Dishaarogya Dham Foundation's Health Card Guidelines
- OBJECTIVE:
- APPLICABILITY:
- LEGAL AND OTHER PROVISIONS:
- EFFECTIVE DATE:
- Accident:
- An accident means sudden, unforeseen and involuntary event caused by external, visible and violent means.
- Any one illness: (not applicable for Travel and Personal Accident Card)
- Any one illness means continuous period of illness and includes relapse within 45 days from the date of last consultation with the Hospital/Nursing Home where treatment was taken.
- Cashless facility:
- Cashless facility means a facility extended by the DAD to the Card Holder where the payments, of the costs of treatment undergone by the Card Holder in accordance with the policy terms and conditions, are directly made to the network provider by the Card Holder to the extent pre-authorization is not approved.
- Condition Precedent:
- Condition Precedent means a policy term or condition upon which the Card Holder liability under the policy is conditional upon.
- Congenital Anomaly:
- Congenital Anomaly means a condition which is present since birth, and which is abnormal with reference to form, structure or position.
- Internal Congenital Anomaly Congenital anomaly which is not in the visible and accessible parts of the body.
- External Congenital Anomaly Congenital anomaly which is in the visible and accessible parts of the body
- Co-payment means a cost sharing requirement under a health Card policy that provides that the Card holder will bear a specified percentage of the admissible claims amount. A co-payment does not reduce the Sum Insured.
- Cumulative Bonus:
- Cumulative Bonus means any increase or addition in the Card Holder granted by the DAD without an associated increase in premium.
- Day Care Centre:
- A day care center means any institution established for day care treatment of illness and/or injuries or a medical setup with a hospital and which has been registered with the local authorities, wherever applicable, and is under supervision of a registered and qualified medical practitioner AND must comply with all minimum criterion as under –
- Has qualified nursing staff under its employment;
- Has qualified medical practitioner/s in charge;
- Has fully equipped of its own where Ayurveda & Naturopathy Treatment procedures are carried out;
- Maintains daily records of patients and will make these accessible to the Card Company’s authorized personnel.
- Day Care Treatment:
- Day care treatment means Ayurveda treatment, and/or Naturopathy procedure which is:
- Undertaken under General or Local Anesthesia in a hospital/day care center in less than 24 hrs. because of technological advancement, and
- Which would have otherwise required hospitalization of more than 24 hours.
- Treatment normally taken on an out-patient basis is not included in the scope of this definition.
- (DAD Center may, in addition, restrict coverage to a specified list).
- Deductible means a cost sharing requirement under a health Card policy that provides that the DAD will not be liable for a specified rupee amount in case of indemnity policies and for a specified number of days/hours in case of hospital cash policies which will apply before any benefits are payable by the DAD. A deductible does not reduce the Sum Insured.
- (DAD to define whether the deductible is applicable per year, per life or per event and the manner of applicability of the specific deductible)
- Grace Period:
- Grace period means the specified period of time immediately following the premium due date during which a payment can be made to renew or continue a policy in force without loss of continuity benefits such as waiting periods and coverage of pre-existing diseases. Coverage is not available for the period for which no premium is received.
- Illness: Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function and requires medical treatment.
- Acute condition - Acute condition is a disease, illness or injury that is likely to respond quickly to treatment which aims to return the person to his or her state of health immediately before suffering the disease/ illness/ injury which leads to full recovery
- Chronic condition - A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics:
- it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /or tests it needs ongoing or long-term control or relief of symptoms
- it requires rehabilitation for the patient or for the patient to be specially trained to cope with it
- it continues indefinitely it recurs or is likely to recur
- Spine Injury means accidental physical bodily harm excluding illness or disease solely and
- Directly caused by external, violent, visible and evident means which is verified and Certified by a Medical Practitioner.
- Inpatient Care (not applicable for Overseas Travel Card):
- Inpatient care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.
- Intensive Care Unit:
- Intensive care unit means an identified section, ward or wing of a hospital which is under the constant supervision of a dedicated medical practitioner(s), and which is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards.
- Maternity expenses:
- Medical treatment expenses traceable to Infertility (including complicated sections incurred during hospitalization);
- Expenses towards lawful medical termination of pregnancy during the policy period.
- Medical Advice:
- Medical Advice means any consultation or advice from a Medical Practitioner including the issuance of any prescription or follow-up prescription.
- Medical Expenses:
- Medical Expenses means those expenses that a Card Holder Person has necessarily the same locality would have charged for the same medical treatment.
- 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 months.
- Motor neuron disease diagnosed by a specialist medical practitioner as spinal muscular atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis or primary lateral sclerosis. There must be progressive degeneration of corticospinal tracts and anterior horn cells or bulbar efferent neurons. There must be current significant and permanent functional neurological impairment with objective evidence of motor dysfunction that has persisted for a continuous period of at least 3 months.
- The unequivocal diagnosis of Definite Multiple Sclerosis confirmed and evidenced by all of the following:
- investigations including typical MRI findings which unequivocally confirm the diagnosis to be multiple sclerosis and
- There must be current clinical impairment of motor or sensory function, which must have persisted for a continuous period of at least 6 months.
- Other causes of neurological damage such as SLE and HIV are included.
Allpsychiatric related causes are excluded.
CHAPTER 3