 5,053 5,614 5,727 5,841 8,050 11,645 15,155 21,984 25,569 26,968 28,144 29,253
3,00,000 6,527 6,527 7,252 7,397 7,397 10,703 15,607 20,117 29,581 33,792 36,761 38,672 40,112
4,00,000 7,907 7,908 8,786 8,962 8,962 13,125 19,237 24,619 36,540 41,208 45,823 48,479 50,206
5,00,000 9,191 9,192 10,212 10,417 10,417 15,391 22,641 28,808 43,061 48,078 54,380 57,784 59,702
6,00,000 10,238 10,238 11,375 11,603 11,604 17,539 25,875 32,764 49,253 54,544 62,006 66,138 68,904
7,00,000 11,228 11,228 12,475 12,725 12,726 19,429 28,808 36,383 55,031 60,537 69,504 74,438 77,603
8,00,000 12,173 12,173 13,526 13,796 13,797 21,244 31,630 39,851 60,593 66,269 76,742 82,361 86,012
9,00,000 13,080 13,081 14,534 14,825 15,439 22,995 34,359 43,193 65,977 71,784 83,641 90,044 94,170
10,00,000 13,956 13,956 15,506 15,817 17,171 24,692 37,008 46,427 71,206 77,113 90,332 97,516 1,02,110
15,00,000 18,822 18,823 27,805 31,204 31,516 34,588 49,491 58,165 75,987 82,200 1,01,142 1,18,835 1,25,080
20,00,000 22,457 22,458 30,006 44,185 44,627 45,073 59,996 68,235 82,673 85,378 1,12,620 1,38,412 1,46,480
25,00,000 25,809 25,810 32,373 46,242 46,704 50,493 69,558 76,300 85,513 88,674 1,19,569 1,53,449 1,63,129
30,00,000 29,450 29,451 35,392 48,886 50,149 58,640 78,513 83,204 86,118 92,549 1,23,623 1,65,327 1,76,055
40,00,000 35,273 35,275 41,082 53,454 58,211 72,688 92,899 92,904 93,727 99,782 1,23,947 1,79,881 1,92,959
50,00,000 40,520 40,521 47,310 57,570 66,973 86,187 1,05,084 1,05,089 1,05,095 1,07,580 1,23,954 1,86,291 2,01,137
Service Tax extra
Rate for Critical Illness (in ₹)
Age 2,00,000 3,00,000 5,00,000 10,00,000 15,00,000 20,00,000 25,00,000
18-25 372 557 929 1,858 2,786 3,715 4,644
26-35 647 970 1,617 3,234 4,851 6,468 8,085
36-45 1,198 1,796 2,994 5,988 8,981 11,975 14,969
46-55 2,217 3,326 5,543 11,086 16,629 22,172 27,715
56-59 3,209 4,813 8,022 16,043 24,065 32,086 40,108
60-65 4,643 6,965 11,608 23,217 34,825 46,434 58,042
66-75 9,501 14,251 23,752 47,505 71,257 95,009 1,18,762
76-85 21,109 31,664 52,773 1,05,546 1,58,319 2,11,093 2,63,866
86+ 47,155 70,733 1,17,889 2,35,777 3,53,666 4,71,555 5,89,443
Service Tax extra

Rate for Outpatient Treatment (in ₹)

Cover 2,000 3,000 4,000 5,000 10,000
Premium 1,200 1,800 2,400 3,000 6,000
Service Tax extra

Discounts (not applicable to optional covers)

Family discount 10%
Youth discount 10%
Online discount 5%

Insurance is the subject matter of solicitation

National Insurance Co. Ltd.

National Mediclaim Plus Policy
Regd. & Head Office: 3, Middleton Street, Page | 12
(UIN: NICHLIP21150V022021)
Kolkata 700071
 Appendix
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 - Chronic
heart disease and valvular rheumaticheart diseases. • Q20 Congenital malformations of cardiac chambers and connections • Q21 Congenital
heart disease 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 Diseases K 50.0 to K 50.9 (including Crohn's and Ulcerative colitis)
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
Parkinson's Disease 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 of L40 - L45 Papulosquamous disorder of the skin including psoriasis lichen planus
the skin
16 Avascular necrosis
M 87 to M 87.9
(osteonecrosis)

National Insurance Co. Ltd.

National Mediclaim Plus Policy
Regd. & Head Office: 3, Middleton Street, Page | 13
(UIN: NICHLIP21150V022021)
Kolkata 700071