The Policy provides base coverage as described below in this section provided that the expenses are incurred on the written Medical Advice of a Medical Practitioner and are incurred on Medically Necessary Treatment of the Insured Person.

1. In-patient Hospitalisation Expenses Cover - We will pay the Reasonable and Customary Charges for the following Medical Expenses of an Insured Person in case of Medically Necessary Treatment taken during Hospitalisation provided that the admission date of the Hospitalisation due to Illness or Injury is within the Policy period:

A.Room, Boarding and Nursing expenses as provided by the Hospital/Nursing Home up to the category/limit specified in the Policy Schedule/ Certificate of Insurance or actual expenses incurred, whichever is less, including nursing care, RMO charges, IV Fluids/Blood transfusion/injection administration charges and similar expenses.

B.Charges for accommodation in ICU/CCU/HDU up to the category/limit specified in the Policy Schedule/ Certificate of Insurance or actual expenses incurred, whichever is less,

C.Operation theatre cost,

D.Anaesthesia, Blood, Oxygen, Surgical Appliances and/ or Medical Appliances, Cost of Artificial Limbs, cost of prosthetic devices implanted during surgical procedure like pacemaker, orthopaedic implants, infra cardiac valve replacements, vascular stents, and other medical expenses related to the treatment.

E.The fees charged by the Medical Practitioner, Surgeon, Specialists and anaesthetists treating the Insured Person;

F.Medicines, drugs and other allowable consumables prescribed by the treating Medical Practitioner;

G.Cost of Investigative tests or diagnostic procedures directly related to the Injury/Illness for which the Insured Person is hospitalized such as but not limited to Radiology, Pathology tests, X-rays, MRI and CT Scans, Physiotherapy.

Note 1: Proportionate Clause: If the Insured Person is admitted in the hospital in a room where the room category or the Room Rent incurred is higher than the eligibility as specified in the Policy Schedule/ Certificate of Insurance, then the Policyholder/ Insured Person shall bear a rateable proportion of the total Associated Medical Expenses (including surcharge or taxes thereon) in the proportion of the difference between the Room Rent of the entitled room category/eligible Room Rent to the Room Rent actually incurred. However, this will not be applicable in respect of Medicines & Drugs and implants.

Note 2: Mental Illness Cover Limit:

In case of following mental illnesses the Inpatient Hospitalization benefit will be covered upto the limit as mentioned in the schedule;

1.Schizophrenia (ICD - F20; F21; F25)

2.Bipolar Affective Disorders (ICD - F31; F34)

3.Depression (ICD - F32; F33)

4.Obsessive Compulsive Disorders (ICD - F42; F60.5)

5.Psychosis (ICD - F 22; F23; F28; F29)

 All claims under this Benefit can be made as per the process defined under Section V. C and D

2. Day Care Treatment Cover - We will cover the Medical Expenses incurred on the Insured Person’s Day Care Treatment during the Policy Period following an Illness or Injury that occurs during the Policy Period provided that:

(i)The Medical Expenses are incurred in case of Day Care Treatment or Surgery undertaken for the Illness/ condition covered under Base Cover that requires less than 24 hours Hospitalisation due to advancement in technology, including for any procedure which requires a period of specialized observation or care after completion of the procedure undertaken by an Insured Person as Day Care Treatment

(ii)The Day Care Treatment is for Medically Necessary Treatment and follows the written Medical Advice;

(iii)Any Treatment in an Out-Patient department (OPD) is not covered under this Benefit.

 The benefit under the policy will be limited to the amount specified in the Policy Schedule/ Certificate of Insurance, whichever is less.

 All claims under this Benefit can be made as per the process defined under Section V. C and D

3. Pre – hospitalisation Medical Expenses Cover - We will cover, on a reimbursement basis, the Insured Person’s Pre-hospitalization Medical Expenses incurred due to an Illness or Injury that occurs during the Policy Period upto the number of days and upto the amount limit as specified in the Policy Schedule or Certificate of Insurance Or actual expenses incurred, whichever is less, provided that:

(i)We have accepted a claim for In-patient Hospitalization under Section II.1 or II.2 above;

(ii)The Pre-hospitalisation Medical Expenses are related to the same Illness or Injury.

(iii)The date of admission to the Hospital for the purpose of this Benefit shall be the date of the Insured Person’s first admission to the Hospital in relation to the same Any One Illness.

 All claims under this Benefit can be made as per the process defined under Section V. D

4. Post – hospitalisation Medical Expenses Cover - We will cover, on a reimbursement basis, the Insured Person’s Post-hospitalization Medical Expenses incurred following an Illness or Injury that occurs during the Policy Period upto the number of days and upto the amount limit as specified in the Policy Schedule or Certificate of Insurance, provided that:

(i)We have accepted a claim for In-patient Hospitalization under Section II.1 or II.2 above;

(ii)The Post-hospitalisation Medical Expenses are related to the same Illness or Injury.

(iii)The date of discharge from the Hospital for the purpose of this Benefit shall be the date of the Insured Person’s last discharge from the Hospital in relation to the same Any One Illness for which We have accepted an In-patient Hospitalization claim under Section II.1 or II.2 above.

 All claims under this Benefit can be made as per the process defined under Section V. D

5. Road Ambulance Cover - We will cover the costs incurred up to the limit as specified in the Policy Schedule or Certificate of Insurance on transportation of the Insured Person by road Ambulance to a Hospital for treatment in an Emergency following an Illness or Injury which occurs during the Policy Period. It becomes payable if a claim has been admitted under Section II.1 or II.2 and the expenses are related to the same Illness or Injury.

We will also cover the costs incurred on transportation of the Insured Person by road Ambulance in the following circumstances up to the limits specified in the Policy Schedule or Certificate of Insurance:

 (i)it is medically required to transfer the Insured Person to another Hospital or diagnostic centre during the course of Hospitalization for advanced diagnostic treatment in circumstances where such facility is not available in the existing Hospital;

(ii)it is medically required to transfer the Insured Person to another Hospital during the course of Hospitalization due to lack of speciality treatment in the existing Hospital.

 All claims under this Benefit can be made as per the process defined under Section V. D

6. Domiciliary Hospitalisation Cover - We will cover Medical Expenses, up to the limit specified in the Policy Schedule/ Certificate of Insurance, incurred for the Insured Person’s Domiciliary Hospitalization during the Policy Period following an Illness or Injury that occurs during the Policy Period provided that:

i.The Domiciliary Hospitalisation continues for at least 3 consecutive days in which case We will make payment under this Benefit in respect of Medical Expenses incurred from the first day of Domiciliary Hospitalisation;

ii.The treating Medical Practitioner confirms in writing that Domiciliary Hospitalization was medically required and the Insured Person’s condition was such that the Insured Person could not be transferred to a Hospital or the Insured Person satisfies Us that a Hospital bed was unavailable;

iii.If a claim is accepted under this Benefit then We shall not pay any Post-hospitalization Medical Expenses, but We will accept a claim for Pre-hospitalization Medical Expenses subject to the terms and conditions of Section II.3 above;

iv.We shall not be liable to pay for any claim in connection with:

a.Asthma, bronchitis, tonsillitis and upper respiratory tract infection including laryngitis and pharyngitis, cough and cold, influenza;

b.Arthritis, gout and rheumatism;

c.Chronic nephritis and nephritic syndrome;

d.Diarrhoea and all type of dysenteries, including gastroenteritis;

e.Diabetes mellitus and insipidus;

f.Epilepsy;

g.Hypertension;

h.Psychiatric or psychosomatic disorders of all kinds;

i.Pyrexia of unknown origin.

 All claims under this Benefit can be made as per the process defined under Section V. D

7. Donor Expenses Cover - We will cover the In-patient Hospitalization Medical Expenses incurred for an organ donor’s treatment during the Policy Period for the harvesting of the organ donated up to the limit as specified in the Policy Schedule or Certificate of Insurance provided that:

i.The donation conforms to The Transplantation of Human Organs Act 1994 and the organ is for the use of the Insured Person;

ii.We have admitted a claim towards In-patient Hospitalisation under the Base Cover and it is related to the same condition; organ donated is for the use of the Insured Person as certified in writing by a Medical Practitioner;

iii.We will not cover:

a.Pre-hospitalization Medical Expenses or Post-hospitalization Medical Expenses of the organ donor;

b.Screening expenses of the organ donor;

c.Costs directly or indirectly associated with the acquisition of the donor’s organ;

d.Transplant of any organ/tissue where the transplant is experimental or investigational;

e.Expenses related to organ transportation or preservation;

f.Any other medical treatment or complication in respect of the donor, consequent to harvesting.

 All claims under this Benefit can be made as per the process defined under Section V. C and D

 There are Optional covers available with the Policy. Refer Section VIII – Optional Covers: Policy Terms and Conditions for Optional Covers for further details on these.

 III.COVER TYPE

The Policy provides cover on an Individual or Family Floater basis. A separate Sum Insured for each Insured Person, as specified in the Policy Schedule/ Certificate, is provided under Individual basis while under Family Floater basis, the Sum Insured limit is shared by the whole family of the group member as specified in the Policy Schedule/ Certificate of Insurance and Our total liability for the family cannot exceed the Sum Insured in a Policy period. The cover type basis shall be as specified in the Policy Schedule/ Certificate of Insurance. The basis of cover chosen for the Base Cover is applicable for the Optional Covers as well.

 Relationships covered under the Policy are as specified in the Policy Schedule/ Certificate of Insurance.