1. Waiting Periods (Only Applicable for Gold & Senior Citizen Plans)

The Company shall not be liable to make any payment under the policy in connection with or in respect of any expenses till the expiry of waiting period mentioned below:

1. Pre-Existing Diseases (Code – Excl01)
   
   • 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.
   • In case of enhancement of the Sum Insured, the exclusion shall apply afresh to the extent of the Sum Insured increase.
   • If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health Insurance) Regulations, then the waiting period for the same would be reduced to the extent of prior coverage.
   • 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.

2. Specified Disease/Procedure Waiting Period (Code – Excl02)
   
   • Expenses related to the treatment of the listed Conditions, surgeries/treatments as per Table A and Table B below, shall be excluded until the expiry of 24 months and 48 months respectively of continuous coverage after the date of inception of the first policy with us. This exclusion shall not be applicable for claims arising due to an accident.
   • In case of enhancement of the sum insured the exclusion shall apply afresh to the extent of the sum insured increase
   • 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
   • The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a specific exclusion.
   • If the Insured Person is continuously covered without any break as defined under the applicable norms on portability stipulated by IRDAI, then the waiting period for the same would be reduced to the extent of prior coverage.
   • List of specific diseases/procedures:

Table A. 24 Months’ waiting period

Table B. 48 Months’ waiting period

3. 30-Day Waiting Period (Code – Excl03):
   
   • 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.
   • This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve months.
   •  The within-referred waiting period is made applicable to the enhanced sum insured in the event of granting a higher sum insured subsequently

2. Standard Permanent Exclusions (Applicable for ALL Plans)

The Company shall not be liable to make any payment under this Policy in respect of any expenses incurred by You in connection with or in respect of:

4. Investigation & Evaluation (Code – Excl04)
   
   • Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.
   • Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.

5. 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:

   • 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, and moving around either by skilled nurses or assistants or non-skilled persons
   • Any services for people who are terminally ill to address physical, social, emotional and spiritual needs

6. Obesity/Weight Control (Code – Excl06)
   

   Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:

   • Surgery to be conducted is upon the advice of the Doctor
   • The surgery/Procedure conducted should be supported by clinical protocols
   • The member has to be 18 years of age or older and
   • Body Mass Index (BMI):
     
     • Greater than or equal to 40 or
     • . 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
     • Obesity-related cardiomyopathy
     • Coronary heart disease
     • Severe Sleep Apnea
     • Uncontrolled Type2 Diabetes

7. 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.

8. 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.

9. 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.

10. 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.

11. 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 on 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.

12. (Code – Excl12)

Treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof.

13. (Code – Excl13)

Treatments 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.

14. (Code – Excl14)

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

15. Refractive Error (Code – Excl15)

Expenses related to the treatment for correction of eyesight due to refractive error less than 7.5 dioptres.

16. 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.

Expenses related to sterility and infertility. This includes:

17. Sterility and Infertility (Code – Excl17)
    
    • Any type of contraception, sterilization
    •  Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
    • Gestational Surrogacy
    • Reversal of sterilization

18. Maternity (Code- Excl18)
    
    • Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalisation) except ectopic pregnancy;
    • Expenses towards miscarriage (unless due to an accident) and lawful medical termination of pregnancy during the policy period

3. Specific Permanent Exclusions (Applicable for ALL Plans)

1. All expenses caused by or arising from or attributable to foreign invasion, act of foreign enemies, hostilities, warlike operations (whether war be declared or not or while performing duties in the armed forces of any country), civil war, public defence, rebellion, revolution, insurrection, military or usurped power.

2. All Illnesses/expenses caused by ionizing radiation or contamination by radioactivity from any nuclear fuel (explosive or hazardous form) or any nuclear waste from the combustion of nuclear fuel, nuclear/chemical/biological attack.

3. Any expenses incurred on Out-patient treatment (OPD treatment). Procedures/treatments usually done in outpatient department are not payable under the policy even if admitted/converted as an in-patient in the hospital for more than 24 hours.

4. Any item(s) or treatment specified in ‘List of Non-Medical Expenses under this Policy’ as per clauses in Annexure – 1 of the policy wordings, unless specifically covered under the Policy.

5. 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.

6. Change of treatment from one system of medicine to another system unless recommended by the consultant/hospital under whom the treatment is taken.

7. Circumcision unless necessary for Treatment of an Illness or Injury not excluded hereunder or due to an Accident.

8. Congenital External Diseases or Defects or anomalies.

9. Cost of hearing aids; including optometric therapy.

10. Cost of routine medical examination and preventive health check-up unless as provided for in clause III.A.7 of the policy wordings.

11. Dental treatment or surgery of any kind unless necessitated by disease or accident and requiring hospitalisation.

12. Intentional self-inflicted Injury or attempted suicide.

13. Routine eye-examination expenses, cost of spectacles, contact lenses.

14. Stem cell implantation/Surgery/Therapy, harvesting, storage or any kind of treatment using stem cells except Hematopoietic stem cells for bone marrow transplant for hematological conditions; growth hormone therapy.

15. 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.

16. Treatments other than Allopathy and AYUAH branches of medicine.

17. 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. This is indicative. Please refer to clauses in Annexure-1 of the policy wordings for the complete list of non-payable items.

18. Vaccination or inoculation of any kind unless it is post animal bite.

19. In respect of the existing diseases, disclosed by the insured and mentioned in the policy schedule (based on insured’s consent), policyholder is not entitled to get the coverage for specified ICD Codes