1. AGE means age of the Insured person on last birthday as on date of commencement of the Policy.
2. ANY ONE ILLNESS will be deemed to mean continuous period of illness and it includes relapse within 45 days from the date of last consultation with the Hospital / Nursing Home where treatment has been taken.
3. ASSOCIATED MEDICAL EXPENSES means hospitalisation related expenses on Surgeon, Anaesthetist, Medical Practitioner, Consultants and Specialist Fees whether paid directly to the treating doctor / surgeon or to the hospital; Anaesthetics, blood, oxygen, operation theatre charges, surgical appliances and such other similar expenses with the exception of:

1. cost of pharmacy and consumables medicines
2. cost of implants/medical devices
3. cost of diagnostics

The scope of this definition is limited to admissible claims where a proportionate deduction is applicable, as per Note a to Section V.1.1.

4. AYUSH Treatment refers to hospitalisation treatments given Ayurveda, Unani and Homeopathy systems (covered under the Policy).
5. BREAK IN POLICY means the period of gap that occurs at the end of the existing policy term, when the premium due for renewal on a given policy is not paid on or before the premium renewal date or within 30 days thereof.
6. CANCELLATION defines the terms on which the policy contract can be terminated either by the Insurer or the Insured person by giving sufficient notice to other which is not lower than a period of fifteen days.
7. CASHLESS FACILITY means a facility extended by the Insurer or TPA on behalf of the Insurer to the Insured, where the payments for 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.
8. CONDITION PRECEDENT shall mean a policy term or condition upon which the Insurer’s liability under the policy is conditional.
9. CONGENITAL ANOMALY refers to a condition(s) which is present since birth, and which is abnormal with reference to form, structure or position.

• Internal Congenital Anomaly: Which is not in the visible and accessible parts of the body.
• External Congenital Anomaly: Which is in the visible and accessible parts of the body.

10. 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.
11. 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.

12. 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.

13. DISCLOSURE TO INFORMATION NORM The policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of misrepresentation, mis-description or non-disclosure of any material fact
14. 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.
15. HOSPITAL/NURSING HOME 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 lacs 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.

The term ' Hospital / Nursing Home ' shall not include an establishment which is a place of rest, a place for the aged, a place for drug-addicts or place for alcoholics, a hotel or a similar place.

For Ayurvedic treatment, hospitalisation expenses are admissible only when the treatment has been undergone in a hospital as defined in clause V.4 below.

16. HOSPITALISATION Means admission in a Hospital/Nursing Home for a minimum period of 24 In-patient care consecutive hours except for the standard day care procedures/treatments as defined above, where such admission could be for a period of less than 24 consecutive hours.
17. ILLNESS means a sickness or a disease or pathological condition leading to the impairment of normal physiological function which manifests itself during the policy period 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

18. INJURY means accidental physical bodily harm excluding illness or disease solely and directly caused by external, violent and visible and evident means which is verified and certified by a Medical Practitioner.
19. 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.
20. INSURED PERSON means person(s) named in the schedule of the Policy.  
21. MATERNITY EXPENSES means;

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 repeat 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 is defined as any treatment, tests, medication, or stay in hospital or part of a stay in hospital which is required for the medical management of the illness or injury suffered by the Insured; Must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration or intensity; Must have been prescribed by a Medical Practitioner; Must conform to the professional standards widely accepted in international medical practice or by the medical community in India.
25. MEDICAL PRACTITIONER is 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 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 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. 

28. NEW BORN BABY means baby born during the Policy Period and is aged upto 90 days.
29. NON-NETWORK HOSPITALS means any hospital, day care centre or other provider that is not part of the network.
30. NOTIFICATION OF CLAIM is the process of notifying a claim to the Insurer or TPA within specified timelines through any of the recognised modes of communication.
31. PERIOD OF INSURANCE means the period for which this policy is taken and is in force as specified in the Schedule.
32. 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
33. 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 Insurer.
34. 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

35. PRE – HOSPITALISATION MEDICAL EXPENSES

Relevant medical expenses incurred immediately 30 days before the Insured Person is hospitalised 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 us.

36. POST-HOSPITALISATION MEDICAL EXPENSES

Relevant medical expenses incurred immediately 60 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 us.

37. REASONABLE AND CUSTOMARY CHARGES mean 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.
38. 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 all waiting periods.
39. ROOM RENT shall mean the amount charged by a hospital for the Occupancy of a bed on per day (24 hours) basis and shall include associated medical expenses.
40. 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.
41. 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 basis) or all Insured Persons (on Floater basis) during the policy period.
42. 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.
43. THIRD PARTY ADMINISTRATOR (TPA) means a company registered under the IRDAI (Third Party Administrators – Health Services) Regulations, 2016 notified by the Authority, and is engaged, for a fee or remuneration by an insurance company, for the purpose of providing health services as defined in the regulations.
44. 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 and his/her family consisting of Self, Spouse and dependent children either on Individual Sum Insured basis or on floater basis. Beyond 65 years, only renewals are allowed.
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 the age of 26 years, provided they are unmarried/unemployed and dependent. The upper age limit will not apply to mentally challenged children. In the event of children becoming independent, employed, getting married, or attaining age above 26 years, a separate policy can be taken on expiry of the current policy for which continuity benefits will be provided.
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. New born baby, between the ages of 91 days to 180 days, born to mother, insured under the policy.

2. SUM INSURED:  

Various options are available as under:

Rs. 3 lacs, 4 lacs, 5 lacs, 6 lacs, 7 lacs, 8 lacs, 9 lacs, 10 lacs, 15 Lacs, 20 Lacs & 25 Lacs.

3. TERM OF POLICY:  

One Year. Renewable annually.

BASE COVERS

The Policy provides base coverage as described below in this section provided that the expenses are incurred on the written Medical Advice of a Medical Practitioner and are incurred on Medically Necessary Treatment of the Insured Person:

1. In-patient Hospitalisation Expenses Cover

We will pay the Reasonable and Customary Charges for the following Medical Expenses 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 upto the limits provided below:

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) upto the limits provided below:

3. The fees charged by the Medical Practitioner, Surgeon, Specialists and anaesthetists treating the Insured Person.
4. Operation theatre charges.
5. Anaesthesia, Blood, Oxygen, Surgical Appliances and/ or Medical Appliances, medicines and drugs, Cost of Artificial Limbs, cost of prosthetic devices implanted during surgical procedure like pacemaker, orthopaedic implants, infra cardiac valve replacements, vascular stents, relevant laboratory/ diagnostic tests, X-Ray and such other similar medical expenses related to the treatment.

1.1

1. PROPORTIONATE PAYMENT CLAUSE: In case of admission to a room at rates exceeding the aforesaid limits in Clause V.1.A, the reimbursement/payment of all associated medical expenses incurred at the Hospital shall be effected in the same proportion as the admissible rate per day bears to the actual rate per day of Room Rent.

Proportionate Deductions shall not be applied in respect of those hospitals where differential billing is not followed or for those expenses where differential billing is not adopted based on the room category.

2. No payment shall be made under 1 C 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.

1.2 Sub-limit:

1. Cataract Surgery Limit: Expenses in respect of the Cataract surgeries will be restricted to 10% of Sum Insured subject to maximum of Rs. 50,000/- per eye. This limit is applicable per hospitalisation / surgery.
2. Mental Illness Cover Limit: In case of following mental illnesses the actual In-patient Hospitalization expenses will be covered upto 25% of Sum Insured subject to a maximum of Rs. 3,00,000 per policy year;

1. Schizophrenia (ICD - F20; F21; F25)
2. Bipolar Affective Disorders (ICD - F31; F34)
3. Depression (ICD - F32; F33)
4. Obsessive Compulsive Disorders (ICD - F42; F60.5)
5. Psychosis (ICD - F 22; F23; F28; F29)

2. Day Care Treatment Cover-

We will cover the Medical Expenses incurred on the Insured Person’s Day Care Treatment during the Policy Period following an Illness or Injury that occurs during the Policy Period provided that the Medical Expenses are incurred in case of Day Care Treatment or Surgery undertaken for the Illness/ condition covered under Base Cover that requires less than 24 hours Hospitalisation due to advancement in technology, including for any procedure which requires a period of specialized observation or care after completion of the procedure undertaken by an Insured Person as Day Care Treatment. All Day Care Treatments as defined in the policy are covered.

Procedures/treatments usually done on out-patient basis are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours or carried out in Day Care Centres. Diagnostic Services are also not covered under this benefit.

3. Pre-Hospitalisation and Post-Hospitalisation Expenses –

We will cover, on a reimbursement basis, the Insured Person’s Pre-hospitalization Medical Expenses incurred due to an Illness or Injury that occurs during the period upto 30 days prior to hospitalisation and Post- hospitalization Medical Expenses incurred due to an Illness or Injury that occurs during the period upto 60 days after the discharge from the hospital, subject to a maximum of 10% of Sum Insured.

4. Ayurvedic/Homeopathic/Unani 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 limits linked to the Sum Insured, as mentioned in the policy and as also in table of benefits.

5.    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.

We will not cover:

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

6. Organ Donor Benefit- When Insured Person is the Donor

A lump sum payment of 10% of Sum Insured, to take care of medical and other incidental expenses is payable to the Insured Person donating an organ provided that the donation conforms to the Transplantation of Human Organs Act 1994 (amended) and any other extant Act, Central / State Rules / regulations, as applicable, in respect of transplantation of human organs.

This benefit is subject to the Policy (Family Medicare Policy) having been continuously in force for at least 12 (twelve) months in respect of that Insured Person.

7.    Road Ambulance Cover

We will cover the costs incurred up to:

1. 0.5% of the Sum Insured subject to a maximum of Rs. 2500 per event and
2. 1% of the Sum Insured 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 Section VI.1 or VI.2 and the expenses are related to the same Illness or Injury.

8. Cost of Health Check-up

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. 5000 per person for policies issued on individual sum insured basis / Rs. 10000 per policy period for policies issued on floater basis for a block of every three claim-free years provided the health check-up is done at network 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 form part of the sum insured and will not impact the Bonus.

In case of the policy on floater basis, if a claim is made by any of the Insured Persons, the health check-up benefits will not be available under the policy.

9. Modern Treatment Methods & Advancement in Technologies:

In case of an admissible claims under Section V.1/ V.2 as applicable, 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:

Note on Co-payment:

For persons with age of entry above 60 years in Family Medicare Policy, every admissible claim under Base Cover 1 to 5, 7 and 9 above shall be subject to a Co-payment of 10% on the admissible claim amount.

OPTIONAL COVERS:

10. Restoration of Sum Insured

If the Basic Sum Insured is exhausted completely or partially due to claims made and paid/ accepted as payable during the Policy Year, then it is agreed that a Restore Sum Insured equal to 100% of the Basic Sum Insured will be automatically and instantly available for the particular Policy Year, provided that:

1. In case of policies on Individual Sum Insured basis the Restore Sum Insured, will be available to each Insured Person individually and in case of a floater policy, the restore Sum Insured will be available for all Insured Persons on floater basis.
2. A single claim in a Policy Year cannot exceed the Basic Sum Insured.
3. Such restored Sum Insured can be utilized only for illness / disease unrelated to the illness / diseases for which claim(s) was / were made.
4. The Restoration of Sum Insured will be applied only once during a Policy Year for family floater policy. For Policy on Individual Sum Insured basis, the restore facility will be available once to each Insured Person individually in a policy year.
5. If the Restore Sum Insured is not utilised in a Policy Year, it shall not be carried forward to any subsequent Policy Year.

10.1       Automatic Restoration of Basic Sum Insured is available only for Sum Insured options from Rs. 3,00,000 and above.

             10.2     For persons with age of entry above 60 years in Family Medicare Policy, every admissible claim under this optional cover shall be subject to a Co-payment of 10% on the admissible claim amount

11. Maternity Expenses and New Born Baby Cover

1. Maternity Expenses: We shall pay the Medical Expenses incurred as an In-patient for a delivery (including caesarean section) or lawful medical termination of pregnancy during the Policy Period limited to two deliveries or terminations or either during the lifetime of the Insured Person. This benefit is applicable only when the Sum Insured is above Rs. 3 Lacs, and available only to the Insured or his spouse, provided that:

1. Family Medicare Policy with this optional cover has been continuously in force for a period of minimum 24 months
2. Those Insured Persons who are already having two or more living children will not be eligible for this benefit
3. Company’s maximum liability per delivery or termination shall be limited to 10% of the Sum Insured as stated in the Schedule subject to a maximum of Rs. 40000 in case of normal delivery and Rs. 60000 in case of caesarean section and in no case shall the Company’s liability under this clause exceed 10% of the Sum Insured, in any one Policy Period.

2. New Born Baby Cover: New born Baby shall be covered from day one upto the age of 90 days and expenses incurred for treatment taken in Hospital as in-patient shall only be payable, provided that:

1. Claim under Maternity clause is admissible under the Policy
2. Company’s liability shall be limited to 10% of the Sum Insured as stated in the Schedule.
3. In case the 90 days’ period for the New Born Baby is spread over two Policy Periods, the aggregate liability of the Company, for all claims in respect of the New Born Baby, shall be limited to 10% of the Sum Insured of the Policy under which Maternity claim was admitted.

11.1 Special conditions applicable to Maternity Expenses and New Born Baby Cover

1. These benefits are admissible only if the expenses are incurred in Hospital/Nursing Home as in-patients in India.
2. Surrogate or vicarious pregnancy is not covered.
3. Expenses incurred in connection with voluntary medical termination of pregnancy during the first twelve weeks from the date of conception are not covered.
4. Pre-natal and post-natal expenses are not covered unless admitted in Hospital/Nursing Home and treatment is taken there.
5. Pre Hospitalisation and Post Hospitalisation benefits are not available under these two clauses.

Subject to the terms & conditions, the Policy covers New Born Baby beyond 90 days only on payment of requisite premium.

If this Option is in force in respect of the Insured Person, then the relevant part of Exclusion VII.B.7 will be deemed inoperative for the purpose of this Option.

12. 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. Deductible equivalent to the first 24 hours Hospitalization benefit will be levied on each and every 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 time limit prescribed under the policy.

2. Procedure for Cashless claims

1. Cashless claims facility shall be available in network hospitals only, if opted for TPA.
2. This is subject to pre authorization by the TPA. The list of network provider/PPN is available on https://uiic.co.in/en/tpa-ppn-network-hospitals and the TPA’s website.
3. Intimate the claim on the TPA’s toll free phone number and quote card ID number.
4. On admission, produce the TPA ID card at the Network/ PPN Hospital Helpdesk. Cashless request form shall be completed and sent to the TPA for authorization.
5. The TPA shall process such cashless request and 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.

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 (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 a reimbursement basis on production of relevant claim papers and cash receipts.
3. Claims for Cost of Health Check-up will be settled on reimbursement basis on production of test reports and cash receipts.

4. 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 above and claim settlement advice duly certified by the other Insurer subject to satisfaction of the company.

5.  Time Limits for Submission of Documents:

Note:

1. Waiver of this Condition may be considered by the Company in genuine cases of hardship.
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.
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.

6.  Claim Settlement (Provision of 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).

7. 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.

A. WAITING PERIOD - EXCLUSIONS

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

1. 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.

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. Two years waiting period

Table B. Four years waiting period

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.
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. 

The exclusions under VII.A.1-3 are subject to portability regulations.

B. 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:

1. 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.
2. 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.
3. a) Stem cell implantation/Surgery/therapy, harvesting, storage or any kind of Treatment using stem cells except as provided for in Clause VI.10.L above; b) growth hormone therapy. 
4. Congenital External Diseases, Defects or anomalies.
5. 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

6. Maternity ((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.

7. Circumcision unless necessary for Treatment of an Illness or Injury not excluded hereunder or due to an Accident.
8. Cost of routine medical examination and preventive health check-up unless as provided for in Base Cover VI.8 above
9. Investigation & Evaluation (Code- Excl04):

1. Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded even if the same requires confinement at a Hospital.
2. Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.

10. 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.
11. 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.
12. 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.   For this to be considered a medical necessity, it must be certified by the attending Medical Practitioner.
13. Vaccination or inoculation of any kind unless it is post animal bite,
14. Routine eye examinations, cost of spectacles, contact lenses;
15. Refractive Error (Code- Excl15): Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres.
16. a) Cost of hearing aids; including optometric therapy;
    b) cochlear implants unless necessitated by an Accident or required intra-operatively.
17. Dental treatment or surgery of any kind unless necessitated by accident and requiring hospitalisation.
18. 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.

19. 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

20. Any treatment related to sleep disorder or sleep apnoea syndrome
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, Homeopathic & Unani branches of medicine.
26. Any expenses incurred on Domiciliary Hospitalization
27. Any expenses incurred on Out-patient treatment (OPD treatment)
28. 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)
29. 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.
30. 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 of the Policy for the complete list of non-payable items.
31. Change of treatment from one system of medicine to another system unless recommended by the consultant/hospital under whom the treatment is taken.
32. Treatments such as 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.
33. 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.
34. Any item(s) or treatment specified in list of expenses (non-medical) - Payable/ Non-payable as per Annexure-1 of the Policy and available on Company website also, unless specifically covered under the Policy.

Please note:

1. Premium rates specified in the illustrations below are standard premium rates exclusive of any loadings and GST.
2. Rates shown below are for Zone I of FMP which includes the following districts:
   • All districts in NCT of Delhi, Faridabad, Gurugram, Palwal, Rohtak, Jhajjar, Gautam Buddh Nagar, Ghaziabad, Bulandshahr
   • Mumbai City, Mumbai Suburban, Thane, Raigad, Palghar
   • Ahmedabad, Vadodara, Gandhinagar, Surat

ILLUSTRATIONS

Illustration 1: Self, Spouse and 2 Dependent Children