A.Standard Definitions

1.Accident

means a sudden, unforeseen, and involuntary event caused by external, visible and violent means.

2.Cashless Facility

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.

3.Condition Precedent

shall mean a policy term or condition upon which the Insurer’s liability under the policy is conditional upon.

4.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.

5.Co-Payment

means a cost sharing requirement under a health insurance policy that provides that the Policyholder/ Insured will bear a specified percentage of the admissible claims amount. A co-payment does not reduce the Sum Insured.

6.Cumulative Bonus

means any increase or addition in the Sum Insured granted by the insurer without an associated increase in premium.

7.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.

8.Day Care Treatment

means medical treatment, and/or surgical procedure which is:

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

Treatment normally taken on an out-patient basis is not included in the scope of this definition

9.Dental Treatment               

means a treatment related to teeth or structures supporting teeth including examinations, fillings (where appropriate), crowns, extractions and surgery.

10.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.

11.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.

12.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:

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

13.Hospitalisation

means admission in a Hospital for a minimum period of 24 Inpatient care consecutive hours except for the standard day care procedures/treatments as defined above, where such admission could be for a period of less than 24 consecutive hours.

14.Illness

means a sickness or a disease or pathological condition leading to the impairment of normal physiological function and requires medical treatment.

1. 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.
2. Chronic Condition – A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics:
   • it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /or tests
   • it needs ongoing or long-term control or relief of symptoms
   • it requires rehabilitation for the patient or for the patient to be specially trained to cope with it
   • it continues indefinitely
   • it recurs or is likely to recur.

15.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.

16.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.

17.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.

18.Intensive Care Unit (ICU) 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.

19.Maternity Expenses means

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.

20.Medical Advice

means any consultation or advice from a Medical Practitioner including the issuance of any prescription or follow-up prescription.

21.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.

22.Medically Necessary Treatment

means any treatment, tests, medication, or stay in hospital or part of a stay in hospital which:

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

23.Medical Practitioner

means a person who holds a valid registration from the Medical Council of any State 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.

24.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.

25.Network Provider

means hospitals or health care providers enlisted by an insurer, TPA or jointly by an Insurer and TPA to provide medical services to an insured by a cashless facility.

26.Non-Network Provider

means any hospital, day care centre or other provider that is not part of the network.

27.Notification Of Claim

means the process of intimating a claim to the insurer or TPA through any of the recognized modes of communication.

28.Out-Patient (OPD) 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.

29.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 insurer.

30.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
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 or its reinstatement.

31.Pre-Hospitalisation Medical Expenses

means medical expenses incurred during pre-defined number of days preceding the hospitalization 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

32.Post-Hospitalisation Medical Expenses

means medical expenses incurred during pre-defined number of days immediately 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.

33.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.

34.Reasonable And Customary Charges

mean 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.

35.Renewal

means 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.

36.Room Rent

means the amount charged by a Hospital towards room and boarding expenses and shall include the Associated Medical Expenses.

37.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.

38.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.

B.Specific Definitions

1.Age

means completed age in years on the Policy Commencement Date.

2.Associated Medical Expenses

means hospitalisation-related expenses on Surgeon, Anesthetist, Medical Practitioner, Consultants and Specialist Fees (whether paid directly to the treating doctor/surgeon or hospital), Anesthetics, Blood, Oxygen, Operation Theatre charges, surgical appliances, and other similar expenses which vary based on the room category occupied by the Insured Person whilst undergoing treatment in a hospital. Associated Medical expenses do not include:

1. cost of pharmacy and consumables
2. cost of implants/medical devices
3. cost of diagnostics

The scope of this definition is limited to admissible claims where a proportionate deduction is applicable.

3.Break in policy

means the period of gap that occurs at the end of the existing policy term, when the premium due for renewal on a given policy is not paid on or before the premium renewal date or within 30 days thereof.

4.Cancellation

defines the terms on which the policy contract can be terminated either by the Insurer or the Insured person by giving sufficient notice to the other which is not lower than a period of fifteen days.

5.Continuous Coverage

means uninterrupted coverage of the Insured Person under the Health Insurance Policy from the date of inception of the 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.

6.Family

means the Insured persons named in the Policy Schedule.

7.Insured Person

means person(s) named in the schedule of the Policy.

8.Material Fact

means all relevant information sought by the Company in the Proposal Form and other connected documents to enable it to take an informed decision in the context of underwriting the risk.

9.Nominee

means the person named in the Policy Schedule, Policy certificate and/or endorsement (if any) who is nominated by the Policy Holder/Insured Person, to receive the benefits under this Policy as per the terms of the Policy if the Insured Person deceases.

10.Organ Donor

means any person whose organ has been made available in accordance and compliance with The Transplantation of Human Organs (Amendment) Act, 1994 and relevant rules and amendments thereof. The organ donated must be for the use of the Insured Person.

11.Policy

means these Policy wordings, the Policy Schedule and any applicable endorsements or extensions attaching to and/or forming part thereof. The Policy contains details of the benefits, exclusions, and applicable terms & conditions.

12.Policy Period

means the period for which this policy is taken and is in force as specified in the Schedule.

13.Preferred Provider Network (PPN)

means a network of hospitals which have agreed to a cashless packaged pricing for certain procedures for the Insured Person. The updated list of network providers/PPN is available on our website (https://uiic.co.in/en/tpa-ppn-network-hospitals) and the website of the TPA mentioned in the schedule and is subject to amendments.

14.Proposal Form

means the form to be filled in by the prospect in written or electronic or any other format as requested by the Company and approved by the IRDAI, for furnishing all material information as required by the Insurer, to:

1. Enable the Insurer to take an informed decision in the context of underwriting the risk
2. And in the event of acceptance of the risk, to determine the rates, benefits, terms and conditions of the cover to be granted.

15.Shared Accommodation

means a twin-sharing room. This room may have an attached washroom, television, telephone, and couch. Such room must be the most economical of all such accommodations available in that hospital as twin-sharing occupancy. This does not include single private room / suite or room with additional facilities other than those stated herein. However, admission to any type of multi-bed ward including general ward will be considered within the ambit of this definition.

16.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.

17.Sum Insured

means the pre-defined limit specified in the Policy Schedule. Sum Insured and Cumulative Bonus represents the maximum, total and cumulative liability for any and all claims made under the Policy, in respect of that Insured Person (on Individual basis) or all Insured Persons (on Floater basis) during the Policy Year.

18.Third-Party Administrator (TPA)

means a company registered under the IRDAI (Third Party Administrators – Health Services) Regulations, 2016 notified by the Authority, and is engaged, for a fee or remuneration by an insurance company, for the purpose of providing health services as defined in the regulations.

19.Waiting Period

means a period from the inception of this Policy during which specified diseases/treatments are not covered. On completion of the period, diseases/treatments shall be covered provided the Policy has been continuously renewed without any break.

20.We/Our/Us/Company/Insurer

means United India Insurance Company Limited

21.You/Your

means the person who has taken this Policy and is shown as Insured Person or the first Insured Person (if more than one person covered in the policy) in the Schedule.