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  • Age means age of the Insured person on last birthday as on date of commencement of the Policy.
  • Cashless Facility means a facility extended by the insurer to the insured where the payments, of the costs of treatment undergone by the insured person in accordance with the Policy terms and conditions, are directly made to the network provider by the insurer to the extent pre-authorization is approved.
  • Co-morbidity is the presence of one or more additional conditions co-occurring with a primary condition; in the countable sense of the term, a comorbidity is each additional condition.
  • 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.
  • Day Care Treatment means medical treatment, and/or surgical procedure which is:
  1. undertaken under general or local anaesthesia in a hospital/day care centre in less than twenty-four hours because of technological advancement, and
  2. which would have otherwise required a hospitalisation of more than twenty-four hours.

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

  • Epidemic: The occurrence of more cases of a disease than would be expected in a community or region spreading rapidly during a given time period; and declared as such by the appropriate Government Authority in India. 
  • Hospital means any institution established for in-patient care and day care treatment of disease/injuries and which has been registered as a Hospital with the local authorities under the Clinical establishments (Registration and Regulation) Act, 2010 or under the enactments specified under Schedule of Section 56(1) of the said Act, OR complies with all minimum criteria as under:
  1. has qualified nursing staff under its employment round the clock;
  2. has at least ten inpatient beds, in those towns having a population of less than ten lakhs and at least fifteen inpatient beds in all other places;
  3. has qualified medical practitioner(s) in charge round the clock;
  4. has a fully equipped operation theatre of its own where surgical procedures are carried out
  5. maintains daily records of patients and shall make these accessible to the Company’s authorized personnel.
  • Hospitalisation means admission in a hospital for a minimum period of twenty four (24) consecutive ‘In-patient care’ hours except for specified procedures/treatments, where such admission could be for a period of less than twenty four (24) consecutive hours.
  • In-Patient Care means treatment for which the Insured Person has to stay in a hospital for more than 24 hours for a covered event.
  • Insured Person means person(s) named in the schedule of the Policy.
  • Medical Advice means any consultation or advice from a Medical Practitioner including the issue of any prescription or follow up prescription.
  • 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.
  • Medically Necessary Treatment means any treatment, tests, medication, or stay in hospital or part of a stay in hospital which 
  1. is required for the medical management of illness or injury suffered by the insured; 
  2. must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity; 
  3. must have been prescribed by a medical practitioner; 
  4. must conform to the professional standards widely accepted in international medical practice or by the medical community in India.
  • Medical Practitioner means a person who holds a valid registration from the Medical Council of any State of India 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 the scope and jurisdiction of the license.
  • Network Provider means hospitals enlisted by Insurer, TPA or jointly by an Insurer and TPA to provide medical services to an Insured by a cashless facility.
  • Non-Network Provider means any hospital that is not part of the network.
  • Notification Of Claim means the process of intimating a claim to the Insurer or TPA through any of the recognised modes of communication.
  • Out-Patient (OPD) Treatment means treatment 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.
  • Pandemic means an epidemic of disease that has spread across a large region, for instance multiple continents or worldwide, affecting a substantial number of people; and declared as such by the World Health Organisation and appropriate Government Authority in India.
  • Pre-Existing Disease (PED): Pre-existing disease means any condition, ailment or injury or disease: 
  1. That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the Insurer or
  2. For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy or its reinstatement.
  • Pre-Hospitalisation Medical Expenses means medical expenses incurred during the period of 30 days preceding the hospitalisation of the Insured Person, provided that:
  1. Such medical expenses are incurred for the same condition for which the Insured Person’s Hospitalisation was required, and
  2. The In-Patient Hospitalisation claim for such Hospitalisation is admissible by the Insurance Company.
  • Post-Hospitalisation Medical Expenses means medical expenses incurred during the period of 60 days immediately after Insured Person is discharged from the hospital, provided that:
  1. Such medical expenses are for the same condition for which the Insured Person’s hospitalisation was required, and
  2. The in-patient hospitalisation claim for such hospitalisation is admissible by the Insurance Company.
  • Policy means these Policy Wordings, the Policy Schedule and any applicable endorsements or extensions attaching to or forming part thereof. The Policy contains details of the extent of cover available to the Insured Person, what is excluded from the cover and the terms & conditions on which the Policy is issued to The Insured Person.
  • Policy period means period of one policy year as mentioned in schedule for which the Policy is issued.
  • Policy Schedule means the Policy Schedule attached to and forming part of Policy
  • 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.
  • 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.
  • Room Rent means the amount charged by a hospital towards Room and Boarding expenses and shall include the associated medical expenses.
  • Sub-Limit means a cost sharing requirement under a health insurance policy in which an Insurer would not be liable to pay any amount in excess of the pre-defined limit.
  • Sum Insured means the pre-defined limit specified in the Policy Schedule. Sum Insured represents the maximum, total and cumulative liability for any and all claims made under the Policy, in respect of that Insured Person (on Individual basis) or all Insured Persons (on Floater basis) during the policy period.
  • 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 of suffering or prolongation of life, performed in a Hospital or Day Care Centre by a Medical Practitioner.
  • Third Party Administrator (TPA) means a Company registered with the Authority, and engaged, by an Insurer, for a fee or by whatever name called and as may be mentioned in the health services agreement, for providing health services. 
  • Waiting Period means a period from the inception of this Policy during which Covid is not covered.

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