The coverages available under this Policy are described below.

1. Base Covers

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

In-patient Hospitalisation Expenses Cover 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:

1. Room, Boarding and Nursing expenses (all inclusive) incurred as provided by the Hospital/Nursing Home up to the limits provided below:

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 the limits provided below:

3.  The fees charged by the Medical Practitioner, Surgeon, Specialists, and anesthetists treating the Insured Person;
4. Operation theatre charges,
5. Anesthesia, Blood, Oxygen, Surgical Appliances and/ or Medical Appliances, medicines and drugs, 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, dialysis, chemotherapy, radiotherapy, and such other similar medical expenses related to the treatment.

1.1 Note:

1. PROPORTIONATE PAYMENT CLAUSE: In case of admission to a room at rates exceeding the aforesaid limits in clause III.A.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.
2. No payment shall be made under clause III.A.1.iii 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
3. All Day Care treatments as per definition are covered.

1.2 Sub-limit:

1. Cataract Surgery Limit:

   Expenses in respect of the Cataract surgeries will be restricted to 10% of Sum Insured subject to maximum of Rs. 50,000/- per eye. This limit is applicable per hospitalisation / surgery.

2. Mental Illness Cover Limit:

   In case of following mental illnesses, the actual In-patient Hospitalization expenses will be covered up to 25% of Sum Insured subject to a maximum of Rs. 3,00,000 per policy period;

   1. Schizophrenia (ICD - F20; F21; F25)
   2. Bipolar Affective Disorders (ICD - F31; F34)
   3. Depression (ICD - F32; F33)
   4. Obsessive Compulsive Disorders (ICD - F42; F60.5)
   5. Psychosis (ICD - F22; F23; F28; F29)

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 above.
2. The Pre-hospitalisation and Post-hospitalisation Medical Expenses are related to the same Illness or Injury.

3. Donor Expenses Cover

We will cover the In-patient Hospitalization Medical Expenses incurred for an organ donor’s treatment during the Policy Period for the harvesting of the organ donated provided that:

1. The donation conforms to The Transplantation of Human Organs Act 1994 and the organ is for the use of the Insured Person;
2. We have admitted a claim towards In-patient Hospitalisation under Clause III.A.1 and it is related to the same condition; organ donated is for the use of the Insured Person as certified in writing by a Medical Practitioner;
3. We will not cover

1. Pre-hospitalization Medical Expenses or Post-hospitalisation Medical Expenses of the organ donor;
2. Screening expenses of the organ donor;
3. Costs directly or indirectly associated with the acquisition of the donor’s organ;
4. Transplant of any organ/tissue where the transplant is experimental or investigational;
5. Expenses related to organ transportation or preservation;
6. Any other medical treatment or complication in respect of the donor, consequent to harvesting.

4. Restoration of Sum Insured

If the Sum Insured is exhausted completely or partially due to claims made and paid/accepted as payable during the Policy Period, then it is agreed that a Restored Sum Insured equal to 100% of the Sum Insured will be automatically and instantly available for the particular Policy Period, provided that:

1. In case of policies on Individual Sum Insured basis, the Restored sum insured will be available only once to each Insured Person individually in a Policy Period.
2. In case of policies of Family Floater basis, the Restored Sum Insured will be available only once to the whole family on floater basis during a Policy Period.
3. Such restored Sum Insured can be utilized only for illness / disease unrelated to the illness(es) / disease(s) for which claim(s) was / were made for the same insured person.
4. The maximum liability for a claim in a Policy Year cannot exceed the Sum Insured
5. If the Restored Sum Insured is not utilized in a Policy Period, it shall not be carried forward to any subsequent Policy Period.

Note:

1. Restoration of Sum Insured is available only for Sum Insured options from Rs. 3 lakhs and above
2. The payment from the Restored Sum Insured will be done only after exhaustion of the Sum Insured.

5. Modern Treatment Methods & Advancement in Technologies

In case of an admissible claim under Clause III.A.1, 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 shall not be applied.

6. Road Ambulance Cover

We will cover the costs incurred up to:

1. 0.5% of the Sum Insured subject to a maximum of Rs. 2,500 per event and
2. 1% of the Sum Insured subject to a maximum of Rs. 5,000 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 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.

7. Cost of Health Check-up

Expenses incurred towards cost of health check-up up to 1% of average Sum Insured of preceding 3 policy years, subject to a maximum of Rs. 5,000 per person for policies issued on individual sum insured basis/ Rs. 10,000 per policy period for policies issued on family floater basis 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 Total Sum Insured. In case of the policy on family floater basis, if a claim is made by any of the Insured Persons, the health check-up benefits will not be available under the policy.

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

8. Organ Donor Benefit

When Insured Person is the Donor A lump sum payment of 10% of Sum Insured, to take care of medical and other incidental expenses is payable to the Insured Person donating an organ provided that the donation conforms to the Transplantation of Human Organs Act 1994 (amended) and any other extant Act, Central / State Rules / regulations, as applicable, in respect of transplantation of human organs.

This benefit is subject to the Policy (Family Medicare Policy) having been continuously in force for at least 12 (twelve) months in respect of that Insured Person.

1. Optional Covers:

1. Maternity Expenses and New Born Baby Cover

1. Maternity Expenses We shall pay the Medical Expenses incurred as an In-patient for a delivery (including caesarean section) or lawful medical termination of pregnancy during the Policy Period limited to two deliveries or terminations or either during the lifetime of the Insured Person. This benefit is applicable only when the Sum Insured is above Rs. 3 Lacs, and available only to the Insured or his spouse, provided that:

1. Family Medicare Policy with this optional cover has been continuously in force for a period of minimum 24 months.
2. Those Insured Persons who are already having two or more living children will not be eligible for this benefit.
3. Company’s maximum liability per delivery or termination shall be limited to 10% of the Sum Insured as stated in the Schedule subject to a maximum of Rs. 40,000 in case of normal delivery and Rs. 60,000 in case of caesarean section and in no case shall the Company’s liability under this clause exceed 10% of the Sum Insured, in any one Policy Period.

2. New Born Baby Cover

New born Baby shall be covered from day one up to the age of 90 days and expenses incurred for treatment taken in Hospital as in-patient shall only be payable, provided that:

1. Claim under Maternity Expenses under Clause III.B.1.a is admissible under the Policy
2. Company’s liability shall be limited to 10% of the Sum Insured as stated in the Schedule
3. In case the 90-days period for the New Born Baby is spread over two Policy Periods, the aggregate liability of the Company, for all claims in respect of the New Born Baby, shall be limited to 10% of the Sum Insured of the Policy under which Maternity claim was admitted.

Special conditions applicable to Maternity Expenses and New Born Baby Cover

1. These benefits are admissible only if the expenses are incurred in Hospital/Nursing Home as in-patients in India.
2. Surrogate or vicarious pregnancy is not covered
3. Expenses incurred in connection with voluntary medical termination of pregnancy during the first twelve weeks from the date of conception are not covered.
4. Pre-natal and post-natal expenses are not covered unless admitted in Hospital/Nursing Home and treatment is taken there.
5. Pre-Hospitalisation and Post-Hospitalisation benefits are not available for Maternity and New Born Baby Cover
6. Subject to the terms & conditions, the Policy covers New Born Baby beyond 90 days only on payment of requisite premium
7. If this Option is in force in respect of the Insured Person

1. The maternity exclusion is inoperative
2. The waiting period for “Internal Congenital Anomaly” will be deemed inoperative for the New Born Baby throughout the time such baby is continuously covered under this product.

2. 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:

The aggregate of Daily Cash Allowance during the policy period shall not exceed ‘per policy period limits’ as mentioned in the table above. Daily Cash Allowance will not be payable for Day Care Treatment claims. Deductible equivalent to Daily Cash Allowance for the first 24 hours Hospitalization will be levied on each Hospitalisation during the Policy Period.