Coverage of HDFC ERGO Medisure Classic Insurance
Basic Cover
Hospitalization Expenses
For treatment of any disease, illness or injury in a Hospital as an in-patient which includes:
- Fees of Surgeon, Anesthetist, Nurses and Specialists;
- Cost of Operation Theatre, diagnostic tests, medicines, blood, oxygen and internal appliances like pacemaker as long as these are medically necessary;
- Treatment should be for a continuous period and includes relapse within 45 days from the date of last consultation at the Hospital/Nursing Home. Occurrence of same illness after a lapse of 45 days will be considered as fresh illness.
Hospitalisation as In Patient for a minimum period of 24 hours subject to the limits set below:
- Room Rent/ Boarding & Nursing as per actual limited to 1% of the Sum Insured (excluding cumulative bonus) per day subject to a maximum of ₹4,000/- per day
- ICU Rent/Boarding & Nursing as per actual limited to 2% of the Sum Insured (excluding cumulative bonus) per day subject to a maximum of ₹6,000/- per day.
- Expenses on account of Room Rent/ ICU Boarding & Nursing if incurred higher than the limits above, shall be reduced in the same proportion as such actual costs bears to the eligible limits above. Such limits shall not apply where Optional Cover for Waiver of Room Rent Sub-limits has been opted
Pre-hospitalisation expenses
This covers the relevant medical expenses the insured incurs within a period of 30 days before you are admitted to a Hospital/Nursing Home provided that;
- such medical expenses are incurred for the same condition for which Your hospitalization was required and
- The Inpatient Hospitalization claim for such hospitalization is admissible by the insurer
Post-hospitalisation expenses
This covers the relevant medical expenses, up to a period of 60 days, after the insured is discharged from the Hospital/Nursing Home provided that
- such medical expenses are incurred for the same condition for which Your hospitalization was required and
- The Inpatient Hospitalization claim for such Hospitalization is admissible by the insurer.
Day Care Procedures
This covers the medical expenses for a day care procedure or surgery incurred by for treatment or procedures that requires less than 24 hours of hospitalisation undertaken under general or local anaesthesia. There is no static list for day care procedures in the Policy as advances in medical science leads to many more being added continuously. However, this cover excludes diagnostic procedures and treatments taken on an outpatient basis.
Domiciliary Hospitalisation
Coverage for medical treatment requiring hospitalisation, taken at home on advice of the attending medical practitioner, due to non-availability of a hospital bed, which continues for at least 3 days. Coverage is extended for pre-hospitalisation expenses incurred upto 30 days. However, the post-hospitalisation expenses are not covered.
Hospitalisation due to Accident
If, during the term of the policy, the entire sum insured gets used up or is not enough to cover a second hospitalisation due to accident, the sum insured of your policy is 'reinstated' or 'replenished' to the extent of the claim amount (but not exceeding the Sum Insured) to cover this hospitalisation. This additional amount will be available only ONCE during the 12-month Policy Year.
Maternity and New-born baby Cover
Coverage towards maternity expenses and new-born baby cover upto the limit of Sum Insured below:
- Maximum of 10% of Sum Insured or ₹20,000/- for a normal delivery and 20% of Sum Insured or ₹40,000/- for a caesarean section or actual cost, whichever is lower.
- Coverage is applicable only for the first two children and/or termination(s)
- Coverage is limited to the female member who has been covered under any Policy issued by us for a continuous period of 48 months
- New-born baby covered for a period of 90 days from date of birth within the maternity limits.
- After 90 days, baby can be added under the Policy by way of endorsement and payment of additional Premium
Ayurvedic Treatment
Coverage for cost of (non cosmetic) Ayurvedic treatment upto₹25,000 per Policy Year, with prior approval from the Company requiring 24 hours hospitalisation/ residential inpatient with government registered hospital for the specified treatments. Coverage for Ayurvedic treatments is applicable subject to terms, conditions, definitions, waiting periods and exclusions under the Policy.
Pre-existing Diseases
After 36 months of continuous coverage, from the 4th year you can claim the payment of relevant medical expenses incurred on pre-existing diseases.
Optional Covers
The insured can also avail of Optional covers on payment of additional premium.
- Double Sum Insured for Critical Illness ▪ Provides for an additional cover equivalent to the Sum Insured excluding the cumulative bonus for treatment of - Cancer, Kidney Failure, Multiple Sclerosis, Primary Pulmonary Hypertension, Major Organ Transplant, Aorta Graft Surgery, Coronary Artery Bypass Graft, First Heart Attack
- Additional Sum Insured (excluding cumulative bonus) is exclusively available only for the treatment of the first occurrence of the above Critical Illnesses
- Coverage will not be extended for the same Critical Illness for any subsequent Policy Year, however, the remaining critical illnesses will continue to be covered.
- This coverage is in addition to the Hospitalisation cover and the cumulative Sum Insured under both could be used for hospitalization against covered Critical Illness.
- The option can be availed only up to the age of 65 years (age last birthday) and for Sum Insured of ₹2 Lacs and above. For customers who avail of such option at or before that age, the cover shall continue to be available in the case of continuous renewals.
- Waiver of Room Rent Sub-limits
- If this coverage is opted, the sub limits of Room Rent and ICU under the Basic Cover of Hospitalisation Expenses will be waived however subject to the overall limit of the Sum Insured. This Option can be availed during inception of the Policy or at the time of renewal.
Other Covers
Medisure Classic Insurance offers the following additional features:
- Hospital Cash: ₹500 per day from 4 to 10 day when hospitalization exceeds 3 continuous days
- Ambulance Charges: Maximum upto `1,500/- per hospitalization
- Recovery Benefit: ₹5,000/- when hospitalisation exceeds 10 continuous days or more.
- Health Check-Up: For all Insured Persons at the end of four continuous claim free Policy Years, limited to 1% of average Sum Insured excluding cumulative bonus, per person in case of Individual Policy and for all members put together in case of a floater.
- Family Floater: The insured can cover upto 4 members of your family - your spouse and 2 dependent children upto the age of 23 years - under a single policy and single sum insured.
- Family Discount: If one opts for Individual Sum Insured for each of your family members under a single policy instead of a Family Floater option, a Family Discount of 10% on the total premium payable for covering more than 2 family members is provided. This will include the insured, his/her lawful spouse, dependent children and dependant parents only. The Family discount will be available for a maximum of 6 persons only.
- Cumulative Bonus: The 'sum insured' of your policy progressively increases by 5% on every renewal, for every claim-free year, subject to a maximum accumulation of 50% of your sum insured (if a claim is made, the Cumulative Benefit that has accrued will be reduced by 20% however, the basic Sum Insured will be maintained at all times)
- Two year policy Option: A discount of 5% is available on the combined premium for both the years.
- Life time renewal of policy: The Policy is renewable for life time.
- Income Tax Benefit: You can get tax exemption on the premium paid under section 80D of the Income Tax Act (Subject to change in Tax Law)
- Free-look Period: If the insured is not satisfied with our coverage or terms, you have the option of cancelling the policy within 15 days, provided there has been no claim. We will refund the premium paid after adjusting the amounts spent on stamp duty charges, Medical examination (wherever applicable) and proportionate premium (If Policy has already commenced). Refund will not be applicable if you have made a claim against the Policy during that period.
- Co-payment: All Insured Persons above the age of 80 years (age last birthday) shall bear a co-pay of 10% for each and every claim.
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HDFC ERGO Medisure Classic insurance
