1. A Policy where entire Family of Four are covered under a single sum insured.
2. Coverage for Parents( Up to age 60 years ) is optional.
3. No pre-acceptance Medical Check.

The insurer will indemnify, subject always to the Sum Insured selected, the Insured against :

1. The Medical Charges incurred by the Insured or family members specified in the Schedule, as a result of suffering Illness or Bodily Injury during the Period of Insurance, which on the advice of a Medical Practitioner requires Hospitalization; expenses of Hospitalization for minimum period of 24 Hours are admissible. However, this time limit is not applied to specific treatments i.e. day care treatment for stitching of wound/s, close reduction/s and application of POP casts, Dialysis, Chemotherapy, Radiotherapy, Arthroscopy, Eye surgery, ENT surgery, Laparoscopic surgery ,Angiographies, Endoscopies, Lithotripsy (Kidney stone removal), D & C, Tonsillectomy taken in the Hospital/Nursing Home and the Insured is discharged on the same day. The treatment will be considered to be taken under Hospitalization benefit. This condition will also not apply in case of stay in Hospital of less than 24 hours provided –  a.   the treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available in Hospitals       and b. due to technological advances hospitalization is required for less then 24 hours only.
   
   
2. Pre-hospitalization Medical Charges incurred by the Insured for a 15 days period immediately preceding the Insured's admission to the Hospital for the illness or Bodily injury;
   
   
3. Post-hospitalization Medical Charges incurred by the Insured for a 30-days period immediately succeeding the Insured's discharge from the Hospital for the illness or Bodily injury, Provided that the entire periods as specified in (ii) and (iii) above fall within the Period of Insurance. Notwithstanding anything contained herein, this Policy shall not apply to any Medical charges incurred by the Insured in any place or geographical area other than in Nepal. The insurer's indemnification liability under this Policy shall not exceed Sum Insured per Insured Person as stated in the  Schedule during the Period of Insurance.

The following Charges shall be reimbursable under the Policy:

1.  Room, Boarding expenses as provided by the Hospital/Nursing Home which also include Nursing care, Inter Venus fluids/Blood transfusion/Injection charges-
   
   • If admitted in I C Unit  -  LIMIT : Up to 4% of Sum Insured per day.                                            
     Other than I C Unit -  LIMIT : Up to 2% of Sum Insured per day .
     
     
2. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees, Nursing Expenses   LIMIT : Actual. 
3. Anesthesia, Blood, Oxygen, OT charges, Surgical appliances (any disposable surgical consumables subject to upper limit of 7% of the S.I), Medicines, Drugs, Diagnostic material & X-Ray, Dialysis, Chemotherapy, Radiotherapy, cost of Pacemaker, artificial Limbs. Cost of Stent and implants LIMIT :   Actuals.
   
   
   • N.B.    (a)   Total expenses incurred for any one illness is limited to 50% of the overall Sum Insured per family.
   • Insurer’s liability in respect of all claims admitted during the period of Insurance shall not exceed the Sum Insured per family as mentioned in the Schedule.
   • Hospitalization expenses of person donating an organ during the course of organ transplant will also be payable subject to the sub limits under “C” above applicable to the insured person within the overall sum insured of the insured person.

Definitions

For the purposes of this policy, the terms specified below shall have the meaning setforth:

“Policy” means the Policy booklet, the Schedule and any applicable endorsement. The policy contains details of the extent of cover available to the insured, the exclusions from the cover and the terms and conditions of the issue of the Policy.

"Insured" means the Individual(s) whose name(s) are specifically appearing as such in Part I of the Schedule to this Policy.

"Accident" means an unexpected, unforeseen and undesirable event, especially one resulting in bodily injury.

"Bodily Injury" means any accidental physical bodily harm solely and directly caused by external, violent and visible and evident causes but does not include any sickness or disease.

"Illness" means sickness, disease first diagnosed during the period of insurance for which immediate treatment by a medical practitioner is necessary.

“Family” means Self, Spouse & two dependant children. Parents may be opted for cover with addl.Premium.

“Limit of Indemnity” means the Sum Insured in the Schedule against the name of each insured which sum represent the insurer’s maximum liability for any and all claims for that insured regardless of the number of claims made by that insured or his/her behalf during the policy period.

Hospital/Nursing Home, means any institution in Nepal established for indoor care and treatment of disease and injuries and which either.

 a. Has been registered either as a Hospital or Nursing Home with the local authorities and is under the supervision of a registered and qualified medical practitioner and Nurses under its employment round the clock.
       or
 b. Hospital/Nursing Home run by Government.
  
3.8.1 ‘Hospital/Nursing Home’, shall not include an establishment which is a place of rest, a place for the aged, a place for drug addiction or place of alcoholics, a hotel or a similar place.

Surgical Operation means manual and/or operative procedures for correction of deformities and defects, repair of injuries, diagnosis and cure of diseases, relief or suffering and prolongation of life.
 
Any One Illness will be deemed to mean continuous period of illness and it includes relapse within 45 days from the date of last consultation with the Hospital/Nursing Home where treatment may have been taken. Occurrence of same illness after a lapse of 45 days as stated above will be considered as fresh illness for the purpose of this policy.
                                                        
Medical Practitioner means a person who holds a degree/diploma from a recognized institution and is registered by the Medical Council of Nepal. The term Medical Practitioner would include Physician, Specialist and Surgeon.
 
Qualified Nurse means a person who holds a certificate of a recognized Nursing Council and who is employed on the recommendations of the attending Medical Practitioner.
 
Pre-Hospitalization : Relevant medical expenses incurred during period up to 15 days prior to hospitalization on disease/illness/injury sustained will be considered as part of claim mentioned under Hospitalization Expenses.
 
Post-Hospitalization : Relevant medical expenses incurred during period upto 30 days after hospitalization on disease/illness/injury sustained will be considered as part of claim mentioned under Hospitalization Expenses.

Limit of Indemnity means the Sum Insured in the Schedule against the name of each insured which sum represent the insurer’s maximum liability for any and all claims for that insured regardless of the number of claims made by that insured or his/her behalf during the policy period.

Exclusions

The Company shall not be liable to make any payment under this Policy in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of :
 
All diseases/injuries which are pre-existing when the cover incepts for the first time. However, those diseases will be covered after four continuous claim free policy years. For the purpose of applying this condition, the period of cover under Health policy taken from National Insurance Company only will be considered. Pre-existing disease like Diabetes and Hypertension will be covered from the inception of the policy on payment of additional premium by the insured.
 
Insured shall bear 10% of any admissible claim if he is suffering from either Diabetes or Hypertension and 25% of the admissible claim amount in case he is suffering from both diabetes and hypertension. This provision is applicable only for claims arising out of Diabetes and/or  Hypertension.
 
Any disease other than those stated in Clause 4.3, contracted by the Insured Person during the first 30 days from the commencement date of the policy. This condition 4.2 shall not however, apply in case hospitalization due to accidental injury or if the Insured Person having been covered under this scheme or a similar Health Insurance Scheme with any of the Nepalese Insurance Companies for a continuous period of preceding 12 months without any break.

 Expenses incurred on treatment of following diseases within the first two years from the commencement of the Policy, will not be payable:
• Cataract       • Benign Prostatic Hypertrophy     • Myomectomy, Hysterectomy unless because of malignancy
 • Hernia, Hydrocele     • Fistula in anus, piles      • Arthritis, gout, rheumatism   • Joint replacements unless due to accident           • Sinusitis and related disorders    • Stones in the urinary and biliary systems  • Dilatation and curettage • Skin and all internal tumors/ cysts/nodules/ polyps of any kind  including breast lumps unless malignant/adenoids and Hemorrhoids     • Dialysis required for chronic renal failure     • Surgery on tonsils, adenoids and sinuses • Gastric and Duodenal ulcers.

In case the above illnesses are not preexisting   at the commencement of this policy, then this exclusion shall cease to apply if the Insured has taken Healthcare   Policy from this insurer and has been covered under the policy,   without a break, for a period of two consecutive years immediately  preceding the Period of Insurance.

In case the above illnesses are pre-existing at the commencement of this policy, then this exclusion shall cease to apply(other than Congenital Disease/Defect) if the Insured has taken a Healthcare Policy from this insuer, without a break, for a period of 4 consecutive years immediately preceding the Period of Insurance.
  
If the Insured is aware of the existence of Congenital Internal Disease/Defect before inception of the policy, the same will be treated as pre-existing.
 
Injury or disease directly or indirectly caused by or arising from or attributable to War Invasion Act of Foreign Enemy Warlike operations (whether war be declared or not).
 
Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident, vaccination or inoculation or change of life or cosmetic or aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as part of any illness.

The cost of spectacles, contact lenses and hearing aids.

Any Dental treatment or surgery which is a corrective, cosmetic or aesthetic procedure, including wear and tear, unless arising from accidental injury and which requires hospitalization for treatment.

Convalescence general debility ‘Run Down’ condition or rest cure, congenital external disease or defects or anomalies, sterility, venereal disease, obesity, intentional self-injury and use of intoxicating drugs/alcohol.

All expenses arising out of any condition directly or indirectly caused to or associated with Human T-Cell Lymphotrophic Virus Type III (HTLB-III) or Lymphadinopathy associated Virus (LAV) or the Mutants Derivative or variations Deficiency Syndrome or any Syndrome or condition of a similar kind commonly referred to as AIDS.
 
Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-Ray or laboratory examinations or other diagnostic studies not consistent with nor incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury for which confinement is required at a Hospital/Nursing Home.

a) Treatment of metal illness, stress, psychiatric or psychological disorder.
 b) Birth control procedures and hormone replacement therapy.
c) Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician.

Injury or disease directly or indirectly caused by or contributed to by nuclear weapons/materials.

Treatment arising from or traceable to pregnancy childbirth, miscarriage, abortion or complication (except accident origin) of any of these  including caesarean section.

• Any treatment other than Allopathic System of Medicine. 4.15 Domiciliary

To Download, Right click "Save Target As"/ "Save Link As"