• Age means age of the Insured person on last birthday as on date of commencement of the Policy.
• AYUSH Treatment refers to hospitalisation treatments given under Ayurveda, Yoga, Naturopathy, Unani, Siddha and Homeopathy systems.
• Cashless Facility means a facility extended by the insurer to the insured where the payments, of the costs of treatment undergone by the insured person 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.
• COVID For the purpose of this Policy, Coronavirus Disease means COVID-19 as defined by the World Health Organisation (WHO) and caused by the virus SARS-CoV2.
• Family means, the Family that consists of the proposer and any one or more of the family members as mentioned below:

        a. Legally  wedded spouse

        b. Parents and Parents-in-law.

        c. Dependent Children (i.e. natural or legally adopted) between the age 1 Day to 25 years. If the child above 18 years of age is financially independent, he or she shall be ineligible for coverage.

• Health Care Worker for the purpose of this policy shall mean doctors, nurses, midwives, dental practitioners and other health professionals including laboratory assistants, pharmacists, physiotherapists, technicians and people working in hospitals.
• Home Care Treatment means treatment availed by the Insured Person at home for Covid on positive diagnosis of Covid in a Government authorised diagnostic centre, which in normal course would require care and treatment at a hospital but is actually taken at home provided that:

1. TheMedical Practitioner advises the Insured Person to undergo treatment at home.
2. There is a continuous active line of treatment with monitoring of the health status by a medical practitioner for each day through the duration of the home care treatment.
3. Daily monitoring chart including records of treatment administered duly signed by the treating doctor is maintained.

• Hospital means any institution established for in-patient care and day care treatment of disease/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 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 ten inpatient beds, in those towns having a population of less than ten lakhs and at least fifteen inpatient 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 shall make these accessible to the Company’s authorized personnel.

• Hospitalisation means admission in a hospital for a minimum period of twenty four (24) consecutive ‘In-patient care’ hours except for specified procedures/treatments, where such admission could be for a period of less than twenty four (24) consecutive hours.
• 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.
• Insured Person means person(s) named in the schedule of the Policy.
• Medical Advice means any consultation or advice from a Medical Practitioner including the issue of any prescription or follow up prescription.
• 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.
• 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 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.

• 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 the scope and jurisdiction of the license.
• Network Provider means hospitals enlisted by Insurer, TPA or jointly by an Insurer and TPA to provide medical services to an Insured by a cashless facility.
• Non-Network Provider means any hospital that is not part of the network.
• Notification Of Claim means the process of intimating a claim to the Insurer or TPA through any of the recognised modes of communication.
• Pre-Hospitalisation Medical Expenses means medical expenses incurred during the period of 15 days preceding the hospitalisation/home care treatment of the Insured Person, provided that:

1. Such Medical expenses are incurred for the same condition for which the Insured Person’s Hospitalisation /home care treatment was required, and
2. The In-patient Hospitalisation claim/home care treatment claim for such Hospitalisation/home care treatment is admissible by us.

• Post-Hospitalisation Medical Expenses means medical expenses incurred during the period of 30 days immediately after the Insured Person is discharged from the hospital/completion of home care treatment provided that:

1. Such Medical expenses are for the same condition for which the Insured Person’s Hospitalisation/home care treatment was required, and
2. The In-patient Hospitalisation/home care treatment claim for such Hospitalisation/home care treatment is admissible by us.

• 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.
• Policy Period means period of three and half months (3 ½ months), six and half months (6 ½ months), nine and half months (9 ½ months) as mentioned in the Schedule for which the Policy is issued.
• Policy Schedule means the Policy Schedule attached to and forming part of Policy
• 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.
• Room Rent means the amount charged by a hospital towards Room and Boarding expenses and shall include the associated medical expenses.
• 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.
• Sum Insured means the pre-defined limit specified in the Policy Schedule. Sum Insured 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 period.
• 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 of suffering or prolongation of life, performed in a Hospital or Day Care Centre by a Medical Practitioner.
• Third Party Administrator (TPA) means a Company registered with the Authority, 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. 
• Waiting Period means a period from the inception of this Policy during which Covid is not covered.

ELIGIBILITY:
Any person aged between 18 years and 65 years can take this insurance for himself and his/her family consisting of Self, Spouse, dependent children, Parents and Parents-in-law, either on Individual Sum Insured basis or on floater basis. Beyond 65 years, only renewals are allowed. 
Dependent children between the age of 1 day and 18 years shall be covered provided either or both parents are covered concurrently. Children above 18 years will continue to be covered along with parents till the age of 25 years. If the child is above 18 years of age and is financially independent, he or she shall be ineligible for coverage under the same policy in the subsequent renewals. However, a separate policy can be taken for him or her on expiry of the current policy for which continuity benefits will be provided.

SUM INSURED:   
Various options are available as under: 
Rs. 50000, 1 lac, 1.5 lacs, 2 lacs, 2.5 lacs, 3 lacs, 3.5 lacs, 4 lacs, 4.5 lacs, 5 Lacs.

TERM OF POLICY:   
3.5 Months, 6.5 Months, 9.5 Months

The covers listed below are in-built Policy benefits and shall be available to all Insured Persons in accordance with the procedures set out in this Policy.
Base Cover:
The covers listed below are in-built Policy benefits and shall be available to all Insured Persons in accordance with the procedures set out in this Policy. 
 1. Covid Hospitalization Cover:
The Company shall indemnify medical expenses incurred for Hospitalization of the Insured Person during the Policy period for the treatment of Covid on Positive diagnosis of Covid in a government authorized diagnostic centre including the expenses incurred on treatment of any comorbidity along with the treatment for Covid up to the Sum Insured specified in the policy schedule, for, 

1. Room Rent, Boarding, Nursing Expenses as provided by the Hospital / Nursing Home.
2. Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) expenses.
3.  Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialist Fees whether paid directly to the treating doctor / surgeon or to the hospital
4. Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, ventilator charges, medicines and drugs, costs towards diagnostics, diagnostic imaging modalities, PPE Kit, gloves, mask and such similar other expenses.
5. Road Ambulance subject to a maximum of Rs.2000/- per hospitalization for the Ambulance services offered by a Hospital or by an Ambulance service provider, provided that the Ambulance is availed only in relation to Covid Hospitalization for which the Company has accepted a claim under section This also includes the cost of the transportation of the Insured Person from a Hospital to the another Hospital as prescribed by a Medical Practitioner. 

Note: 1. Expenses of Hospitalization for a minimum period of 24 consecutive hours only shall be admissible. 

2. Home Care Treatment Expenses:
Home Care Treatment means Treatment availed by the Insured Person at home for Covid on positive diagnosis of Covid in a Government authorized diagnostic Centre, which in normal course would require care and treatment at a hospital but is actually taken at home maximum up to 14 days per incident provided that: 

1. The Medical practitioner advices the Insured person to undergo treatment at home.
2. There is a continuous active line of treatment with monitoring of the health status by a medical practitioner for each day through the duration of the home care treatment. 
3. Daily monitoring chart including records of treatment administered duly signed by the treating doctor is maintained. 
4. Insured shall be permitted to avail the services as prescribed by the medical practitioner. Cashless or reimbursement facility shall be offered under homecare expenses subject to claim settlement policy disclosed in the website.
5. In case the insured intends to avail the services of non-network provider claim shall be subject to reimbursement, a prior approval from the Insurer needs to be taken before availing such services. 

In this benefit, the following shall be covered if prescribed by the treating medical practitioner and is related to treatment of COVID, 

1. Diagnostic tests undergone at home or at diagnostics centre 
2. Medicines prescribed in writing 
3. Consultation charges of the medical practitioner 
4. Nursing charges related to medical staff 
5. Medical procedures limited to parenteral administration of medicines 
6. Cost of Pulse oximeter, Oxygen cylinder and Nebulizer 

3. AYUSH Treatment:
The Company shall indemnify medical expenses incurred for inpatient care treatment for Covid on Positive diagnosis of COVID test in a government authorized diagnostic centre including the expenses incurred on treatment of any comorbidity along with the treatment for Covid under Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems of medicines during the Policy Period up to the limit of sum insured as specified in the policy schedule in any AYUSH Hospital. Covered expenses shall be as specified under Covid Hospitalization Expenses (Section 4.1)

 4. Pre Hospitalization:

The company shall indemnify pre-hospitalization/home care treatment medical expenses incurred, related to an admissible hospitalization/home care treatment, for a fixed period of 15 days prior to the date of admissible hospitalization/home care treatment covered under the policy.

 5. Post Hospitalization:

The company shall indemnify post hospitalization//home care treatment medical expenses incurred, related to an admissible hospitalization//home care treatment, for a fixed period of 30days from the date of discharge from the hospital, following an admissible hospitalization covered under the policy.
 6. The expenses that are not covered in this policy are placed under List-I of Annexure-A. The list of expenses that are to be subsumed into room charges, or procedure charges or costs of treatment are placed under List-II, List-III and List-IV of Annexure-A respectively.

1. Procedure for Cashless claims:

(i) Treatment may be taken in a network provider and is subject to pre authorization by the Company or its authorized TPA. (ii) Cashless request form available with the network provider and TPA shall be completed and sent to the Company/TPA for authorization. (iii) The Company/ TPA upon getting cashless request form and related medical information from the insured person/ network provider will issue preauthorization letter to the hospital after verification. (iv) At the time of discharge, the insured person has to verify and sign the discharge papers, pay for non-medical and inadmissible expenses. (v) The Company / TPA reserves the right to deny pre-authorization in case the insured person is unable to provide the relevant medical details. (vi)In case of denial of cashless access, the insured person may obtain the treatment as per treating doctor’s advice and submit the claim documents to the Company / TPA for reimbursement.  

2. Procedure for reimbursement of claims:

For reimbursement of claims the insured person may submit the necessary documents to TPA (if applicable)/Company within the prescribed time limit as specified hereunder. 

3. Notification of Claim

Notice with full particulars shall be sent to the Company/TPA (if applicable) as under: 

Within 24 hours from the date of emergency hospitalization/cashless home care treatment.  

At least 48 hours prior to admission in Hospital in case of a planned Hospitalization. 

4. Documents to be submitted:

The claim is to be supported with the following documents and submitted within the prescribed time limit. 

Note:

1. The company shall only accept bills/invoices/medical treatment related documents only in the Insured Person’s name for whom the claim is submitted 
2. In the event of a claim lodged under the Policy and the original documents having been submitted to any other insurer, the Company shall accept the copy of the documents and claim settlement advice, duly certified by the other insurer subject to satisfaction of the Company 
3. Any delay in notification or submission may be condoned on merit where delay is proved to be for reasons beyond the control of the Insured Person 

5. Claim Settlement (provision for Penal Interest)

1. The Company shall settle or reject a claim, as the case may be, within 30 days from the date of receipt of last necessary document.  
2. In the case of delay in the payment of a claim, the Company shall be liable to pay interest from the date of receipt of last necessary document to the date of payment of claim at a rate 2% above the bank rate.
3.  However, where the circumstances of a claim warrant an investigation in the opinion of the Company, it shall initiate and complete such investigation at the earliest in any case not later than 30 days from the date of receipt of last necessary document. In such cases, the Company shall settle the claim within 45 days from the date of receipt of last necessary document. 
4.  In case of delay beyond stipulated 45 days the company shall be liable to pay interest at a rate 2% above the bank rate from the date of receipt of last necessary document to the date of payment of claim. 

6. Services Offered by TPA (To be stated where TPA is involved)

Servicing of claims, i.e., claim admissions and assessments, under this Policy by way of pre-authorization of cashless treatment or processing of claims other than cashless claims or both, as per the underlying terms and conditions of the policy.  

The services offered by a TPA shall not include 

1. Claim settlement and claim rejection;  
2. Any services directly to any insured person or to any other person unless such service is in accordance with the terms and conditions of the Agreement entered into with the Company. 

7. Payment of Claim

All claims under the policy shall be payable in Indian currency only. 

VI. WHAT POLICY DOES NOT COVER:  
 
A.WAITING PERIOD – EXCLUSIONS:
  The Company shall not be liable to make any payment under the policy in connection with or in respect of following expenses till the expiry of waiting period mentioned below:  
1. First Fifteen Days Waiting Period  
Expenses related to the treatment of Covid within 15 days from the policy commencement date shall be excluded.    
B.EXCLUSIONS 
The company shall not be liable to make any payment under the policy, in respect of any expenses incurred in connection with or in respect of:  
2. Investigation & Evaluation (Code- Excl04)  
Expenses related to any admission primarily for diagnostics and evaluation purposes. Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment  
 
3. 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, moving around either by skilled nurses or assistant or non-skilled persons.  
Any services for people who are terminally ill to address physical, social, emotional and spiritual needs. 
 
 4.Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals and organic substances unless prescribed by a medical practitioner as part of hospitalization claim or Home care treatment. 
 
5. Unproven Treatments: 
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. However, treatment authorized by the government for the treatment of COVID shall be covered. 
 
6. Any claim in relation to Covid where it has been diagnosed prior to Policy Start Date. 
 
7.Any expenses incurred on Day Care treatment and OPD treatment 
 
8. Diagnosis /Treatment outside the geographical limits of India 
 
9.Testing done at a Diagnostic centre which is not authorized by the Government shall not be recognized under this Policy 
 
10.All covers under this Policy shall cease if the Insured Person travels to any country placed under travel restriction by the Government of India. 

Please note:

1. Premium rates specified in the illustrations below are standard premium rates exclusive of any loadings and GST.
2. Rates shown below are for 3.5 Months policy tenure.

ILLUSTRATION

Family consisting of Self, Spouse, 2 Dependent Children, Father, Mother and Mother-in-Law