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What's Copay in Employee Group Health Insurance?

An organization’s performance and success is always the result of the hard work of all its employees. As a result, the owner or the employer feels it is a moral duty to provide them with the best possible working conditions as well as security. In turn, a happy workforce proves to be more loyal towards […]

Definitioner

Claim

Claim - means a demand made by You or on Your behalf for payment of Medical Expenses or any other expenses or benefits, as covered under the Policy

Sum Insured

"Sum Insured" means the sum as specified in the Schedule to this Policy against the name of Insured / each Insured Person, which sum represents the Company's maximum liability for any or all claims under this Policy during the Policy period for the respective benefit(s) against which the sum is mentioned in the Schedule to this Policy.

Schedule

Schedule means Schedule attached to and forming part of this Policy mentioning the details of the Insured/ Insured Persons, the Sum Insured, the period and the limits to which benefits under the Policy are subject to.

Policy

"Policy" means this document of Policy describing the terms and conditions of this contract of insurance, including the company's covering letter to the insured if any, the Schedule attached to and forming part of this Policy, the Insured's Proposer form and any applicable endorsement thereon. The Policy contains details of the scope and extent of cover available to the Insured/Insured Person, the exclusions from the scope of cover and the terms and conditions of the issue of the Policy.

Insured

"Insured" means the individual who has a permanent place of residence in India and on whose name the Policy is issued.

Illness

"Illness" means sickness or disease first diagnosed during the period of insurance for which immediate treatment by a Medical Practitioner is necessary.

Family

"Family" means the Insured, his/her lawful spouse and maximum of two dependent children up to the age of 23 years. xii) Arthritis, goutandrheumatism.

Critical Illnesses

Critical Illnesses means diseases/illnesses limited to the following:

Cancer represented by a malignant tumor characterized by the uncontrolled growth and spread of malignant cells with invasion and destruction of normal tissue.
First Heart Attack involving death of a portion of the heart muscle arising from inadequate blood supply to the relevant area.

Coronary Artery Disease involving narrowing of the lumen of at least one coronary artery by a minimum of 75% and of two others by a minimum of 60%, as proven by coronary arteriography, regardless of whether or not any form of coronary artery surgery has been performed. Coronary arteries herein refer to left main stem, left anterior descending circumflex and right coronary artery.

Coronary Artery bypass surgery involving the actual undergoing of open-chest surgery to correct the narrowing or blockage of one or more coronary arteries with bypass grafts.
Heart Valve Surgery involving the actual undergoing of open heart surgery to replace or repair heart valve abnormalities.
Surgery to Aorta involving actual undergoing of major surgery to repair or correct aneurysm, narrowing, obstruction or dissection of the aorta through surgical opening of the chest or abdomen. For the purpose of this definition aorta shall mean the thoracic and abdominal aorta but not its branches.

Stroke referring to a cerebrovascular incident including infarction of brain tissue, cerebral and subarachnoid hemorrhage, cerebral embolism, and cerebral thrombosis.
Kidney Failure involving chronic irreversible failure of both kidneys requiring either permanent renal dialysis or kidney transplantation

Aplastic Anemia involving Chronic persistent bone marrow failure which results in anemia, neutropenia and thrombocytopenia requiring treatment
End Stage Lung Disease causing chronic respiratory failure
End Stage Liver Failure evidenced by Permanent jaundice ascites and Hepatic Encephalopathy.

Coma that persists for at least 30 days.
Major Burns representing third degree (full thickness of the skin) burns covering at least 30% of the surface of the Insured / Insured person's body.
xiv) Major Organ/Bone Marrow Transplantation involving human bone marrow using hematopoietic stem cells preceded by total bone marrow ablation; or any one of the human organs limited to heart, lung, liver, kidney or pancreas, that resulted from irreversible end stage failure of the relevant organ.

Multiple Sclerosis

Fulminant Hepatitis involving sub-massive to massive necrosis of the liver by the Hepatitis virus, leading precipitously to liver failure
Motor Neuron Disease characterized by progressive degeneration of corticospinal tracts and anterior horn cells or bulbar efferent neurons which include spinal muscular atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis and primary lateral sclerosis.
Primary Pulmonary Hypertension with substantial right ventricular enlargement confirmed by investigations including cardiac catheterization, resulting in permanent physical impairment due to cardiac impairment resulting in not being able to engage in any physical activity without discomfort. Symptoms may be present even at rest
Terminal Illness involving conclusive diagnosis of an illness that is expected to result in the death of the insured person within 12 months.

Bacterial Meningitis involving bacterial infection causing in severe inflammation of the membranes of the brain or spinal cord resulting in significant, irreversible and permanent neurological deficit. The neurological deficit must persist for at least 6 weeks.

Accident

"Accident" means a sudden, unforeseen and unexpected physical event beyond the control of the Insured/Insured Person resulting in bodily injury, caused by external, visible and violent means.

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Group health insurance features that benefit both employers and employees

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