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EXCLUSIONS
WHAT POLICY DOES NOT COVER:  
 
 5.WAITING PERIOD

The company shall not be liable to make any payment under the policy in connection with or in respect of the following expenses till the expiry of waiting period mentioned below:
5.1 Pre-Existing Diseases (Code-Excl01).

  1. Expenses related to the treatment of a pre-existing disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with us. 
  2. In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
  3. If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health Insurance) Regulations, then waiting period for the same would be reduced to the extent of prior coverage.
  4. Coverage under the policy after the expiry of 48 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by us.

5.2 First Thirty Days Waiting Period (Code-Excl03)

  1. Expenses related to the treatment of any illness within 30 days from the first policy commencement date shall be excluded except claims arising due to an accident, provided the same are covered.
  2. This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve months.
  3. The within referred waiting period is made applicable to the enhanced sum insured in the event of granting higher sum insured subsequently.

5.3 Specific Waiting Period (Code-Excl02)

  1. Expenses related to the treatment of the following listed Conditions, surgeries/treatments shall be excluded until the expiry of 24/48 months of continuous coverage, as may be the case after the date of inception of the first policy with the Insurer. This exclusion shall not be applicable for claims arising due to an accident.
  2. In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
  3. If any of the specified disease/procedure falls under the waiting period specified for pre-existing diseases, then the longer of the two waiting periods shall apply.
  4. The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a specific exclusion.
  5. If the Insured Person is continuously covered without any break as defined under the applicable norms on portability stipulated by IRDAI, then waiting period for the same would be reduced to the extent of prior coverage.

24 Months Waiting Period

  • Benign ENT disorders
  • Tonsillectomy
  • Adenoidectomy
  • Mastoidectomy
  • Tympanoplasty
  • Hysterectomy
  • All internal and external benign tumours, cysts, polyps of any kind, including benign breast lumps
  • Benign prostate hypertrophy
  • Cataract and age related eye ailments
  • Gastric/Duodenal Ulcer
  • Gout and Rheumatism
  • Hernia of all types
  • Hydrocele
  • Non Infective Arthritis
  • Piles, Fissure and Fistula in anus
  • Pilonidal sinus, Sinusitis and related disorders
  • Prolapse inter Vertebral Disc and Spinal Diseases unless arising from accident
  • Calculi in urinary system, Gall Bladder and Bile duct, excluding malignancy.
  • Varicose Veins and Varicose Ulcers
  • Internal Congenital Anomalies

48 Months Waiting Period

  • Treatment for joint replacement unless arising from accident
  • Age-related Osteoarthritis & Osteoporosis

6. EXCLUSIONS
The company shall not be liable to make any payment under the policy, in respect of any expenses incurred in connection with or in respect of:

6.1 Investigation & Evaluation (Code-Excl04)

  1. Expenses related to any admission primarily for diagnostics and evaluation purposes.
  2. Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment.

6.2 Rest Cure, rehabilitation and respite care (Code-Excl05)
Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:

  1. Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing, dressing, moving around either by skilled nurses or assistant or non-skilled persons.
  2. Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.

6.3 Obesity/Weight Control (Code-Excl06)
Expenses related to the surgical treatment of obesity that does not fulfill all the below conditions:

  1. Surgery to be conducted is upon the advice of the Doctor
  2. The surgery/procedure conducted should be supported by clinical protocols
  3. The member has to be 18 years of age or older and
  4. Body Mass Index (BMI); 
  1. greater than or equal to 40 or

  2. greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive methods of weight loss:

  1. Obesity-related cardiomyopathy
  2. Coronary heart disease 
  3. Severe Sleep Apnoea
  4. Uncontrolled Type2 Diabetes

6.4 Change-of-Gender Treatments: (Code-Excl07)
Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.

6.5 Cosmetic or Plastic Surgery: (Code-Excl08)
Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident, Burn(s) or Cancer or as part of medically necessary treatment to remove a direct and immediate health risk to the Insured. For this to be considered a medical necessity, it must be certified by the attending Medical Practitioner.

6.6 Hazardous or Adventure sports: (Code-Excl09)
Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports, including but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.

6.7 Breach of law: (Code-Excl10)
Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with criminal intent.

6.8 Excluded Providers: (Code-Excl11)
Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website/notified to the policyholders are not admissible. However, in case of life threatening situations or following an accident, expenses up to the stage of stabilization are payable but not the complete claim.

6.9 Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof.(Code-Excl12)

6.10Treatments received in health hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing home attached to such establishments or where admission is arranged wholly or partly for domestic reasons.(Code-Excl13)

6.11 Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals and organic substances unless prescribed by a medical practitioner as part of hospitalisation claim or day care procedure. (Code-Excl14)

6.12 Refractive Error: (Code-Excl15)
Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres.

6.13 Unproven Treatments: (Code-Excl16)
Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are treatments, procedures or supplies that lack significant medical documentation to support their effectiveness.

6.14 Sterility and Infertility: (Code-Excl17)
Expenses related to sterility and infertility. This includes:

  1. Any type of sterilization
  2. Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
  3. Gestational Surrogacy
  4. Reversal of Sterilization

6.15 Maternity Expenses (Code-Excl18):

  1. Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalisation) except ectopic pregnancy;
  2. Expenses towards miscarriage (unless due to an accident) and lawful medical termination of pregnancy during the policy period.

6.16 War (whether declared or not) and war like occurrence or invasion, acts of foreign enemies, hostilities, civil war, rebellion, revolutions, insurrections, mutiny, military or usurped power, seizure, capture, arrest, restraints and detainment of all kinds.

6.17 Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from or from any other cause or event contributing concurrently or in any other sequence to the loss, claim or expense. For the purpose of this exclusion:

  1. Nuclear attack or weapons means the use of any nuclear weapon or device or waste or combustion of nuclear fuel or the emission, discharge, dispersal, release or escape of fissile/fusion material emitting a level of radioactivity capable of causing any Illness, incapacitating disablement or death.
  2. Chemical attack or weapons means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing any Illness, incapacitating disablement or death.
  3. Biological attack or weapons means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organisms and/or biologically produced toxins (including genetically modified organisms and chemically synthesized toxins) which are capable of causing any Illness, incapacitating disablement or death.

6.18 Any expenses incurred on Domiciliary Hospitalisation

6.19 Treatment taken outside the geographical limits of India

6.20 a) Stem cell implantation/Surgery/therapy, harvesting, storage or any kind of Treatment using stem cells except as provided for in Clause 4.6.L above; b) Growth Hormone Therapy.  
6.21
Congenital External Diseases, Defects or anomalies. 
6.22
Circumcision unless necessary for Treatment of an Illness or Injury not excluded hereunder or due to an Accident.
6.23
Cost of routine medical examination and preventive health check-up.
6.24
a) Cost of hearing aids; including optometric therapy; b) cochlear implants unless necessitated by an Accident or required intra-operatively.
6.25
Intentional self-inflicted Injury, attempted suicide
6.26
Treatments other than Allopathy and Ayurvedic, Homeopathic & Unani branches of medicine.
6.27
Any expenses incurred on Outpatient treatment (OPD treatment) 
6.28
Unless used intra-operatively, any expenses incurred on prosthesis, corrective devices; External and or durable Medical / Non-medical equipment of any kind used for diagnosis and/or treatment and/or monitoring and/or maintenance and/or support including instruments used in treatment of sleep apnoea syndrome; Infusion pump, Oxygen concentrator, Ambulatory devices, sub cutaneous insulin pump and also any medical equipment, which are subsequently used at home.
6.29
Change of treatment from one system of medicine to another system unless recommended by the consultant/ hospital under whom the treatment is taken.
6.30
Treatments including Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy, chondrocyte or osteocyte implantation, procedures using platelet rich plasma, Trans Cutaneous Electric Nerve Stimulation; Use of oral immunomodulatory/ supplemental drugs.
6.31
Artificial life maintenance including life support machine use, from the date of confirmation by the treating doctor that the patient is in a vegetative state

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