The coverages available under this policy are classified as Base Cover and Optional Cover. Base Cover refers to the coverage available as default under Individual Health Insurance Policy whereas Optional Cover is available only upon payment of additional premium.

IMPORTANT: Please note that the coverage mentioned below is applicable for ALL the plans i.e., Platinum/ Gold/ Senior Citizen, under Individual Health Insurance Policy unless explicitly mentioned otherwise.

1. Base Cover

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

1. 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: Room, Boarding and Nursing expenses (all inclusive) incurred as provided by the Hospital/Nursing Home up to 1% of Sum Insured per day or actual expenses whichever is less. These expenses will include nursing care, RMO charges, patient’s diet charges, IV Fluids/Blood transfusion/injection administration charges and similar expenses.
2.  Charges for accommodation in Intensive Care Unit (ICU)/ Intensive Cardiac Care Unit (ICCU) up to 2% of Sum Insured per day or actual expenses whichever is less.
3. The fees charged by the Medical Practitioner, Surgeon, Specialists, Consultants and Anesthetists treating the Insured Person.
4.  Operation theatre charges; Expenses incurred for Anesthetics, Blood, Oxygen, Surgical Appliances and/or Medical Appliances; Cost of Artificial Limbs, cost of prosthetic devices implanted during surgical procedure like pacemaker, orthopedic implants, infra cardiac valve replacements, vascular stents, relevant laboratory/ diagnostic tests, X-Ray and such other similar medical expenses related to the treatment.
5. All hospitalisation expenses (excluding cost of organ) incurred for donor in respect of organ transplant to the Insured Person provided the donation conforms to The Transplantation of Human Organs Act 1994.
   1. Note i. PROPORTIONATE PAYMENT CLAUSE: In case of admission to a room at rates exceeding the aforesaid limits in Clause III.A.1.i of the policy wordings, 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.

1. No payment shall be made under clause III.A.1.iii of the policy wordings other than as part of the hospitalisation bill. However, the bills raised by Surgeon, Anesthetist directly and not forming part of the hospital bill shall be paid provided a pre-numbered bill/receipt is produced in support thereof, when such payment is made ONLY by cheque/ credit card/debit card or digital/online transfer
2. All day care treatments as per definition in Clause II.A.8 of the policy wordings are covered
   1. Sub-limit

(Applicable only for Gold and Senior Citizen plans)

2. Pre-Hospitalisation and Post-Hospitalisation Expenses

We will cover, on a reimbursement basis, the Insured Person’s

1. Pre-hospitalisation Medical Expenses incurred due to an Illness or Injury during the period up to 30 days prior to hospitalisation; and
2. Post- hospitalisation Medical Expenses incurred due to an Illness or Injury during the period up to 60 days after the discharge from the hospital,

Subject to a maximum of 10% of Sum Insured for Pre- and Post-Hospitalisation combined, provided that:

1. We have accepted a claim for primary In-patient Hospitalization under Clause III.A.1 of the policy wordings.
2. The Pre-hospitalisation and Post-hospitalisation Medical Expenses are related to the same Illness or Injury.

Note: The maximum limit of 10% of Sum Insured will not be applicable for Platinum Plan.

3. Domiciliary Hospitalisation

We will cover, on a reimbursement basis, expenses for Domiciliary Hospitalisation of an Insured person in case of Medically Necessary Treatment at home due to illness/disease/injury. However, the charges for the first three days of duration of Domiciliary Hospitalisation will not be payable.

Domiciliary Hospitalisation benefits shall not cover expenses incurred for treatment for any of the following diseases:

Liability of the Company under this clause is restricted as stated in the Schedule as per clauses in Annexure – 3 of the policy wordings.

4.    Road Ambulance Cover

We will cover the costs incurred up to Rs. 2500 per person per policy period 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. The necessity of use of an Ambulance must be certified by the treating Medical Practitioner and becomes payable if a claim has been admitted under Clause III.A.1 of the policy wordings 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 above under this cover, if:

1. 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;
2. it is medically required to transfer the Insured Person to another Hospital during the course of Hospitalization due to lack of super specialty treatment in the existing Hospital.

5. Modern Treatment Methods & Advancement in Technologies: 

In case of an admissible claim under Clause III.A.1 of the policy wordings, expenses incurred on the following procedures (wherever medically indicated) shall be covered:

1. Uterine Artery Embolization and HIFU (High Intensity focused ultrasound)
2.  Balloon Sinuplasty
3.  Deep Brain Stimulation
4.  Oral Chemotherapy
5.  Immunotherapy - Monoclonal Antibody to be given as an injection
6. Intra-vitreal injections
7. Robotic Surgeries
8.  Stereotactic Radio Surgeries
9.  Bronchial Thermoplasty
10.  Vaporization of the Prostrate (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 hematological conditions to be covered

Note: The claims under Oral Chemotherapy and Immunotherapy-Monoclonal Antibody to be given as injection shall be treated as post-Hospitalisation claim(s). However, the time and monetary limits as mentioned in Clause III.A.2 of the policy wordings shall not be applied.

6. Cost of Health Check-up

We will cover expenses incurred towards the cost of health check-ups up to 1% of the average Sum Insured of the preceding 3 policy years, subject to a maximum of Rs. 5,000 per person per policy period for a block of every three claim-free years provided the health check-up is done at hospitals/diagnostic Centre authorised by us within a year from the date when it got due and the policy is in force. Payment under this benefit does not reduce the sum insured.

Note: Payment of expenses towards cost of health check-up will not prejudice the company's right to deal with a claim in case of non-disclosure of material fact and /or Pre-Existing Diseases in terms of the policy.

2.  Optional Cover:

1. Daily Cash Allowance on Hospitalisation

We will pay Daily Cash Allowance 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, as per the table below:

1. The aggregate of Daily Cash Allowance during the policy period shall not exceed ‘per policy period limits’ as mentioned in the table above.
2.  Daily Cash Allowance will not be payable for Day Care Treatment claims.

Deductible equivalent to Daily Cash Allowance for the first 48 hours Hospitalization will be levied on each Hospitalisation during the Policy Period.