1.Age or Aged means age of the Insured person on last birthday as on date of commencement of the Policy.

2.Accident means sudden, unforeseen and involuntary event caused by external, visible and violent means.

3.Annual Renewal Date means the anniversary of the Inception Date each year or any other date which We and the Policyholder may agree in writing.

4.Alternative Treatments are forms of Treatments other than "Allopathy" or "modern medicine" and includes Ayurveda, Unani, Siddha and Homeopathy in the Indian context.

5.Annexure means a document attached and marked as Annexure to this Policy.

6.Ambulance means a road vehicle operated by a licensed/authorized service provider and equipped for the transport and paramedical Treatment of the person requiring medical attention.

7.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.

8.Associated Medical Expenses shall include Room Rent, nursing charges, operation theatre charges, fees of Medical Practitioner/surgeon/ anesthetist/ Specialist and diagnostic tests conducted within the same Hospital where the Insured Person has been admitted.

9.AYUSH Treatment refers to the medical and /or Hospitalization Treatments given under Ayurveda, Unani, Siddha and Homeopathy Systems.

10.Benefit means any benefit shown in the Policy Schedule and/or Certificate of Insurance.

11.Base Sum Insured means the Sum Insured for the Base Cover as specified in the Policy Schedule and/or Certificate of Insurance.

12.Cashless facility means a facility extended by the insurer to the insured where the payments, of the costs of treatment undergone by the insured in accordance with the policy terms and conditions, are directly made to the network provider by the insurer to the extent pre- authorisation is approved.

13.Certificate of Insurance means the certificate We issue to the Insured Person confirming the Insured Person’s cover under the Policy.

14.Condition Precedent means a policy term or condition upon which the Insurer's liability under the policy is conditional upon.

15.Congenital Anomaly means a condition which is present since birth, and which is abnormal with reference to form, structure or position.

a)Internal Congenital Anomaly – Congenital anomaly which is not in the visible and accessible parts of the body.

b)External Congenital Anomaly – Congenital anomaly which is in the visible and accessible parts of the body.

16.Co-Payment means a cost sharing requirement under a health insurance policy that provides that the policyholder/ insured will bear a specified percentage of the admissible claims amount. A co-payment does not reduce the Sum Insured.

17.Cosmetic Surgery means Surgery or medical Treatment that modifies, improves, restores or maintains normal appearance of a physical feature, irregularity, or defect.

18.Cumulative Bonus means any increase or addition in the Sum Insured granted by the insurer without an associated increase in premium.

19.Day Care Treatment means medical treatment, and/or surgical procedure which is:

i.undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 hours because of technological advancement, and

ii.which would have otherwise required a hospitalization of more than 24 hours.

Treatment normally taken on an out-patient basis is not included in the scope of this definition.

20.Day Care Centre means any institution established for day care treatment of illness and / or injuries or a medical setup within 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-

i)has qualified nursing staff under its employment;

ii)has qualified medical practitioner/s in charge;

iii)has fully equipped operation theatre of its own where surgical procedures are carried out;

iv)Maintains daily records of patients and will make these accessible to the insurance company’s authorized personnel.

21.Deductible means a cost sharing requirement under a health insurance policy that provides that the insurer 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 insurer. A deductible does not reduce the Sum Insured.

22.Dental Emergency means severe pain which cannot be relieved by painkillers, or facial swelling or uncontrollable bleeding after an extraction, where such Emergency occurs either outside the business hours of the Employee’s/ Members or Dependent’s usual Dentist or if the Employee/ Member or Dependent is staying at a place which is away from the Dentist they usually visit. The Treatment covered in such an instance is to purely stabilize the problem and relieve severe pain.

23.Dental Injury means an Injury to the Employee/ Member or Dependent’s dentition and supporting structures (including damage to dentures while being worn) caused by extra-oral impact.

24.Dentist means a dentist, dental surgeon or dental practitioner who is registered or licensed as such under the laws of the country, state or other regulated area in which the Treatment is provided.

25.Dependent means the Employee’s / Member’s parents, Spouse or child who have been enrolled in the Policy.

26.Dependent Child refers to a child (natural or legally adopted), who is under Age 25, either in full-time education or residing at the same residence as the Employee/ Member and is financially dependent on the Employee/         Member.

27.Disclosure to information norm -The policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of misrepresentation, miss-description or non-disclosure of any material fact.

28.Dental Treatment means a treatment related to teeth or structures supporting teeth including examinations, fillings (where appropriate), crowns, extractions and surgery.

29.Domiciliary Hospitalization means medical treatment for an illness/disease/injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances:

     a.the condition of the patient is such that he/she is not in a condition to be removed to a hospital, or

b.the patient takes treatment at home on account of non-availability of room in a hospital.

30.Effective Date means the date shown on the Certificate of Insurance on which the Insured Person was first included under the Policy.

31.Eligibility means the provisions of the Policy that state the requirements to be complied with.

32.Employee means any member of Your staff who is proposed and sponsored by You and who becomes an Insured Person under this Policy.

33.Emergency Care means management for an illness or injury which results in symptoms which occur suddenly and unexpectedly, and requires immediate care by a medical practitioner to prevent death or serious long term impairment of the insured person’s health.

34.Emergency shall mean a serious medical condition or symptom resulting from Injury or sickness which arises suddenly and unexpectedly, and requires immediate care and treatment by a Medical Practitioner, generally received within 24 hours of onset to avoid jeopardy to life or serious long term impairment of the Insured Person’s health, until stabilization at which time this medical condition or symptom is not considered an emergency anymore.

35.Exclusions mean specified coverage, hazards, services, conditions, and the like that are not provided for (covered) under a particular health insurance contract.

36.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.

37.Home nursing is arranged by the Hospital for a Qualified Nurse to visit the patient’s home to give expert nursing services immediately after Hospital Treatment for as long as is required by medical necessity, visits for as long as is required by medical necessity for Treatment which would normally be provided in a Hospital.In either case, the Specialist who treated the patient must have recommended these services.

38.Hospital means any institution established for in- patient care and day care treatment of illness and/or injuries and which has been registered as a hospital with the local authorities under Clinical Establishments (Registration and Regulation) Act 2010 or under enactments specified under the Schedule of Section 56(1) and the said act or complies with all minimum criteria as under:

i)has qualified nursing staff under its employment round the clock;

ii)has at least 10 in-patient beds in towns having a population of less than 10,00,000 and at least 15 in-patient beds in all other places;

iii)has qualified medical practitioner(s) in charge round the clock;

iv)has a fully equipped operation theatre of its own where surgical procedures are carried out;

v)Maintains daily records of patients and makes these accessible to the insurance company’s authorized personnel.

40.Hospitalization means admission in a Hospital for a minimum period of 24 consecutive ‘In- patient Care’ hours except for specified procedures/treatments, where such admission could be for a period of less than 24 consecutive hours.

41.Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function and requires medical treatment.

(a)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

(b)Chronic condition - A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics:

(i)it needs on going or long-term monitoring through consultations, examinations, check- ups, and/ or tests

(ii)it needs on going or long-term control or relief of symptoms

(iii)it requires rehabilitation for the patient or for the patient to be specially trained to cope with it

(iv)it continues indefinitely

(v)it recurs or is likely to recur

43.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.

44.Inception Date means the inception date of this Policy as specified in the Policy Schedule or Certificate of Insurance when the coverage under the Policy commences.

45.Inpatient Care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.

46.In-patient means an Employee/ Member or Dependent who is admitted to a Hospital and stays for at least 24 hours for the sole purpose of receiving Treatment.

47.Insured Person means the Employee/ Member or Dependents named in the Policy Schedule/ Certificate of Insurance, who is / are covered under this Policy, for whom the insurance is proposed and the appropriate premium is paid.

48.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.

48.ICU Charges means the amount charged by a Hospital towards ICU expenses which shall include the expenses for ICU bed, general medical support services provided to any ICU patient including monitoring devices, critical care nursing and intensive charges.

49.IRDAI means the Insurance Regulatory and Development Authority of India.

50.Maternity expenses means:

a)medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalization);

b)expenses towards lawful medical termination of pregnancy during the Policy period.

51.Medical Assistance Service is a service which provides Medical Advice, evacuation, assistance and repatriation. This service can be multi-lingual and is available 24 hours a day.

52.Medical Advice means any consultation or advice from a Medical Practitioner including the issuance of any prescription or follow-up prescription.

53.Medical Expenses means those expenses that an Insured Person has necessarily and actually incurred for medical treatment on account of Illness or Accident on the advice of a Medical Practitioner, as long as these are no more than would have been payable if the Insured Person had not been insured and no more than other hospitals or doctors in the same locality would have charged for the same medical treatment.

54.Medical Practitioner means a person who holds a valid registration from the Medical Council of any State or Medical Council of India or Council for Indian Medicine or for Homeopathy set up by the Government of India or a State Government and is thereby entitled to practice medicine within its jurisdiction; and is acting within its scope and jurisdiction of license.

55.Medically Necessary Treatment means any treatment, tests, medication, or stay in hospital or part of a stay in hospital which:

i)is required for the medical management of the illness or injury suffered by the insured; 

ii)must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity;

iii)must have been prescribed by a medical practitioner; 

iv)must conform to the professional standards widely accepted in international medical practice or by the medical community in India.

56.Network Provider means hospitals or health care providers enlisted by an insurer, TPA or jointly by an Insurer and TPA to provide medical services to an insured by a cashless facility.

57.Nominee means the person named in the Policy Schedule or Certificate of Insurance (as applicable) who is nominated to receive the Benefits in respect of an Insured Person or Dependent covered under the Policy in accordance with the terms and conditions of the Policy, if such person is deceased when the Benefit becomes payable.

58.Non-Network Provider means any hospital, day care centre or other provider that is not part of the network.

59.New Born Baby means baby born during the Policy period and is aged upto 90 days.

60.Notification of Claim means the process of intimating a claim to the insurer or TPA through any of the recognized modes of communication.

61.Operation means any procedure described as an operation in the schedule of Surgical Procedures.

62.Out-Patient means a patient who undergoes OPD treatment.

63.OPD treatment means the one in which the Insured visits a clinic / hospital or associated facility like a consultation room for diagnosis and treatment based on the advice of a Medical Practitioner. The Insured is not admitted as a day care or in-patient.

64.Private Room means a single occupancy accommodation in a private Hospital.

65.Policy is sent to You comprising of Policy wordings, Certificates of Insurance issued to the Insured Persons, group proposal form and Policy Schedule/ Certificate Of Insurance which form part of the Policy contract including endorsements, as amended from time to time which form part of the Policy contract and shall be read together.

66.Policy Anniversary Date means the day of the calendar year on which the current Policy coverage commenced.

67.Policy Period means the period between the Inception Date and the expiry date of the Policy as specified in the Policy Schedule/ Certificate of Insurance or the date of cancellation of this Policy, whichever is earlier.

68.Policy Schedule means the schedule attached to and forming part of this Policy mentioning the details of the Insured Persons, the Sum Insured, the period and the limits to which Benefits under the Policy are subject to, including any Annexures and/or endorsements, made to or on it from time to time, and if more than one, then the latest in time.

69.Pre-Existing Disease means any condition, ailment or injury or related condition(s) for which there were signs or symptoms, and / or were diagnosed, and / or for which medical advice / treatment was received within 48 months prior to the first policy issued by the insurer and renewed continuously thereafter.

70.Portability means the right accorded to an individual health insurance policyholder (including family cover) to transfer the credit gained for Pre-Existing Diseases and time bound exclusions if the policyholder chooses to switch from one insurer to another insurer or from one plan to another plan of the same insurer.

71.Pre-hospitalisation Medical Expenses means medical expenses incurred during pre-defined number of days preceding the hospitalisation of the Insured Person, provided that:

i.Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalization was required, and

ii.The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.

72.Post-hospitalisation Medical Expenses means medical expenses incurred during pre-defined number of days immediately after the insured person is discharged from the hospital provided that:

i.Such Medical Expenses are for the same condition for which the insured person’s hospitalisation was required, and

ii.The inpatient hospitalisation claim for such hospitalisation is admissible by the insurance company.

73.Qualified Nurse means a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India.

74.Reasonable and Customary Charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness/ injury involved.

76. Room Rent means the amount charged by a Hospital towards Room and Boarding expenses and shall include the associated medical expenses.

78. Renewal means the terms on which the contract of insurance can be renewed on mutual consent with a provision of grace period for treating the renewal continuous for the purpose of gaining credit for pre-existing diseases, time-bound exclusions and for all waiting periods.

79.Spouse means the Employee's legal husband or wife proposed to be covered under the Policy.

80.Specialist is a Medical Practitioner who:

-- Has received advanced specialist training;

-- Practices a particular branch of medicine or Surgery;

-- Is or has been appointed as a consultant in a Hospital or is or has been appointed to a position in a Hospital Which We accept as being of equivalent status.

It is clarified that a physiotherapist who is registered or licensed as such under the laws of the country, state or other regulated area in which the Treatment is provided is only a Specialist for the purpose of physiotherapy as described in the list of Benefits.

81.Short-Term means a period of time consistent with the recuperation time required for the Treatment and as prescribed by the treating Medical Practitioner with the approval of Our medical director.

82.Sum Insured means, subject to the terms, conditions and exclusions of this Policy, the amount representing Our maximum, total liability for any or all claims arising under this Policy for the respective Benefit(s) in respect of an Insured Person and is as specified in the Policy Schedule and/or Certificate of Insurance against the particular Benefit(s).

83.Surgical Appliance and/or Medical Appliance means:

-- An artificial limb, prosthesis or device which is required for the purpose of or in connection with a Surgery;

-- An artificial device or prosthesis which is a necessary part of the Treatment immediately following Surgery for as long as such device or prosthesis is required by medical necessity.

-- A prosthesis or appliance which is medically necessary and is part of the recuperation process on a Short-Term basis.

84.Service Partner is an assistance company utilized by Us to support You for facilitation of access to Network Providers and for providing Medical Assistance Services. In India such services will be provided by a TPA.

85.Sub Limit defines limitation on the amount of coverage available to cover a specific type of claim. A sublimit is part of, rather than in addition to, the limit that would otherwise apply to the admissible claim amount.

86.Surgery or Surgical Procedure means manual and / or operative procedure (s) required for treatment of an illness or injury, correction of deformities and defects, diagnosis and cure of diseases, relief from suffering and prolongation of life, performed in a hospital or day care centre by a medical practitioner.

87.TPA means any person who is licensed under the IRDAI (Third Party Administrators – Health Services) Regulations 2016 by the IRDAI and is engaged for a fee or remuneration by Us for the purposes of providing health services.

88.Treatment means any relevant treatment controlled or administered by a Medical Practitioner to cure or substantially relieve Illness within the scope of the Policy.

89.Unproven/Experimental Treatment means the treatment, including drug experimental therapy, which is not based on established medical practice in India, is treatment experimental or unproven.

90.Waiting Period means a time bound exclusion period related to condition(s) specified in the Policy Schedule or Certificate of Insurance or Policy which shall be served before a claim related to such condition(s) becomes admissible.

91.We/Our/Us means the United India Insurance Company Limited.

92.You/Your/Policyholder means the person named in the Policy Schedule/ Certificate of Insurance who has concluded this Policy with Us.