Letter of Pragmatic Insurance - THE ORIGINAL TERMS & CONDITIONS CONVEYED BY NIA SUPER TOP UP POLICY BROKING AGENT. Broking services.pdf

"This Thursday Tambola"
ONLY TWO DAYS LEFT & THE LAST MINUTE WAITERS STILL UNSATISFIED & WITH SOME DOUBTS REG> SUPER TOP UP POLICY.

As per almost all retirees opinipn, both the insurance agents or banks/aibrf not divulging original terms and conditions of insurance companies reg. super top up policy so that a wise decisio can be taken.

Evn in interactive meetings also, the organisers or TPA representatives furished FAQs only when asked for terms and conditions and the FAQs created further doubts and some described them as beating the bush but no factual information.  Even what is super top up policy many could not understand.

IN LIGHT OF ABOVE,

HERE THE ORIGINAL TERMS & CONDITIONS CONVEYED BY NIA SUPER TOP UP POLICY BROKING AGENT.

ANNEXURE A
Super Top Up Health Insurance - Coverage, Exclusions and Conditions:
Super Top Up:
1. Super Top Up Coverage meaning would be as below:
 A single claim or multiple claims in a policy period which exceeds the threshold Sum Insured /
deductible of hospitalization claims.
 The aggregate of Covered Expenses in respect of hospitalisation/s of insured person individually
or for all insured persons in the family exceeds the Threshold Level/deductible.
 The claim payable under this Policy will be the amount by which the aggregate of such
Covered Expenses in respect of hospitalisations with dates of admission falling
within the policy period exceeds the threshold Level/deductible per family as stated in
the schedule.
 In no case the Company shall be liable to pay any sum in excess of the Sum Insured as stated in
the Super Top Up Policy.
2. Super Top Up Cover the threshold would be in excess of hospitalisation claims only.
Domiciliary benefit amount would not be part of threshold for triggering Super Top Up Cover. Thus, if
amount is inclusive of domiciliary benefits then Super Top Up Cover would trigger only after amount
exceeds Rs.3,30,000/- or Rs.4,40,000/- provided this utilization is 100% of the domiciliary benefit
available under the base policy since domiciliary benefit allowed is only 10% of the basic policy (Rs.
30,000/- or Rs. 40,000/-)
3. All members who would be opting for Super Top Up cover would have definite identification details
as well as proof of them being retiree and only those who are part of basic policy would be forming
part of Super Top Up Policy and no one else is entitled to join the scheme.
4. The basic policy or Super Top Up Policy would not allow any change of Sum Insured than as agreed
for in advance which is Rs.4,00,000/- for Officer cadre and Rs.3,00,000/- for other staff members.
5. Policy also has coverage for widows of deceased employees.
6. Minimum participation is 25% of total families in base policy are compulsory to trigger the policy.
Coverage:
 Hospitalisation expenses incurred for self for any disease or illness or accident
 Hospitalisation expenses incurred for donor in respect of organ transplant
 Pre-hospitalisation expenses - 30 days
 Post-Hospitalisation expenses- 90 days
 All standard definitions as per IRDA guidelines
 AYUSH treatment covered till Sum Insured limits
 Pre-Existing disease are covered
 Day care treatment admissible for specific diseases as mentioned below even if hospitalisation is
not 24 hrs.
 Adenoidectomy, Appendectomy, Ascitic/ Plural Tapping, Auroplasty not cosmetic in nature,
Coronary Angiography/ Renal Coronary Angiography, Dental Surgery, D & C, Excision of
cyst/granuloma/lump/tumor, Eye Surgery, Fracture including hair line fracture/dislocation,
Radiotherapy, Chemotherapy including parental chemotherapy, LIthotripsy, Incision/drainage
of abscess, Varicocelectomy, Wound Suturing, FESS, Operations/ Microsurgical operations on
the nose, middle ear/internal ear, tongue, mouth, face, tonsils and adenoids, salivary glands and
salivary ducts, breast, skin &sub-cutaneous tissues, digestive tract, female/male sexual organs,
Haemodialysis, ventral, Fissurectomy/Fistulectomy, Mastoidectomy, Hydrocele, Hysterectomy,
Inguinal/ventral/umbilical/femoral hernia, Parenteral chemotherapy, Polypectomy, Septoplasty,
Piles/Fistula, Prostate Surgeries, Sinusitis surgeries, Tonsillectomy, Liver aspiration,
Sclerotherapy, varicose vain legation, All scopies along with biopsies, lumbar puncture.
 Alternative therapies covered as defined if treatment taken in hospital as defined
 Ambulance charges covered upto Rs.2500/- per trip to hospital if medically advised, Taxi/Auto
expenses max upto Rs.750/- per hospitalisation
 Congenital anomalies are covered
 Psychiatric diseases are covered
 Advance medical treatment like laser surgery, stem cell therapy is covered
 Treatment taken for accidental expenses covered even on OPD basis upto Sum Insured
 Taxes and Other charges are payable
 Treatment for genetic disorder and stem cell therapy are covered
 Treatment for age related disorders such as AMRD, RFQMR, EECP are covered
 Rental charges for external or durable medical equipment are covered
 Ambulatory devises are covered
 Physiotherapy charges are payable
Exclusions
 For Critical Illnesses hospitalisation medical alone is payable.
 No Expenses related to Maternity is payable
 No expenses related to for new born child is payable
 No corporate Buffer is available
 No dependent children are covered in policy
 Standard exclusion of War Invasion..etc.
 Vaccination/ Cosmetic Surgery or plastic surgery unless necessitated due to accident
 Cost of spectacles and contact lenses, hearing aids, other than intra-ocular lenses and cochlear
implant
 Dental treatment or surgery in clinic and cosmetic in nature
 Rest, Cure, Obesity treatment
 AIDS
 Charges incurred only for diagnostic purpose
 Vitamins/ Tonics unless forming part of treatment
 Nuclear weapon standard exclusion
 Non medical expenses which are not covered
 Suicide or attempted suicide expenses
PLEASE SEE THE ATTACHMENT fOR ORIGINAL INFORMATION.



= VBV Ramesh

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