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Base Cover:
The covers listed below are in-built Policy benefits and shall be available to all Insured Persons in accordance with the procedures set out in this Policy.
4.1 Hospitalization
The company shall indemnify medical expenses incurred for Hospitalisation of the Insured Person during the Policy period, up to the Sum Insured specified in the policy schedule, for:

  1. Room Rent, Boarding, Nursing Expenses as provided by the Hospital/Nursing Home up to 1% of the sum insured per day.
  2. Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) expenses up to 2% of the sum insured per day.
  3. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialist Fees whether paid directly to the treating doctor / surgeon or to the hospital
  4. Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, implants, medicines and drugs, costs towards diagnostics, diagnostic imaging modalities and such similar other expenses.

4.1.1 Other Expenses

  1. Actual expenses incurred on treatment of cataract (including cost of the lens) upto 15% of Sum Insured or Rs. 30,000/-, whichever is lower, per eye during the Policy period.
  2. Dental treatment, necessitated due to injury
  3. Plastic surgery necessitated due to disease or injury
  4. All the day care treatments
  5. Expenses incurred on Road Ambulance subject to a maximum of Rs. 2000/- per hospitalisation.

Note to 4.1

  1. Expenses of Hospitalisation for a minimum period of 24 consecutive hours only shall be admissible. However, the time limit shall not apply in respect of Day Care Treatment.
  2. In case of admission to a room at rates exceeding the aforesaid limits in Clause 4.1.i, the reimbursement/payment of all associated medical expenses incurred at the Hospital shall be effected in the same proportion as the admissible rate per day bears to the actual rate per day of Room Rent.

Proportionate Deductions shall not be applied in respect of those hospitals where differential billing is not followed or for those expenses where differential billing is not adopted based on the room category.

4.1.2 Notwithstanding the provisions mentioned in 4.1 above, the maximum city-wise* limit of payment for following medical procedures shall be as under:

Medical Procedure/ Treatment City-wise* Maximum Limit upto Rs. (Inclusive of Room/ICU/OT Charges; Surgeon’s, Anaesthetist’s, doctor’s fees, medicines, internal appliances and the charges incurred during hospitalization period); Procedure Performed in
   Tier I Cities   Tier II Cities   Tier III Cities 
Appendicectomy - laparoscopic 50,000 35,000 30,000
Appendicectomy – open 40,000 30,000 25,000
Arthroscopy 28,000 19,000 17,500
Cholecystectomy – laparoscopic 50,000 37,500 35,000
Cholecystectomy-open 35,000 25,000 23,000
Coronary Angiogram(including dye) 15,000 12,000 11,000
Exploratory Laparotomy 30,000 25,000 20,000
Fissurectomy 25,000 18,500 17,500
Haemorrhoidectomy(Excluding staples & tackers) 36,000 24,000 22,500
Hernia repair - laparoscopic 32,000 23,000 21,000
Hernia repair - Open(including mesh) 31,000 22,000 21,000
Hydrocelectomy - Bilateral 50,000 35,000 30,000
Hydrocelectomy - Unilateral 30,000 18,000 17,000
Hysterectomy - laparoscopic 60,000 50,000 45,000
Hysterectomy - vaginal/open 31,000 22,000 21,000
Mastectomy(Radical) 60,000 38,000 36,000
PID- Discectomy 72,000 47,500 45,000
Septoplasty 22,500 17,000 16,000
Thyroidectomy -HEMI 35,000 25,000 23,000
Thyroidectomy - TOTAL 68,000 43,000 40,500
Tonsillectomy 20,000 14,000 13,000
TURP 51,000 41,000 39,000
Tympanoplasty 41,000 25,000 23,000
Ureterorenoscopic Lithotripsy 35,000 25,000 23,000

 

City classification* City
Tier-I Ahmadabad (including Gandhinagar); Bengaluru; Chennai; Delhi; Greater Mumbai (incl. Thane); Hyderabad (incl. Secunderabad); Kolkata; Pune
Tier-II Agra; Ajmer; Aligarh; Amravati; Amritsar; Asansol; Aurangabad; Bareilly; Belgaum; Bhavnagar; Bhiwandi; Bhopal; Bhubaneshwar; Bikaner; Bokaro Steel City; Chandigarh (including Panchkula and Mohali); Coimbatore; Cuttack; Dehradun; Dhanbad; Durgapur; Durg-Bhilai Nagar; Erode; Faridabad; Firozabad; Ghaziabad; Gorakhpur; Greater Visakhapatnam; Gulbarga; Guntur; Gurugram; Guwahati; Gwalior; Hubli-Dharwad; Indore; Jabalpur; Jaipur; Jalandhar; Jammu; Jamnagar; Jamshedpur; Jhansi; Jodhpur; Kannur; Kanpur; Kochi; Kolhapur; Kollam; Kota; Kozhikode; Lucknow; Ludhiana; Madurai; Malappuram; Malegaon; Mangalore; Mathura-Vrindavan; Meerut; Moradabad; Mysore; Nagpur; Nanded-Waghala; Nashik; Nellore; Noida; Patna; Prayagraj; Puducherry; Raipur; Rajkot; Ranchi; Raurkela; Saharanpur; Salem; Sangli; Siliguri; Solapur; Srinagar; Surat; Thiruvananthapuram; Thrissur; Tiruchirappalli; Tiruppur; Ujjain; Vadodara; Varanasi; Vasai-Virat City; Vijayawada and Warangal
Tier-III All other cities/towns not covered by classification Tier-I or Tier-II

4.2 AYUSH Treatment
The company shall indemnify medical expenses incurred for inpatient care treatment under Ayurveda, Unani, Siddha and Homeopathy systems of medicines during each Policy Year up to the limit of Rs. 15000 in any AYUSH Hospital.

4.3 Pre Hospitalisation
The company shall indemnify pre hospitalisation medical expenses incurred, related to an admissible hospitalisation requiring inpatient care, upto a period of 30 days prior to the date of admissible hospitalisation covered under the policy.

4.4 Post Hospitalisation
The company shall indemnify post hospitalisation medical expenses incurred, related to an admissible hospitalisation requiring inpatient care, upto 60 days from the date of discharge from the hospital, following an admissible hospitalisation covered under the policy.

4.5 Modern Treatment Methods & Advancement in Technologies:
The following procedures will be covered (wherever medically indicated) either as inpatient care or as part of day care treatment in a hospital with a co-payment of 20%, up to 50% of Sum Insured, specified in the policy schedule, during the policy period:

  1. Uterine Artery Embolization & HIFU (High intensity focused ultrasound)
  2. Balloon Sinuplasty
  3. Deep Brain stimulation
  4. Oral Chemotherapy
  5. Immunotherapy- Monoclonal Antibody to be given as injection
  6. Intra Vitreal Injections
  7. Robotic Surgeries
  8. Stereotactic radio surgeries
  9. Bronchial Thermoplasty
  10. Vaporisation of the Prostate (Green laser treatment or holmium laser treatment)
  11. IONM – Intra Operative Neuro Monitoring
  12. Stem Cell Therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered.

OPTIONAL COVERS:
4.6 Out-patient Treatment Cover: (within the Base Sum Insured)
We will cover the Reasonable and Customary Charges incurred on an out-patient basis for medically required consultations, visit(s) to a doctor, diagnostic tests and pharmacy expenses as per standard medical protocol for any epidemic/ pandemic only up to Rs.5000.
The Benefit payable will be within the Base Sum Insured.
For the purpose of this Cover, Out-patient means an Insured Person who is not hospitalized but who visits a hospital, clinic or associated facility for diagnosis or treatment.
The relevant part of Exclusion 6.29 under the policy will stand deleted for this Option.
All claims under this Benefit can be made as per the process defined under Section 8 of the policy, as applicable.

4.7 Daily Cash Allowance on Hospitalisation
We will pay Daily Cash Allowance of Rs. 500 per day subject to a maximum of Rs. 7500 per policy period to the Insured Person for every continuous and completed period of 24 hours of Hospitalisation, subject to the hospitalisation claim being admissible under the policy.
Daily Cash Allowance will not be payable for Day Care Procedure claims where the hospitalisation is less than 24 hours. Deductible equivalent to Daily Cash Allowance for the first 24 hours Hospitalization will be levied on each Hospitalisation during the Policy Period.
The payment under this benefit is over and above the Base Sum Insured.
All claims under this Benefit can be made as per the process defined under Section 8 of the policy, as applicable.

4.8 Benefit Cover for First Diagnosis of Any Epidemic/ Pandemic:;
If an Insured Person is First Diagnosed with any Epidemic/ Pandemic during the Period of Cover, then We will pay Rs. 25000 as a lump sum amount, provided that the Illness/disease was first diagnosed after 14 days from the Risk Inception Date.
On the acceptance of a claim under this Benefit, the cover under this Benefit will terminate in relation to the Insured Person.
This Benefit shall be payable subject to the following:

  1. The Insured must have tested positive for the Epidemic/ Pandemic by a Government authorized/ Government designated laboratory in India, appointed for testing of the Epidemic/ Pandemic.
  2. The diagnosis must be confirmed by only those specific test(s) as defined by Government authorities or as per standard medical protocol.
  3. The lab diagnosis must have been performed after the completion of the initial waiting period of 14 days.

4.8.1 No benefit will be payable if the Insured has been quarantined for any suspected epidemic/ pandemic OR diagnosed with any epidemic/ pandemic prior to the risk inception date or within the initial waiting period of 14 days.
4.8.2 The initial waiting period of 14 days will not apply for this Benefit Cover if the Optional Cover for ‘Waiver of Initial Waiting Period of 30 days for any epidemic/ pandemic has been opted for.
4.8.3 The payment under this benefit is over and above the Base Sum Insured.
4.8.4 Claim documents for this Benefit Cover:
On the occurrence of an Insured Event which may give rise to a claim under this benefit of the Policy, We shall be provided with the following necessary and mandatory information and documentation specified in relation to the Benefit being claimed within 30 days of occurrence of the Insured Event:

  • Duly filled claim form (physical or digital) by the Insured Person/claimant.
  • Lab report with sign and stamp, confirming positive for Epidemic/ Pandemic.
  • Certificate from Government medical officer confirming diagnosis or from any medical practitioner authorised by Government to issue such certificates.

4.9 Waiver of Initial Waiting Period of 30 days for any epidemic/ pandemic: 
On payment of additional Premium as mentioned in Schedule, it is hereby agreed and declared that Exclusion no. 5.2 shall not apply for claims arising out of the hospitalisation due to any Epidemic/ Pandemic.

4.10 Waiver of  Co-Payment clause for pre-existing co-morbidities in case of any epidemic/ pandemic:
On payment of additional Premium as mentioned in Schedule, it is hereby agreed and declared that co-payment condition no. 8.5 shall not apply for claims arising out of the hospitalisation due to any Epidemic/ Pandemic.

4.11 Maternity Benefit Cover:
We will pay a lump sum benefit amount of Rs. 20000 to the female Insured Person above 18 years during the Policy Period for the delivery of a child in a Hospital (including but not limited to caesarean section, vacuum birthing, water birthing, hypnobirthing, midwife birthing).  
4.11.1 This Benefit will be available subject to the following: 

  1. After a waiting period of 9 months from the Date of Inception of cover for the first time under this policy for the Female Insured Member;
  2. Up to a maximum number of two deliveries;
  3. Payment under this cover will be limited to per event and will be over and above the Base Sum Insured.

4.11.2 We will not be liable to make any payment in respect of the following:

  1. Medical Expenses incurred in respect of the delivery/ termination of pregnancy.
  2. Medical Expenses for ectopic pregnancy, which will be covered under Section 4.1 of the Base Cover Terms and Conditions.
  3. Complications arising as a result of infertility Treatment (assisted conception).

4.11.3 The payment under this benefit is over and above the Base Sum Insured.
4.11.4 Claim documents for this Benefit Cover:
On the occurrence of an Insured Event which may give rise to a claim under this Base Benefit of the Policy, We shall be provided with the following necessary and mandatory information and documentation specified in relation to the Benefit being claimed within 30 days of occurrence of the Insured Event:

  • Duly filled claim form (physical or digital) by the Insured Person/claimant.
  • Birth Certificate issued by local Government Body. 
  • Proof of delivery at Hospital/ Medical Centre equipped for conducting delivery.

NOTE:   The expenses that are not covered in this policy are placed under List–I of Annexure–A. The list of expenses that   are to be subsumed into room charges, or procedure charges or costs of treatment are placed under List–II, List–III, and List–IV of Annexure–A respectively of the Policy.

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