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Note : A brief snapshot about the policy is given.For complete information refer to policy wordings or visit our nearest branch office.

The Policy provides cover on an Individual Sum Insured basis for an individual. The policy is offered on family package basis also, for family comprising of the Proposer, Spouse, Dependent Children, and Parents, with Individual Sum Insured for each family member.  Policy is available under three plans based on age of entry into the policy.

  • 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 Ayurvedic system of Medicine (covered under the Policy).
  • 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.
  • 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 out-patient basis is not included in the scope of this definition.

  • 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 the hospital/nursing home or health care providers enlisted by an Insurer or by a TPA and Insurer together to provide medical services to an Insured on payment by a cashless facility.  The list of Network Hospitals is maintained by and available with the TPA and the same is subject to amendment from time to time.

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. 

  • 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-Existing Disease (PED): Pre-existing disease means any condition, ailment or 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.
  • Pre-Hospitalisation Medical Expenses means medical expenses incurred during the period of 30 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 Insurance Company.
  • Post-Hospitalisation Medical Expenses means medical expenses incurred during the period of 60 days immediately after Insured Person is discharged from the hospital, provided that:
    1. Such medical expenses are 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 Insurance Company.
  • 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 one policy year as mentioned in 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.
  • 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 the illness / injury involved.
  • 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 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.
  1. ELIGIBILITY:
  1. Any person aged between 18 years and 65 years can take this insurance for himself/herself and his/her family consisting of Self, Spouse, Dependent Children and Parents on Individual Sum Insured basis.
  2. Entry Age of Proposer and insured family members for different plans is as under:
    1. Platinum: between 18 and 35 years. Children from the age of 91 days can be covered provided either or both of the parents are covered
    2. Gold: between 36 and 60 years
    3. Senior Citizen: between 61 and 65 years
  3. An Insured Person will continue to be in the same plan that they were under at the time of entry into the policy, even if they cross the maximum age prescribed for that plan, provided the policies are renewed with us without break.
  4. Dependent children between the age of 91 days 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 provided they are unmarried/unemployed and dependent. In the event of children becoming independent, employed, or getting married, a separate policy can be taken on expiry of the current policy for which continuity benefits will be provided.
  5. Midterm inclusion of family members is allowed at pro-rata premium only in case of:
  1. Newly married spouse within 60 (sixty) days of marriage.
  2. New born baby, between the ages of 91 days to 180 days, born to mother insured under the policy.

 

  1. SUM INSURED:  

The various Sum Insured options available under the three plans are as follows:

  1. Platinum                    : ₹ 2 Lakhs, ₹ 3 Lakhs, ₹ 5 Lakhs, ₹ 8 Lakhs, ₹ 10 Lakhs, ₹ 15 Lakhs, ₹ 20 Lakhs
  2. Gold                           : ₹ 2 Lakhs, ₹ 3 Lakhs, ₹ 5 Lakhs, ₹ 8 Lakhs, ₹ 10 Lakhs
  3. Senior Citizen          : ₹ 2 Lakhs, ₹ 3 Lakhs, ₹ 5 Lakhs

 

  1. TERM OF POLICY:  

One Year

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 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 1% of Sum Insured per day or actual expenses whichever is less. These expenses will include nursing care, RMO 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 2% of Sum Insured per day or actual expenses whichever is less.
  3. The fees charged by the Medical Practitioner, Surgeon, Specialists, Consultants and Anaesthetists treating the Insured Person.
  4. Operation theatre charges; Expenses incurred for Anaesthetics, Blood, Oxygen, Surgical Appliances and/or Medical Appliances; 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 and such other similar medical expenses related to the treatment.
  5. All hospitalisation expenses (excluding cost of organ) incurred for donor in respect of organ transplant to the Insured Person provided the donation conforms to The Transplantation of Human Organs Act 1994.

Note to 1

  1. Expenses of Hospitalisation for a minimum period of 24 consecutive hours only shall be admissible. However, the time limit shall not apply in respect of Day Care Treatment.
  1. In case of admission to a room at rates exceeding the aforesaid limits in Clause 5.1.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.

  1. No payment shall be made under 5.1 (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.

1.1 Other expenses covered:

  1. Dental treatment, necessitated due to injury
  2. Plastic surgery necessitated due to disease or injury
  3. All day care treatments as per standard definition

1.2 Expenses in respect of the following specified illnesses will be restricted as detailed below:

(Only Applicable for Gold & Senior Citizen Plans only)

 

Surgery / Illness / Disease / Procedure

Maximum Limits per Surgery/Hospitalisation restricted to

Cataract

Up to 25% of Sum Insured or Rs. 40,000 per eye, whichever is less

Hernia & Hysterectomy

Up to 25% of Sum Insured or Rs. 1,00,000, whichever is less

Major surgeries which include Cardiac Surgeries; Brain Tumour Surgeries; Pace Maker Implantation for Sick Sinus Syndrome; Cancer Surgeries; Hip, Knee, Joint Replacement Surgery; Organ Transplant

Up to 70% of the Sum Insured

 

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, provided that:

  1. We have accepted a claim for primary In-patient Hospitalization under Section 5.1 above;
  2. The Pre-hospitalisation & Post-hospitalisation Medical Expenses are related to the same Illness or Injury.
  3. The date of admission to the Hospital for the purpose of this Benefit shall be the date of the Insured Person’s first admission to the Hospital in relation to the same Any One Illness.

Note: The maximum limit of 10% of Sum Insured will not be applicable for Platinum Plan.

3              Domiciliary Hospitalisation

We will cover, on a reimbursement basis, medical treatment for a period exceeding three days for such an illness/disease/injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances:

  1. The condition of the patient is such that he/she is not in a condition to be moved to a hospital or
  2. The patient takes treatment at home on account of non-availability of room in a hospital.

However, domiciliary hospitalisation benefits shall not cover:

Expenses incurred for treatment for any of the following diseases:

  1. Asthma
  2. Bronchitis
  3. Chronic Nephritis and Nephritic Syndrome
  4. Diarrhoea and all type of Dysenteries including Gastroenteritis
  5. Diabetes Mellitus and Insipidus
  6. Epilepsy
  7. Hypertension
  8. All Psychiatric or Psychosomatic Disorders
  9. Influenza, Cough and Cold
  10. Pyrexia of unknown Origin for less than 10 days
  11. Tonsillitis and Upper Respiratory Tract infection including Laryngitis and pharyngitis
  12. Arthritis, Gout and Rheumatism              

Liability of the Company under this clause is restricted as stated in the Schedule as per Annexure – 2 of the Policy Wordings.

4              Ayurvedic Treatment

We will pay the Reasonable & Customary Charges incurred as in-patient for an Insured Person in case of Medically Necessary Treatment taken during Hospitalisation subject to the condition that the hospitalisation expenses are admissible only when the treatment has been undergone in an AYUSH Hospital.

5              Modern Treatment Methods & Advancement in Technologies

In case of an admissible claim under section 5.1, expenses incurred on the following procedures (wherever medically indicated) either as in-patient or as part of day care treatment in a hospital, shall be covered. The claim shall be subject to additional sub-limits indicated against them in the table below:

Sr. No.

Modern Treatment Methods & Advancement in Technology

Limits per Surgery

1

Uterine Artery  Embolization & High Intensity Focussed Ultrasound (HIFU)

Up to 20% of Sum Insured subject to a maximum of Rs.2 Lacs per policy period for claims involving Uterine Artery Embolization & HIFU

2

Balloon Sinuplasty

Up to 10% of Sum Insured subject to a maximum of Rs.1 Lac per policy period for claims involving Balloon Sinuplasty

3

Deep Brain Stimulation

Up to 70% of Sum Insured per policy period for claims involving Deep Brain Stimulation

4

Oral Chemotherapy

Up to 20% of Sum Insured subject to a maximum of Rs.2 Lacs per policy period for claims involving Oral Chemotherapy

5

Immunotherapy-Monoclonal Antibody to be given as injection

Up to 20% of Sum Insured subject to a maximum of Rs.2 Lacs per policy period

6

Intra vitreal Injections

Up to 10% of Sum Insured subject to a maximum of Rs. 1 Lac per policy period

7

Robotic Surgeries (Including Robotic Assisted Surgeries)

  • Up to 75% of Sum Insured per policy period for claims involving Robotic Surgeries for (i) the treatment of any disease involving Central Nervous System irrespective of aetiology; (ii) Malignancies
  • Up to 50% of Sum Insured per policy period for claims involving Robotic Surgeries for other diseases

8

Stereotactic Radio Surgeries

Up to 50% of Sum Insured per policy period for claims involving  Stereotactic Surgeries

9

Bronchial Thermoplasty

Up to 30% of Sum Insured subject to a maximum of Rs.3 Lacs per policy period for claims involving Bronchial Thermoplasty.

10

Vaporisation of the Prostate (Green laser treatment for holmium laser treatment)

Up to 30% of Sum Insured subject to a maximum of Rs.2 Lacs per policy period.

11

Intra Operative Neuro Monitoring (IONM)

Up to 15% of Sum Insured per policy period for claims involving Intra Operative Neuro Monitoring subject to a maximum of Rs. 1 Lac per policy period.

12

Stem Cell Therapy: Hematopoietic Stem Cells for bone marrow transplant for haematological conditions to be covered only

No additional sub-limit

Note: If, for a given admissible claim, limits as listed in the Table above AND limits mentioned in Clause 5.1.2 are applicable simultaneously, then the lower of the two limits shall apply.

6              Cost of Health Check-Up

We will cover expenses incurred towards cost of health check-up up to 1% of average Sum Insured of preceding 3 years, subject to a maximum of Rs. 5,000 per person per policy period 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 sum insured.

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.

OPTIONAL COVERS

7              Road Ambulance Cover

We will cover the costs incurred up to Rs. 2500 per person 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 Section 5.1 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 speciality treatment in the existing Hospital.

8              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:

Additional Annual Premium

Daily Cash Allowance Limit (in Rs.)

Rs. 150/-

Rs. 250 per day subject to a maximum of Rs. 2500 per policy period

Rs. 300/-

Rs. 500 per day subject to a maximum of Rs. 5000 per policy period

 
  1. The aggregate of Daily Cash Allowance during the policy period shall not exceed ‘per policy period limits’ as mentioned in the table above.
  2. Daily Cash Allowance will not be payable for Day Care Treatment  claims.
  3. Deductible equivalent to Daily Cash Allowance for the first 48 hours Hospitalization will be levied on each Hospitalisation during the Policy Period.
  1. Notification of Claim

Upon the happening of any event which may give rise to a claim under this Policy, the Insured Person/Insured Person’s representative shall notify the TPA (if claim is processed by TPA)/Company (if claim is processed by the Company) in writing providing all relevant information relating to claim including plan of treatment, policy number etc. within the prescribed time limit as under:

  1. Within 24 hours from the date of emergency hospitalization required or before the Insured Person’s discharge from Hospital, whichever is earlier.
  2. At least 48 hours prior to admission in Hospital in case of a planned Hospitalization.

 

  1. Procedure for Cashless Claims
  1. Cashless facility for treatment in network hospitals only shall be available to Insured if opted for claim processing by TPA.
  2. Treatment may be taken in a network provider/PPN hospital and is subject to pre authorization by the TPA. Booklet containing list of network provider/PPN hospitals shall be provided by the TPA. Updated list of network provider/PPN is available on website of the Company (https://uiic.co.in/en/tpa-ppn-network-hospitals) and the TPA mentioned in the schedule.
  3. Call the TPA’s toll free phone number provided on the health ID card for intimation of claim and related assistance. Inform the ID number for easy reference
  4. On admission in the network provider/PPN hospital, produce the ID card issued by the TPA at the Hospital Helpdesk. Cashless request form available with the network provider/PPN and TPA shall be completed and sent to the TPA for authorization.
  5. The TPA upon getting cashless request form and related medical information from the Insured Person/Network Provider/PPN shall issue pre-authorization letter to the hospital after verification.
  6. At the time of discharge, the Insured Person shall verify and sign the discharge papers and pay for non-medical and inadmissible expenses.
  7. The TPA reserves the right to deny pre-authorization in case the Insured Person is unable to provide the relevant medical details.
  8. Denial of a Pre-authorization request is in no way to be construed as denial of treatment or denial of coverage. The Insured Person may get the treatment as per treating doctor’s advice and submit the claim documents to the TPA for possible reimbursement.

 

  1. Procedure for Reimbursement of Claims
  1. In non-network hospitals payment must be made up-front and for reimbursement of claims the Insured Person may submit the necessary documents to TPA (if claim is processed by TPA)/Company (if claim is processed by the Company) within the prescribed time limit.
  2. Claims for Pre and Post-Hospitalization will be settled on reimbursement basis on production of relevant claim papers and cash receipts within the prescribed time limit.
  3. Claims for Cost of Health Check-up will be settled on reimbursement basis on production of test reports and cash receipts within the prescribed time limit.

 

  1. Supporting Documents

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

  1. Duly completed claim form
  2. Attending medical practitioner’s / surgeon’s certificate regarding diagnosis/ nature of operation performed, along with date of diagnosis, advise for admission, investigation test reports etc. supported by the prescription from attending medical practitioner.
  3. Medical history of the patient recorded, bills (including break up of charges) and payment receipts duly supported by the prescription from attending medical practitioner/ hospital.
  4. Discharge certificate/ summary from the hospital.
  5. Cash-memo from the Diagnostic Centre(s)/ hospital(s)/ chemist(s) supported by proper prescription.
  6. Payment receipts from doctors, surgeons and anaesthetist. 
  7. Bills, receipt, Sticker of the Implants.
  8. Any other document required by Company/ TPA

Note

In the event of a claim lodged as per Settlement under multiple policies clause and the original documents having been submitted to the other Insurer, the Company may accept the duly certified documents listed under condition 18 (D) above and claim settlement advice duly certified by the other Insurer subject to satisfaction of the Company.

  1. Time Limit for Submission of Documents

 

Type of Claim

Time Limit for Submission of Documents to Company / TPA

Reimbursement of hospitalisation and pre hospitalisation expenses (limited to 30 days)

Within 15 (fifteen) days of date of discharge from hospital

Reimbursement of post-hospitalisation expenses (limited to 60 days)

Within 15 (fifteen) days from completion of post-hospitalisation treatment

Reimbursement of Cost of Health Check-up

Within 15 (fifteen) days from Health Check-up

 

Note

  1. Waiver of this Condition may be considered in extreme cases of hardship where it is proved to the satisfaction of the Company that under the circumstances in which the Insured was placed it was not possible for him or any other person to give such notice or file claim within the prescribed time-limit.
  2. The Company shall only accept bills/invoices/medical treatment related documents only in the Insured Person’s name for whom the claim is submitted.
  3. The Insured Person shall also give the TPA / Company such additional information and assistance as the TPA / Company may require in dealing with the claim including an authorisation to obtain Medical and other records from the hospital, lab, etc.
  4. All the documents submitted to TPA shall be electronically collected by us for settlement/denial of the claims by the appropriate authority.
  5. Any medical practitioner or Authorised Person authorised by the TPA / Company shall be allowed to examine the Insured Person in case of any alleged injury or disease leading to Hospitalisation if so required.

 

  1. 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 to the Policyholder 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 or reject 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 to the Policyholder at a rate 2% above the bank rate from the date of receipt of last necessary document to the date of payment of claim.

(Explanation: "Bank rate" shall mean the rate fixed by the Reserve Bank of India (RBl) at the beginning of the financial year in which claim has fallen due).

  1. Services Offered by TPA

Servicing of claims i.e. claim admissions and assessments, under this Policy by way of pre-authorization of cashless treatment or processing of claims, as per the 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.

 

  1. Payment of Claim

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

A.WAITING PERIODS (Only Applicable for Gold & Senior Citizen Plans)

The Company shall not be liable to make any payment under the policy in connection with or in respect of any expenses till the expiry of waiting period mentioned below:

1              Pre-Existing Disease (Code- Excl01):

  1. Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with us.
  2. In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
  3. If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health Insurance) Regulations, then waiting period for the same would be reduced to the extent of prior coverage.
  4. Coverage under the policy after the expiry of 48 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by us.

2              Specific Disease/ Procedure Waiting Period (Code- Excl02):

  1. Expenses related to the treatment of the listed Conditions, surgeries/treatments as per Table A and Table B below, shall be excluded until the expiry of 24 months and 48 months respectively of continuous coverage after the date of inception of the first policy with us. This exclusion shall not be applicable for claims arising due to an accident.
  2. In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
  3. If any of the specified disease/procedure falls under the waiting period specified for Pre-Existing diseases, then the longer of the two waiting periods shall apply.
  4. The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a specific exclusion.
  5. If the Insured Person is continuously covered without any break as defined under the applicable norms on portability stipulated by IRDAI, then waiting period for the same would be reduced to the extent of prior coverage.
  6. List of specific diseases/procedures:

Table A: 24 Months’ Waiting Period

Cataract

Piles, Fissures and Fistula-in-Ano

Benign Prostatic Hypertrophy

Sinusitis and related disorders

Treatment for Menorrhagia/ Fibromyoma, Myoma and Prolapse of Uterus

Gout and Rheumatism

Hernia of all types

Calculus diseases

Hydrocele

Congenital Internal diseases

 

Table B: 48 Months’ Waiting Period

Joint Replacement due to Degenerative condition, unless necessitated due to an accident.

Age-related Osteoarthritis & Osteoporosis

Age-related Macular Degeneration (ARMD)

All Neurodegenerative disorders

 

3              First Thirty Days Waiting Period (Code- Excl03):

  1. Expenses related to the treatment of any illness within 30 days from the first policy commencement date shall be excluded except claims arising due to an accident, provided the same are covered.
  2. This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve months.
  3. The within referred waiting period is made applicable to the enhanced sum insured in the event of granting higher sum insured subsequently.

 

B.PERMANENT EXCLUSIONS (Applicable for ALL Plans)

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:

4              All expenses caused by or arising from or attributable to foreign invasion, act of foreign enemies, hostilities, warlike operations (whether war be declared or not or while performing duties in the armed forces of any country), civil war, public defence, rebellion, revolution, insurrection, military or usurped power.

5              All Illness/expenses caused by ionizing radiation or contamination by radioactivity from any nuclear fuel (explosive or hazardous form) or from any nuclear waste from the combustion of nuclear fuel nuclear, chemical or biological attack.

6              a) Stem cell implantation/Surgery, harvesting, storage or any kind of Treatment using stem cells except as provided for in clause 5.5 (12) above; b) growth hormone therapy. 

             7              Congenital External Diseases or Defects or anomalies.

        8              Sterility and Infertility (Code-Excl17): Expenses related to Sterility and infertility. This includes:

  1. Any type of contraception, sterilization
  2. Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
  3. Gestational Surrogacy
  4. Reversal of sterilization

           9              Maternity (Code-Excl18):

  1. Medical treatment expenses traceable to child birth (Including complicated deliveries and caesarean sections incurred during hospitalisation) except ectopic pregnancy;
  2. Expenses towards miscarriage (unless due to an accident) and lawful medical termination of pregnancy during the policy period.

        10           Circumcision unless necessary for Treatment of an Illness or Injury not excluded hereunder or due to an Accident.

        11           Cost of routine medical examination and preventive health check-up unless as provided for in Base Cover 5.6.

        12           Investigation & Evaluation (Code-Excl04):

  1. Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded;
  2. Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.

13           Unproven Treatments (Code- Excl16): 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.

14           Change-of-Gender treatments (Code-Excl07): Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.

15           Cosmetic or plastic Surgery (Code-Excl08): Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident, Burn(s) or Cancer or as part of medically necessary treatment to remove a direct and immediate health risk to the Insured. For this to be considered a medical necessity, it must be certified by the attending Medical Practitioner.

16           Vaccination or inoculation of any kind unless it is post animal bite.

17           i.        Routine eye-examination expenses, cost of spectacles, contact lenses;

                            ii.        Cost of hearing aids; including optometric therapy;

  1. Cochlear implants unless necessitated by an Accident or required intra-operatively.

18           Refractive Error (Code-Excl15): Expenses related to the treatment for correction of eyesight due to refractive error less than 7.5 dioptres.

19           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:

  1. 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.
  2. Any services for people who are terminally ill to address physical, social, emotional, and spiritual needs.

20           Obesity/ Weight Control (Code-Excl06): Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:

  1. Surgery to be conducted is upon the advice of the Doctor
  2. The surgery/Procedure conducted should be supported by clinical protocols
  3. The member has to be 18 years of age or older and
  4. Body Mass Index (BMI)
    1. greater than or equal to 40 or
    2. greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive methods of weight loss:
      1. Obesity-related cardiomyopathy
      2. Coronary heart disease
      3. Severe Sleep Apnoea
      4. Uncontrolled Type2 Diabetes

21           Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof. (Code-Excl12)

22           Intentional self-inflicted Injury, attempted suicide.

23           Breach of law (Code-Excl10): Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with criminal intent.

24           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 hospitalisation claim or day care procedure. (Code-Excl14)

25           Treatments other than Allopathy and Ayurvedic branches of medicine.

26           Treatments received in health hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing home attached to such establishments or where admission is arranged wholly or partly for domestic reasons. (Code-Excl13)

27           Excluded Providers (Code-Excl11): Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website/notified to the policyholders are not admissible. However, in case of life threatening situations or following an accident, expenses up to the stage of stabilisation are payable but not the complete claim.

28           Unless used intra-operatively, any expenses incurred on prosthesis, corrective devices; External and/or durable Medical /Non-medical equipment of any kind used for diagnosis and/or treatment and/or monitoring and/or maintenance and/or support including instruments used in treatment of sleep apnoea syndrome; Infusion pump, Oxygen concentrator, Ambulatory devices, sub cutaneous insulin pump and also any medical equipment, which are subsequently used at home. This is indicative and please refer to Annexure – 1 in the Policy Wordings for the complete list of non-payable items.

29           Change of treatment from one system of medicine to another system unless recommended by the consultant/hospital under whom the treatment is taken.

30           Treatments including Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy, chondrocyte or osteocyte implantation, procedures using platelet rich plasma, Trans Cutaneous Electric Nerve Stimulation; Use of oral immunomodulatory/ supplemental drugs.

31           Artificial life maintenance including life support machine use, from the date of confirmation by the treating doctor that the patient is in a vegetative state.

32           Any item(s) or treatment specified in ‘List of Non-Medical Expenses– Payable/Non-Payable’ as per Annexure – 1 of the Policy Wordings and available on Company web site also, unless specifically covered under the Policy.

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