The terms defined below and at other junctures in the Policy have the meanings ascribed to them wherever they appear in this Policy and, where, the context so requires, references to the singular include references to the plural; references to the male includes the female and references to any statutory enactment includes subsequent changes to the same.

1. STANDARD DEFINITIONS

1. Accident is a sudden, unforeseen and involuntary event caused by external, visible and violent means.
2. Any One Illness means continuous period of illness and includes relapse within 45 days from the date of last consultation with the Hospital/Nursing Home where treatment was taken.
3. AYUSH Hospital is a healthcare facility wherein medical/surgical/para-surgical treatment procedures and interventions are carried out by AYUSH Medical Practitioner(s) comprising any of the following:

1. Central or State Government AYUSH Hospital; or
2. Teaching hospital attached to AYUSH College recognised by the Central Government/Central Council of Indian Medicine/Central Council for Homeopathy; or
3. AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any recognised system of medicine, registered with the local authorities, wherever applicable, and is under the supervision of a qualified registered AYUSH Medical Practitioner and must comply with the following criterion:

• Having at least 5 in-patient beds;
• Having qualified AYUSH Medical Practitioner in charge round the clock;
• Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures are carried out;
• Maintaining daily records of the patients and making them accessible to the insurance company’s authorised representative.

4. AYUSH Day Care Centre means and includes Community Health Care Centre (CHC), Primary Health Centre (PHC), Dispensary, Clinic, Polyclinic or any such health centre which is registered with the local authorities, wherever applicable and having facilities for carrying out treatment procedures and medical or surgical/para-surgical interventions or both under the supervision of registered AYUSH Medical Practitioner (s) on day care basis without in-patient services and must comply with all the following criterion:
   
   1. Having qualified registered AYUSH Medical Practitioner (s) in charge;
   2. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures are to be carried out;
   3. Maintaining daily records of the patients and making them accessible to the insurance Company’s authorized representative
5. Cashless Facility means a facility extended by the Insurer to the Insured, where the payments of the costs of treatment undergone by the Insured in accordance with the policy terms and conditions, are directly made to the network provider by the Insurer to the extent pre-authorization is approved.
6. Condition Precedent shall mean a policy term or condition upon which the Insurer’s liability under the policy is conditional.
7. Congenital Anomaly refers to a condition(s) which is present since birth, and which is abnormal with reference to form, structure or position.

1. Internal Congenital Anomaly: Congenital Anomaly which is not in the visible and accessible parts of the body.
2. External Congenital Anomaly: Congenital Anomaly which is in the visible and accessible parts of the body.

8. Day Care Centre means any institution established for day care treatment of illness and/or injuries or a medical set-up within a hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified medical practitioner AND must comply with all minimum criteria as under:

1. Has qualified nursing staff under its employment
2. Has qualified Medical Practitioner(s) in charge
3. Has a fully equipped operation theatre of its own where surgical procedures are carried out;
4. Maintains daily records of patients and will make these accessible to the Insurance Company’s authorized personnel.

9. Day Care Treatment means medical treatment, and/or surgical procedure, which is:

1. undertaken under general or local anaesthesia in a hospital/day care centre in less than twenty-four hours because of technological advancement, and
2. which would have otherwise required a hospitalisation of more than twenty-four hours.

Treatment normally taken on an outpatient basis is not included in the scope of this definition.

10. Deductible is a cost sharing requirement under a health insurance policy that provides that the Insurer will not be liable for a specified rupee amount in case of Indemnity policies and for a specified number of days/hours in case of hospital cash policies which will apply before any benefits are payable by the Insurer.  A deductible does not reduce the sum insured. The deductible is applicable in aggregate towards hospitalization expenses incurred during the policy period by Insured (individual policy) or Insured family (in case of floater policy).
11. Dental Treatment means a treatment related to teeth or structures supporting teeth including examinations, fillings (where appropriate), crowns, extractions and surgery.
12. Emergency Care means management for an illness or injury, which results in symptoms which occur suddenly and unexpectedly, and requires immediate care by a medical practitioner to prevent death or serious long-term impairment of the Insured Person’s health
13. Grace Period means the specified period of time immediately following the premium due date during which a payment can be made to renew or continue a policy in force without loss of continuity benefits such as waiting periods and coverage of pre-existing diseases.  Coverage is not available for the period for which no premium is received.
14. Hospital means any institution established for in-patient care and day care treatment of illness and/or injuries and which has been registered as a Hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under:

• Has qualified nursing staff under its employment round the clock;
• Has at least 10 in-patient beds in towns having a population of less than 10 lakhs and at least 15 in-patient beds in all other places;
• Has qualified Medical Practitioner(s) in charge round the clock;
• Has a fully equipped Operation Theatre of its own where surgical procedures are carried out;
• Maintains daily records of patients and makes these accessible to the insurance company’s authorized personnel.

15. Hospitalisation means admission in a Hospital for a minimum period of 24 consecutive ‘In-patient care’ hours except for the day-care treatments, where such admission could be for a period of less than 24 consecutive hours.
16. Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function and requires medical treatment.

(a) Acute condition - Acute condition is a disease, illness or injury that is likely to respond quickly to treatment which aims to return the person to his or her state of health immediately before suffering the disease/illness/ injury which leads to full recovery

(b) Chronic condition - A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics:

1. It needs ongoing or long-term monitoring through consultations, examinations, check-ups, and/or tests

2. It needs ongoing or long-term control or relief of symptoms

3. It requires rehabilitation for the patient or for the patient to be specially trained to cope with it

4. It continues indefinitely

5. It recurs or is likely to recur

17. Injury means accidental physical bodily harm excluding illness or disease solely and directly caused by external, violent, visible and evident means which is verified and certified by a Medical Practitioner.
18. In-Patient Care means treatment for which the Insured Person has to stay in a hospital for more than 24 hours for a covered event.
19. Intensive Care Unit means an identified section, ward or wing of a hospital which is under the constant supervision of a dedicated Medical Practitioner(s), and which is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards.
20. ICU (Intensive Care Unit) Charges means the amount charged by a Hospital towards ICU expenses which shall include the expenses for ICU bed, general medical support services provided to any ICU patient including monitoring devices, critical care nursing and intensivist charges.
21. Maternity Expenses mean

1. medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalization);
2. expenses towards lawful medical termination of pregnancy during the policy period.

22. Medical Advice means any consultation or advice from a Medical Practitioner including the issue of any prescription or follow-up prescription.
23. Medical Expenses means those expenses that an Insured Person has necessarily and actually incurred for medical treatment on account of Illness or Accident on the advice of a Medical Practitioner, as long as these are no more than would have been payable if the Insured Person had not been insured and no more than other hospitals or doctors in the same locality would have charged for the same medical treatment.
24. Medically Necessary Treatment means any treatment, tests, medication, or stay in hospital or part of a stay in hospital which:

1. is required for the medical management of the illness or injury suffered by the Insured;
2. Must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration or intensity;
3. Must have been prescribed by a Medical Practitioner;
4. Must conform to the professional standards widely accepted in international medical practice or by the medical community in India.

25. Medical Practitioner means a person who holds a valid registration from the Medical Council of any State of India or Medical Council of India or Council for Indian Medicine or for Homeopathy set up by the Government of India or a State Government and is thereby entitled to practice medicine within its jurisdiction; and is acting within its scope and jurisdiction of license.

The term Medical Practitioner would include Physician, Specialist and Surgeon. The Registered Medical Practitioner should not be the Insured or any member of his family including parents and in-laws.

26. Migration means the right accorded to health insurance policyholders (including all members under family cover and members of group health insurance policy), to transfer the credit gained for pre-existing conditions and time bound exclusions, with the same insurer.
27. Network Provider means hospital enlisted by an Insurer, a TPA or jointly by an Insurer and a TPA to provide medical services to an Insured by a cashless facility.

PPN-Preferred Provider Network means a network of hospitals, which have agreed to a cashless packaged pricing for certain procedures for the Insured Person.

Updated list of network provider/PPN is available on website of the company (https://uiic.co.in/en/tpa-ppn-network-hospitals) and website of the TPA mentioned in the schedule and is subject to amendment from time to time.

28. Non-Network Provider means any hospital, day care centre or other provider that is not part of the network.
29. Notification of Claim means the process of notifying a claim to the Insurer or TPA through any of the recognised modes of communication.
30. OPD (Out-Patient) Treatment means the one in which the Insured visits a clinic/hospital or associated facility like a consultation room for diagnosis and treatment based on the advice of a Medical Practitioner. The Insured is not admitted as a day care or in-patient.
31. Portability means, the right accorded to individual health insurance policyholders (including all members under family cover), to transfer the credit gained for pre-existing conditions and time-bound exclusions, from one Insurer to another.
32. Pre-Existing Disease means any condition, ailment, injury or disease:

1. That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the Insurer or its reinstatement or
2. For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy issued by the Insurer or its reinstatement

33. Pre-Hospitalisation Medical Expenses means medical expenses incurred during pre-defined number of days preceding the hospitalisation of the Insured Person, provided that:

1. Such Medical expenses are incurred for the same condition for which the Insured Person’s hospitalisation was required; and
2. The In-patient hospitalisation claim for such Hospitalisation is admissible by the Insurer.

34. Post-Hospitalisation Medical Expenses means medical expenses incurred during pre-defined number of days after the Insured Person is discharged from the hospital provided that:

1. Such Medical expenses are incurred for the same condition for which the Insured Person’s hospitalisation was required; and
2. The In-patient hospitalisation claim for such hospitalisation is admissible by the Insurer.

35. Qualified Nurse means a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any State in India.
36. Reasonable and Customary Charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of illness/injury involved.
37. Renewal defines the terms on which the contract of insurance can be renewed on mutual consent with a provision of grace period for treating the renewal continuous for the purpose of gaining credit for pre-existing diseases, time-bound exclusions and for all waiting periods.
38. Room Rent shall mean the amount charged by a hospital towards room and boarding expenses and shall include the associated medical expenses.
39. Surgery or Surgical Procedure means manual and/or operative procedure(s) required for treatment of an illness or injury, correction of deformities and defects, diagnosis and cure of diseases, relief from suffering and prolongation of life, performed in a Hospital or Day Care Centre by a Medical Practitioner.
40. Third Party Administrator (TPA) means a company registered with the Insurance Regulatory & Development Authority of India (IRDAI) and engaged by an insurer, for a fee or by whatever name called and as may be mentioned in the health services agreement, for providing health services as mentioned under the IRDAI (Third Party Administrators – Health Services) Regulations, 2016.
41. Unproven/Experimental Treatment means the treatment including drug experimental therapy which is not based on established medical practice in India, is treatment experimental or unproven.

2. SPECIFIC DEFINITIONS

42. Age means age of the Insured person on last birthday as on date of commencement of the Policy.
43. Continuous Coverage means uninterrupted coverage of the Insured Person under the Top Up/ Super Top-Up Health Insurance Policy from the date of inception of policy for the first time as mentioned in the policy schedule. However, for the purpose of applying waiting periods, the break in insurance period for which the premium was not received shall be excluded from it.
44. Epidemic means the occurrence of more cases of a disease than would be expected in a community or region spreading rapidly during a given time period; and declared as such by the appropriate Government Authority in India. Insured Person means person(s) named in the schedule of the Policy.
45. Pandemic means an epidemic of disease that has spread across a large region, for instance multiple continents or worldwide, affecting a substantial number of people; and declared as such by the appropriate Government Authority in India.
46. Policy means these Policy wordings, the Policy Schedule and any applicable endorsements or extensions attaching to or forming part thereof. The Policy contains details of the extent of cover available to the Insured Person, what is excluded from the cover and the terms & conditions on which the Policy is issued to The Insured Person.
47. Policy Period means period of one policy year as mentioned in schedule for which the Policy is issued.
48. Policy Schedule means the Policy Schedule attaching to and forming part of the Policy.
49. Psychiatrist means a Medical Practitioner possessing a post-graduate degree or diploma in psychiatry awarded by an university recognized by the University Grants Commission, or awarded or recognized by the National Board of Examinations and included in the First Schedule to the Indian Medical Council Act, 1956, or recognized by the Medical Council of India and includes, in relation to any State, any medical officer who having regard to his knowledge and experience in psychiatry, has been declared by the Government of that State to be a psychiatrist.
50. Sub-Limit means a cost-sharing requirement under a health insurance policy in which an Insurer would not be liable to pay any amount in excess of the pre-defined limit.
51. Sum Insured means the pre-defined limit specified in the Policy Schedule that represents, the maximum, total and cumulative liability for any and all claims made under the Policy, in respect of that Insured Person (on Individual Sum Insured basis) or all Insured Persons (on Floater basis) during the policy period.
52. Threshold means deductible which is a cost sharing requirement under the Policy that provides that the Insurer will not be liable for a specified rupee amount which will apply before any benefits are payable by the Insurer.  It does not reduce the sum insured. The threshold is applicable in aggregate towards hospitalization expenses incurred during the policy period by Insured (individual policy) or Insured family (in case of floater policy).
53. We/Our/Us/Company means the United India Insurance Company Limited.
54. You/Your/Policyholder means the person named in the Policy Schedule who has concluded this Policy with Us.