This is a Family Floater Health Insurance Policy wherein entire family will be covered under single Sum Insured.
The Policy covers reimbursement of Hospitalization expenses for illness/diseases contracted or injury sustained by the Insured Person. In the event of any claim becoming admissible under the policy, the Company either pay directly to the insured if TPA service is not availed by the insured or pay to the Hospital/Nursing Home through TPA the amount of such expenses subject to limits as would fall under different heads mentioned below, as are reasonably and necessarily incurred in respect thereof anywhere in India by or on behalf of such Insured Person but not exceeding Sum Insured (all claims in aggregate) for that family as stated in the Schedule in any one period of insurance.
National Insurance company - PARIVAR – Mediclaim for Family
Cashless Access Services
Claims in respect of Cashless Access Services will be through the list of the network of Hospitals/Nursing Homes and is subject to pre admission authorization. The TPA shall, upon getting the related medical information from the insured persons/ network provider, verify that the person is eligible to claim under the policy and after satisfying itself will issue a pre-authorisation letter/ guarantee of payment letter to the Hospital/Nursing Home mentioning the sum guaranteed as payable, also the ailment for which the person is seeking to be admitted as a patient.
The TPA reserves the right to deny pre-authorisation in case the insured person is unable to provide the relevant medical details as required by the TPA. The TPA will make it clear to the insured person that denial of Cashless Access is in no way construed to be denial of treatment. The insured person may obtain the treatment as
per his/her treating doctor’s advice and later on submit the full claim papers to the TPA for reimbursement subject to admissibility of claim as per terms and conditions of policy.
The TPA may repudiate the claim, giving reasons, if not covered under the terms of the policy. The insured person shall have right of appeal to the insurance company if he/she feels that the claim is payable. The insurance company’s decision in this regard will be final and binding on TPA.