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060. The premium of the “Community based Universal Health Insurance Scheme” launched during 2003-04 ranges from
1. Rs.1 per day poor and individual to Rs.2 per day for a family of seven
2. Rs.1 per day poor and individual to Rs.3 per day for a family of seven
3. Rs.2 per day poor and individual to Rs.2 per day for a family of seven
4. Rs.1 per day poor and individual to Rs.7 per day for a family of seven
Answer
1. Rs.1 per day poor and individual to Rs.2 per day for a family of seven
Reference
http://www.niacl.com/social-universal.html
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Discussion and Explanation
Salient features of the Universal Health Insurance Scheme are given below
Benefits
Ä Medical Reimbursement
o The policy provides reimbursement of hospitalisation expenses upto Rs.30,000/- to an individual /family subject to the following sublimits:
o (i) Room, Boarding expenses upto Rs.150/- per day
o (ii) If admitted in ICU upto Rs.300/- per day
o Surgeon, Anaesthetist, Consultant, specialists fees, Nursing expenses upto Rs.4,500/- per illness/ injury
o Anaesthesia, Blood, Oxygen, OT charges, Medicines, Diagnostic material & X-Ray, Dialysis, Radiotherapy, Chemotherapy, Cost of pacemaker, Artificial limb, etc upto Rs. 4,500/- per illness/ injury
o Total expenses incurred for any one illness upto Rs. 15,000/-
Ä Personal Accident Cover
o Coverage for Death of the Earning Head of the family (as named in the schedule) due to accident: Rs. 25,000/-.
Ä Disability Cover
o If the earning head of the family is hospitalized due to an accident / illness a compensation of Rs.50/- per day will be paid per day of hospitalization up to a maximum of 15 days after a waiting period of 3 days.
Ä For purpose of this policy HOSPITAL means:
o Any Hospital/ Nursing home registered with the local authorities and under the supervision of a registered and qualified Medical practitioner.
o Hospital/ Nursing Home run by Government.
o Enlisted hospitals run by NGOS / Trusts / selected private hospitals with fixed schedule of charges.
o It should have minimum 15 beds (10 in case of class 'C' cities having a population lest than 5 lakhs) with fully equipped OT, fully qualified nursing staff round the clock and fully qualified doctor should be in charge round the clock.
o Hospitalization should be for a minimum period of 24 hrs. However this time limit is not applied to some specific treatments and also where due to technological advancement hospitalization for 24 hrs may not be required.
Ä For an individual
o Rs. 1.00 per day
o Rs. 365/- per annum
Ä For a family upto 5 (including the first3 children)
o Rs. 1.00 per day
o Rs. 548/- per annum
Ä For a family upto 7 (including the first 3 children and dependent parents)
o Rs. 2.00 per day
o Rs. 730/- per annum
Premium Subsidy For BPL Families
Ä For families below the poverty line the Government will provide a premium subsidy of Rs.100/- per family.
Main Exclusions
Ä All pre-existing diseases.
Ä All diseases contracted during the first 30 days from the Commencement date of the policy Provided that in the opinion of the panel doctor/s the insured person could not have known about the existence of disease or its symptoms at the time of making the proposal AND had not taken any consultation, treatment for the disease prior to taking the insurance.
Ä Some of the diseases such as Cataract, Benign Prismatic Hypertrophy, Hysterectomy, hernia, Hydrocele, Fistula in anus, piles, sinusitis, Congenital internal disease are not covered in the first year of the policy.
Ä Corrective, cosmetic or aesthetic dental surgery or treatment.
Ä Cost of spectacles, contact lens and hearing aid.
Ä Vaccination, inoculation, change of life or cosmetic treatment or surgery HIV, AIDS, Sterility, Venereal Disease, Intentional Self injury, use of Intoxicating Drugs/ Alcohol.
Ä Primarily diagnostic expenses not related to sickness/ injury.
Ä Treatment for Pregnancy, Childbirth, Miscarriage, abortion etc.
Ä Claim settlement to be done through TPAS mentioned in the schedule or by the insurance company. To be made cashless as far as possible through listed hospitals.
Ä Any One Illness
o Will be deemed to mean continuous period of illness and it includes relapse within 60 days from the date of last consultation with the hospital.
Ä Age Limitations
o This Policy covers people between the age of 3 months to 65 years.
Ä Family
o Means earning head, spouse and up to maximum of three dependent children. Dependent parents can also be included.
Ä Floater Basis
o The benefit of family will operate on floater basis i.e. the total reimbursement of Rs.30,000/- can be availed of individually or collectively by members of the family.
Comments
Policy details given are indicative, not exhaustive. Please contact your nearest NIA office (www.niacl.com) for further details.
Tips
This scheme is also being offered by Oriental Insurance Company Ltd http://orientalinsurance.nic.in/
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