• Age means age of the Insured person on last birthday as on date of commencement of 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.
• Co-morbidity is the presence of one or more additional conditions co-occurring with a primary condition; in the countable sense of the term, a comorbidity is each additional condition.
• Co-payment means a cost sharing requirement under a health insurance policy that provides that the policyholder/Insured will bear a specified percentage of the admissible claims amount. A co-payment does not reduce the Sum Insured.
• 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.

• Epidemic: 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. 
• 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.
• Out-Patient (OPD) Treatment means treatment 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.
• 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 World Health Organisation and appropriate Government Authority in India.
• 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 Covid is not covered.

ELIGIBILITY:

All Employer–Employee Groups (including those where Principal covers contractor’s/ sub-contractor’s employees) with minimum group size of 7 Insured Persons are eligible to take this policy. More specifically, the aim is to target all industrial and commercial establishments, workplaces, offices, etc. so that these organisations can provide medical insurance coverage to their workers.
The Policy provides cover on an Individual Sum Insured basis. 
Employer–Employee Group members aged between  18 years and 65 years are eligible for this insurance. 

SUM INSURED:   

1. Five Sum Insured options are available as under:             Rs. 1 lac, 2 lacs, 3 lacs, 4 lacs, 5 Lacs.
2. Different Sum Insureds can be opted for different grades/ Class of employees. However, within the same Salary Scale/ Grade/ Class/ Designation, the Sum Insured must be equal for all the members. 

TERM OF POLICY:   

One Year

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.
4.1 Hospitalization
The company shall indemnify medical expenses incurred for Hospitalisation of the Insured Person during the Policy period, up to the Sum Insured specified in the policy schedule, for:

1. Room Rent, Boarding, Nursing Expenses as provided by the Hospital/Nursing Home up to 1% of the sum insured per day.
2. Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) expenses up to 2% of the sum insured per day.
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, implants, medicines and drugs, costs towards diagnostics, diagnostic imaging modalities and such similar other expenses.

4.1.1 Other Expenses

1. Actual expenses incurred on treatment of cataract (including cost of the lens) upto 15% of Sum Insured or Rs. 30,000/-, whichever is lower, per eye during the Policy period.
2. Dental treatment, necessitated due to injury
3. Plastic surgery necessitated due to disease or injury
4. All the day care treatments
5. Expenses incurred on Road Ambulance subject to a maximum of Rs. 2000/- per hospitalisation.

Note to 4.1

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.
2. In case of admission to a room at rates exceeding the aforesaid limits in Clause 4.1.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.

4.1.2 Notwithstanding the provisions mentioned in 4.1 above, the maximum city-wise* limit of payment for following medical procedures shall be as under:

4.2 AYUSH Treatment
The company shall indemnify medical expenses incurred for inpatient care treatment under Ayurveda, Unani, Siddha and Homeopathy systems of medicines during each Policy Year up to the limit of Rs. 15000 in any AYUSH Hospital.

4.3 Pre Hospitalisation
The company shall indemnify pre hospitalisation medical expenses incurred, related to an admissible hospitalisation requiring inpatient care, upto a period of 30 days prior to the date of admissible hospitalisation covered under the policy.

4.4 Post Hospitalisation
The company shall indemnify post hospitalisation medical expenses incurred, related to an admissible hospitalisation requiring inpatient care, upto 60 days from the date of discharge from the hospital, following an admissible hospitalisation covered under the policy.

4.5 Modern Treatment Methods & Advancement in Technologies:
The following procedures will be covered (wherever medically indicated) either as inpatient care or as part of day care treatment in a hospital with a co-payment of 20%, up to 50% of Sum Insured, specified in the policy schedule, during the policy period:

1. Uterine Artery Embolization & HIFU (High intensity focused ultrasound)
2. Balloon Sinuplasty
3. Deep Brain stimulation
4. Oral Chemotherapy
5. Immunotherapy- Monoclonal Antibody to be given as injection
6. Intra Vitreal Injections
7. Robotic Surgeries
8. Stereotactic radio surgeries
9. Bronchial Thermoplasty
10. Vaporisation of the Prostate (Green laser treatment or holmium laser treatment)
11. IONM – Intra Operative Neuro Monitoring
12. Stem Cell Therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered.

OPTIONAL COVERS:
4.6 Out-patient Treatment Cover: (within the Base Sum Insured)
We will cover the Reasonable and Customary Charges incurred on an out-patient basis for medically required consultations, visit(s) to a doctor, diagnostic tests and pharmacy expenses as per standard medical protocol for any epidemic/ pandemic only up to Rs.5000.
The Benefit payable will be within the Base Sum Insured.
For the purpose of this Cover, Out-patient means an Insured Person who is not hospitalized but who visits a hospital, clinic or associated facility for diagnosis or treatment.
The relevant part of Exclusion 6.29 under the policy will stand deleted for this Option.
All claims under this Benefit can be made as per the process defined under Section 8 of the policy, as applicable.

4.7 Daily Cash Allowance on Hospitalisation
We will pay Daily Cash Allowance of Rs. 500 per day subject to a maximum of Rs. 7500 per policy period 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.
Daily Cash Allowance will not be payable for Day Care Procedure claims where the hospitalisation is less than 24 hours. Deductible equivalent to Daily Cash Allowance for the first 24 hours Hospitalization will be levied on each Hospitalisation during the Policy Period.
The payment under this benefit is over and above the Base Sum Insured.
All claims under this Benefit can be made as per the process defined under Section 8 of the policy, as applicable.

4.8 Benefit Cover for First Diagnosis of Any Epidemic/ Pandemic:;
If an Insured Person is First Diagnosed with any Epidemic/ Pandemic during the Period of Cover, then We will pay Rs. 25000 as a lump sum amount, provided that the Illness/disease was first diagnosed after 14 days from the Risk Inception Date.
On the acceptance of a claim under this Benefit, the cover under this Benefit will terminate in relation to the Insured Person.
This Benefit shall be payable subject to the following:

1. The Insured must have tested positive for the Epidemic/ Pandemic by a Government authorized/ Government designated laboratory in India, appointed for testing of the Epidemic/ Pandemic.
2. The diagnosis must be confirmed by only those specific test(s) as defined by Government authorities or as per standard medical protocol.
3. The lab diagnosis must have been performed after the completion of the initial waiting period of 14 days.

4.8.1 No benefit will be payable if the Insured has been quarantined for any suspected epidemic/ pandemic OR diagnosed with any epidemic/ pandemic prior to the risk inception date or within the initial waiting period of 14 days.
4.8.2 The initial waiting period of 14 days will not apply for this Benefit Cover if the Optional Cover for ‘Waiver of Initial Waiting Period of 30 days for any epidemic/ pandemic has been opted for.
4.8.3 The payment under this benefit is over and above the Base Sum Insured.
4.8.4 Claim documents for this Benefit Cover:
On the occurrence of an Insured Event which may give rise to a claim under this benefit of the Policy, We shall be provided with the following necessary and mandatory information and documentation specified in relation to the Benefit being claimed within 30 days of occurrence of the Insured Event:

• Duly filled claim form (physical or digital) by the Insured Person/claimant.
• Lab report with sign and stamp, confirming positive for Epidemic/ Pandemic.
• Certificate from Government medical officer confirming diagnosis or from any medical practitioner authorised by Government to issue such certificates.

4.9 Waiver of Initial Waiting Period of 30 days for any epidemic/ pandemic: 
On payment of additional Premium as mentioned in Schedule, it is hereby agreed and declared that Exclusion no. 5.2 shall not apply for claims arising out of the hospitalisation due to any Epidemic/ Pandemic.

4.10 Waiver of  Co-Payment clause for pre-existing co-morbidities in case of any epidemic/ pandemic:
On payment of additional Premium as mentioned in Schedule, it is hereby agreed and declared that co-payment condition no. 8.5 shall not apply for claims arising out of the hospitalisation due to any Epidemic/ Pandemic.

4.11 Maternity Benefit Cover:
We will pay a lump sum benefit amount of Rs. 20000 to the female Insured Person above 18 years during the Policy Period for the delivery of a child in a Hospital (including but not limited to caesarean section, vacuum birthing, water birthing, hypnobirthing, midwife birthing).  
4.11.1 This Benefit will be available subject to the following: 

1. After a waiting period of 9 months from the Date of Inception of cover for the first time under this policy for the Female Insured Member;
2. Up to a maximum number of two deliveries;
3. Payment under this cover will be limited to per event and will be over and above the Base Sum Insured.

4.11.2 We will not be liable to make any payment in respect of the following:

1. Medical Expenses incurred in respect of the delivery/ termination of pregnancy.
2. Medical Expenses for ectopic pregnancy, which will be covered under Section 4.1 of the Base Cover Terms and Conditions.
3. Complications arising as a result of infertility Treatment (assisted conception).

4.11.3 The payment under this benefit is over and above the Base Sum Insured.
4.11.4 Claim documents for this Benefit Cover:
On the occurrence of an Insured Event which may give rise to a claim under this Base Benefit of the Policy, We shall be provided with the following necessary and mandatory information and documentation specified in relation to the Benefit being claimed within 30 days of occurrence of the Insured Event:

• Duly filled claim form (physical or digital) by the Insured Person/claimant.
• Birth Certificate issued by local Government Body. 
• Proof of delivery at Hospital/ Medical Centre equipped for conducting delivery.

NOTE:   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 of the Policy.

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 pre-authorization 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 treatment.
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:

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

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

1. Duly completed claim form
2. Photo Identity proof of the patient
3. Medical practitioner’s prescription advising admission
4. Original bills with itemized break up
5. Payment receipts
6. Discharge summary including complete medical history of the patient along with other details.
7. Investigation/Diagnostic test reports etc. supported by the prescription from attending medical practitioner
8. OT notes or Surgeon’s certificate giving details of the operation performed (for surgical cases).
9. Sticker/Invoice of the Implants, wherever applicable.
10. MLR (Medico Legal Report copy if carried out and FIR (First Information Report) if registered, wherever applicable)
11. NEFT Details (to enable direct credit of claim amount in bank account) and cancelled Cheque
12. KYC (Identity proof with Address) of the proposer, where claim liability is above Rs. 1 Lakh as per AML Guidelines
13. Legal heir/succession certificate, wherever applicable. 
14. Any other relevant document required by Company/TPA for assessment of the claim

[Note: The Company may specify the documents required in original and waive off any of above required as per our claim procedure]

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. Co-Payment in the event of Claims due to any epidemic/ Pandemic in presence of a pre-existing co-morbid condition:
In the event of each and every Claim for hospitalisation due to any epidemic/ Pandemic in presence of a pre-existing co-morbid condition, a co-payment will be applicable as per the following table:

6. 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 Insured Person 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 Insured Person 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).

7.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-authorisation 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 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.

8. Payment of Claim
All claims under the policy shall be payable in Indian currency only.

EXCLUSIONS
WHAT POLICY DOES NOT COVER:  
 
 5.WAITING PERIOD
The company shall not be liable to make any payment under the policy in connection with or in respect of the following expenses till the expiry of waiting period mentioned below:
5.1 Pre-Existing Diseases (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.

5.2 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.

5.3 Specific Waiting Period (Code-Excl02)

1. Expenses related to the treatment of the following listed Conditions, surgeries/treatments shall be excluded until the expiry of 24/48 months of continuous coverage, as may be the case after the date of inception of the first policy with the Insurer. 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.

24 Months Waiting Period

• Benign ENT disorders
• Tonsillectomy
• Adenoidectomy
• Mastoidectomy
• Tympanoplasty
• Hysterectomy
• All internal and external benign tumours, cysts, polyps of any kind, including benign breast lumps
• Benign prostate hypertrophy
• Cataract and age related eye ailments
• Gastric/Duodenal Ulcer
• Gout and Rheumatism
• Hernia of all types
• Hydrocele
• Non Infective Arthritis
• Piles, Fissure and Fistula in anus
• Pilonidal sinus, Sinusitis and related disorders
• Prolapse inter Vertebral Disc and Spinal Diseases unless arising from accident
• Calculi in urinary system, Gall Bladder and Bile duct, excluding malignancy.
• Varicose Veins and Varicose Ulcers
• Internal Congenital Anomalies

48 Months Waiting Period

• Treatment for joint replacement unless arising from accident
• Age-related Osteoarthritis & Osteoporosis

6. 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:

6.1 Investigation & Evaluation (Code-Excl04)

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

6.2 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.

6.3 Obesity/Weight Control (Code-Excl06)
Expenses related to the surgical treatment of obesity that does not fulfill 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

6.4 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.

6.5 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.

6.6 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.

6.7 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.

6.8 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.

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

6.10Treatments 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)

6.11 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)

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

6.13 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.

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

1. Any type of 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

6.15 Maternity Expenses (Code-Excl18):

1. Medical treatment expenses traceable to childbirth (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.

6.16 War (whether declared or not) and war like occurrence or invasion, acts of foreign enemies, hostilities, civil war, rebellion, revolutions, insurrections, mutiny, military or usurped power, seizure, capture, arrest, restraints and detainment of all kinds.

6.17 Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from or from any other cause or event contributing concurrently or in any other sequence to the loss, claim or expense. For the purpose of this exclusion:

1. Nuclear attack or weapons means the use of any nuclear weapon or device or waste or combustion of nuclear fuel or the emission, discharge, dispersal, release or escape of fissile/fusion material emitting a level of radioactivity capable of causing any Illness, incapacitating disablement or death.
2. Chemical attack or weapons means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing any Illness, incapacitating disablement or death.
3. Biological attack or weapons means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organisms and/or biologically produced toxins (including genetically modified organisms and chemically synthesized toxins) which are capable of causing any Illness, incapacitating disablement or death.

6.18 Any expenses incurred on Domiciliary Hospitalisation

6.19 Treatment taken outside the geographical limits of India

6.20 a) Stem cell implantation/Surgery/therapy, harvesting, storage or any kind of Treatment using stem cells except as provided for in Clause 4.6.L above; b) Growth Hormone Therapy.  
6.21 Congenital External Diseases, Defects or anomalies. 
6.22 Circumcision unless necessary for Treatment of an Illness or Injury not excluded hereunder or due to an Accident.
6.23 Cost of routine medical examination and preventive health check-up.
6.24 a) Cost of hearing aids; including optometric therapy; b) cochlear implants unless necessitated by an Accident or required intra-operatively.
6.25 Intentional self-inflicted Injury, attempted suicide
6.26 Treatments other than Allopathy and Ayurvedic, Homeopathic & Unani branches of medicine.
6.27 Any expenses incurred on Outpatient treatment (OPD treatment) 
6.28 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.
6.29 Change of treatment from one system of medicine to another system unless recommended by the consultant/ hospital under whom the treatment is taken.
6.30 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.
6.31 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