A.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

We will pay the Reasonable and Customary Charges for the following Medical Expenses taken during Hospitalisation provided that the admission date of the Hospitalisation due to Illness or Injury is within the Policy Period:

1. Room Rent (for Shared Accommodation), Boarding and Nursing expenses incurred as provided by the Hospital. 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).
3. The fees charged by the Medical Practitioner, Surgeon, Specialists, and anaesthetists treating the Insured Person;
4. Operation Theatre charges,
5. Anaesthesia, 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, orthopaedic implants, infra cardiac valve replacements, vascular stents, relevant laboratory/ diagnostic tests, X-Ray, dialysis, chemotherapy, radiotherapy, and such other associated expenses related to the treatment.

1.1 Note:

1. PROPORTIONATE PAYMENT CLAUSE: In case of admission to a room other than Shared Accommodation, 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 8.A.1.iii other than as part of the hospitalisation bill. However, the bills raised by Surgeon, Anaesthetist 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 defined in the policy are covered.

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 60 days prior to hospitalisation; and
2. Post- hospitalisation Medical Expenses incurred due to an Illness or Injury during the period up to 90 days after the discharge from the hospital.

Conditions:

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

3.Organ 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 8.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:
   
   • Pre-hospitalization Medical Expenses or Post-hospitalisation Medical Expenses of the organ donor;
   • Screening expenses of the organ donor;
   • Costs directly or indirectly associated with the acquisition of the donor’s organ;
   • Transplant of any organ/tissue where the transplant is experimental or investigational;
   • Expenses related to organ transportation or preservation;
   • Any other medical treatment or complication in respect of the donor, consequent to harvesting.

4.Modern Treatment Methods & Advancement in Technologies:

In case of an admissible claim under Clause 8.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 haematological conditions to be covered

5.Cumulative Bonus (CB)

The insured person(s) shall be rewarded Cumulative Bonus calculated at 50% of the Sum Insured as bonus for each claim free year subject to a maximum of 100% of the Sum Insured. If a claim is made in any particular year, the cumulative bonus accrued shall be reduced at the same rate at which it has accrued.

Note:

1. The CB shall be withdrawn if the policy is not renewed within Grace Period.
2. In case where the policy is on individual basis, the CB shall be available individually to each insured person. CB shall reduce only in case of claim from the same Insured Person. In case where the policy is on floater basis, the CB shall be available to the family on floater basis, provided no claim has been reported from any member of the family. CB shall reduce in case of claim from any of the Insured Persons.
3. If the Insured Persons in the expiring policy are covered on an individual basis as specified in the Policy Schedule and there is an accumulated CB for such Insured Person under the expiring policy, and such expiring policy has been renewed on a floater policy basis as specified in the Policy Schedule then the CB to be carried forward for credit in such Renewed Policy shall be the one that is applicable to the lowest among all the Insured Persons.
4. In case of floater policies where Insured Persons renew their expiring policy by splitting the Sum Insured into two or more floater policies/individual policies, the CB of expiring policy shall be apportioned to such renewed Policies in the proportion of the Sum Insured of each renewed Policy.
5. If the Sum Insured has been reduced at the time of renewal, the applicable CB shall be reduced in the same proportion to the Sum Insured in current Policy.
6. If the Sum Insured under the Policy has been increased at the time of Renewal the CB shall be calculated on the Sum Insured of the last completed Policy Year.
7. If a claim is made in the expiring Policy Year, and is notified to Us after the acceptance of Renewal premium any awarded CB shall be withdrawn.

6.Road Ambulance Cover

We will cover the costs incurred 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 8.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 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.

B.Optional Cover:

1.Waiver of Co-payment

If this cover is opted, then the applicable Co-Payment will be waived off, subject to payment of premium for Zone A.