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.

ELIGIBILITY

1. Any person aged between 18 years and 65 years can take this insurance for himself/herself and his/her family consisting of:
   1. Self, Spouse, Dependent Children, Parents and Parents-in-law on Individual Sum Insured basis or
   2. Self, Spouse and Dependent Children on Family Floater basis.
2. 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 till they complete 26 years and 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 the expiry of the current policy for which continuity benefits will be provided. The upper age limit will not apply to mentally challenged children.
3. 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. Parents of Newly married spouse within 60 (sixty) days of marriage.
   3. New born baby, between the ages of 91 days to 180 days, born to mother insured under the policy or the adopted child between the ages of 91 days to 18 years within 60 (sixty) days of date of adoption.

SUM INSURED OPTIONS

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

POLICY TERM:  One Year. Renewable annually.

The coverages available under this policy are classified as Base Cover and Optional Cover. Base Cover refers to the coverage available as default under Super Top-Up Medicare Policy whereas Optional Cover is available only upon payment of additional premium.

BASE COVER

The Policy provides base coverage as described below in this section:

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 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. 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)
3. The fees charged by the Medical Practitioner, Surgeon, Specialists and anaesthetists treating the Insured Person;
4. Anaesthesia, blood, oxygen, operation theatre charges, surgical appliances, implants, prosthetic devices implanted during surgical procedure, medicines and drugs, costs towards diagnostics, diagnostic imaging modalities and such similar other expenses.
5. Other In-patient Expenses
   1. Dental treatment, necessitated due to disease or injury
   2. Plastic surgery necessitated due to disease or injury
   3. All the day care treatments
   4. v. Mental illness cover

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 subject to following limits:

2. Post- hospitalisation Medical Expenses incurred due to an Illness or Injury during the period subject to following limits

Provided that:

1. We have accepted a claim for primary In-patient Hospitalization
2. The Pre-hospitalisation and/or Post-hospitalisation Medical Expenses are related to the same Illness or Injury.
3. Home Care Treatment also will be deemed as hospitalisation for this cover.

3. Home Care Treatment Expenses:

We will pay the Reasonable and Customary Charges for Home Care Treatment for any epidemic/ pandemic subject to the limits linked to the Threshold, as mentioned in the table below:

Home Care Treatment means Treatment availed by the Insured Person at home for any epidemic/ pandemic on positive diagnosis of the epidemic/ pandemic in a Government authorised 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 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 throughout 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.  in case the insured intends to avail the services of a 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 epidemic/ pandemic,

a. Diagnostic tests undergone at home or at diagnostics centre;

b. Medicines prescribed in writing;

c. Consultation charges of the medical practitioner;

d. Nursing charges related to medical staff;

e. Medical procedures limited to the parenteral administration of medicines;

f. Cost of Pulse oximeter, Nebulizer and Rental cost for Oxygen cylinder, oxygen concentrator, if needed.

4. 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 up to the Sum Insured 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 the Base Cover 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:

a. pre-hospitalization Medical Expenses or Post-hospitalisation Medical Expenses of the organ donor;

b. screening expenses of the organ donor;

c. costs directly or indirectly associated with the acquisition of the donor’s organ;

d. transplant of any organ/tissue where the transplant is experimental or investigational;

e. expenses related to organ transportation or preservation;

f. any other medical treatment or complication in respect of the donor, consequent to harvesting.

5. Road Ambulance Cover

We will cover the expenses incurred:

i. subject to a maximum of Rs. 2500 per event; and further

ii. subject to a maximum of Rs. 5000 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 In-patient hospitalization 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:   

a. 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;

b. 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.

6.   Modern Treatment Methods & Advancement in Technologies

In case of an admissible claim under In-patient hosptalization, 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:

OPTIONAL COVERS

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:

The aggregate of Daily Cash Allowance during the policy period shall not exceed ‘per policy period limits’ as mentioned in the table above. Daily Cash Allowance will not be payable for Day Care Procedure claims where the hospitalisation is less than 24 hours. A deductible equivalent to Daily Cash Allowance for the first 24-hours of 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 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 before admission in Hospital in case of a planned Hospitalization.

2. Procedure for Cashless Claims

1. For the first claim under the Policy (i.e., the claim in which cumulative medical expenses exceeds the threshold) cashless facility shall be available provided all evidences and documents are produced prior to cashless authorization, to substantiate that the Cumulative Medical Expenses exceeds the Threshold. For all subsequent claims under the Policy cashless facility shall be available as usual, subject to sl. no ii to ix below.
2. Cashless facility for treatment shall be available to the Insured in network hospitals only.
3. Treatment may be taken in a network provider/PPN hospital and is subject to pre-authorization by the TPA. The 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.
4. 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
5. On admission in the network provider/PPN hospital, please 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.
6. 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.
7. At the time of discharge, the Insured Person shall verify and sign the discharge papers and pay for non-medical and inadmissible expenses.
8. The TPA reserves the right to deny pre-authorization in case the Insured Person is unable to provide the relevant medical details.
9. 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 the treating doctor’s advice and submit the claim documents to the TPA for possible reimbursement.

3. 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 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.

4. 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. Photo Identity proof of the patient
3. Attending medical practitioner’s / surgeon’s certificate regarding diagnosis/ nature of operation performed or Operation Theatre (OT) Notes, along with the date of diagnosis, advice for admission, investigation/test-reports etc. supported by the prescription from attending medical practitioner.
4. Medical history of the patient as recorded, Hospital bills (including break up of charges) and payment receipts duly supported by the prescription from attending medical practitioner.
5. Discharge certificate/ summary from the hospital.
6. Cash-memo/ bills/ invoices from the Diagnostic Centre(s)/ hospital(s)/ chemist(s) supported by proper prescription.
7. Payment receipts from doctors, surgeons and anaesthetist. 
8. Bills, receipt, Sticker of the Implants.
9. MLR (Medico-Legal Report copy if carried out and FIR (First Information Report) if registered, wherever applicable)
10. NEFT Details (to enable direct credit of claim amount in bank account) and cancelled cheque
11. KYC (Identity proof with Address) of the proposer, where claim liability is above Rs. 1 Lac as per AML Guidelines
12. Any other document required by company/ TPA

Note

1. The Insured shall preserve and submit all original documents and/ or certified copies of documents related to all hospitalisation(s) during the policy period to enable the Company to calculate the cumulative medical expenses and threshold, for determining admissibility and payment of claims.
2. 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 19.D and claim settlement advice duly certified by the other Insurer subject to satisfaction of the Company. In all such cases, any amount payable under this Policy for any covered expense shall be reduced by any amount paid/ payable by the other insurer for the same expense during the same hospitalisation.

5. Time Limit for Submission of Documents

6. Claim Assessment

We will assess all admissible indemnity claims under the Policy in the following progressive order:

1. Limit/ Sub Limit on Medical Expenses as applicable under the policy
2. Opted Threshold Amount

7. Basis of Payment

1. Any claim under this policy shall be payable by the Company only if

1. it is in respect of Covered Expenses specified in this Policy and
2. the aggregate of Covered Expenses in respect of hospitalisation/s of insured person in case of Individual Policy or all insured persons in case of Family Policy exceeds the Threshold Level

2. The claim payable under this Policy will be the amount:

• by which the aggregate of such Covered Expenses in respect of hospitalisations with dates of admission falling within the policy period  exceeds the Threshold Level opted for the Insured Person/Family as applicable and stated in the schedule,
• after deducting any amount above threshold received/receivable under any/all Health Insurance Policies (whether or not issued by the Company)/ Reimbursement Scheme and including any amount paid earlier under this policy covering the Insured Person/Family as applicable for such covered expenses.

3. Each claim, if more than one, during the period of this policy shall be separately subject to the above Basis of Payment.
4. In no case shall the Company be liable to pay any sum in excess of the Sum Insured in aggregate of all claims during the period of this Policy.

8. 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.

Notes on Claim Procedure:

1. Waiver of condition of timelines as mentioned above 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. 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.

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 the waiting period mentioned below:

1. Pre-Existing Disease Waiting Period (Code- Excl01):

a. 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.

b. In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.

 c. 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. d. 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.

B. PERMANENT EXCLUSIONS

B.1 Standard Permanent 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):

i. Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded;

ii. Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.

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:

 i. 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.

ii. any services for people who are terminally ill to address physical, social, emotional, and spiritual needs.

4. Obesity/ Weight Control (Code-Excl06):

Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:

i. Surgery to be conducted is upon the advice of the Doctor

ii. The surgery/Procedure conducted should be supported by clinical protocols

 iii. The member has to be 18 years of age or older and

 iv. Body Mass Index (BMI) a. greater than or equal to 40 or

 b. 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:

 i. Obesity-related cardiomyopathy

ii. Coronary heart disease

 iii. Severe Sleep Apnoea

iv. Uncontrolled Type2 Diabetes

5. 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

6. 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.

7. Hazardous or Adventure sports (Code- Excl09):

 Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports, including but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.

 8. 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.

9. 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 stabilization are payable but not the complete claim.

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

 11. 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)

 12. Dietary supplements and substances that can be purchased without a 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. (CodeExcl14)

13. Refractive Error (Code-Excl15):

 Expenses related to the treatment for correction of eyesight due to refractive error less than 7.5 dioptres.

14. 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.

 15. Sterility and Infertility (Code-Excl17): Expenses related to Sterility and infertility. This includes: i. Any type of contraception, sterilization ii. Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI iii. Gestational Surrogacy iv. Reversal of sterilization

16. Maternity (Code- Excl18): a. Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalisation) except ectopic pregnancy; b. Expenses towards miscarriage (unless due to an accident) and lawful medical termination of pregnancy during the policy period.

C. SPECIFIC PERMANENT EXCLUSIONS

17. All expenses caused by or arising from or attributable to foreign invasion, an 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.

 18. 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.

19. Stem cell implantation/Surgery, harvesting, storage or any kind of treatment using stem cells except as provided for in clause 6.7 (L) above; growth hormone therapy.

20. Congenital external diseases or defects or anomalies.

21. a) Routine eye-examination expenses, cost of spectacles, contact lenses; b) Cost of hearing-aids; 22. Intentional self-inflicted injury; attempted suicide.

23. Treatments other than Allopathic and AYUSH

24. Treatments including Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP).

 25. Dental treatment or surgery of any kind unless necessitated by disease or accident and requiring hospitalisation

 26. 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

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

28. Any expenses incurred on OPD (Out-Patient) Treatment

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

Please note that the premium rates specified in the illustrations below are standard premium rates exclusive of any loadings and GST.

Illustration 1: Self, Spouse and 2 Dependent Children

Illustration 2: Self and Spouse

Illustration 3: Self and Spouse