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

will be deemed to mean a 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. AYUSH Treatment

refers to the medical and / or hospitalization treatments given under Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems.

is a healthcare facility wherein medical/ surgical/ para-surgical treatment procedures and interventions are carried out by AYUSH Medical Practitioner(s) comprising of any of the following:

4. AYUSH Hospital
   1. Central or State Government AYUSH Hospital; or
   2.  Teaching hospital attached to AYUSH College recognized 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 recognized 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 all 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 to be carried out;
      • 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 preauthorization is approved

6. Condition Precedent

shall mean a policy term or condition upon which the Insurer’s liability under the policy is conditional upon.

refers to a condition(s) which is present since birth, and which is abnormal with reference to form, structure or position

7. Congenital Anomaly
   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. 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.

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

9. Day Care Centre 
   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.

means medical treatment, and/or surgical procedure which is:

Treatment normally taken on an out-patient basis is not included in the scope of this definition.

10. Day Care Treatment
    1.  undertaken under general or local anesthesia in a hospital/Day Care Centre in less than twenty-four hours because of technological advancement, and
    2. which would have otherwise required hospitalisation of more than twenty-four hours.

11. 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.

12. Dental Treatment

means a treatment related to teeth or structures supporting teeth including examinations, fillings (where appropriate), crowns, extractions and surgery.

means medical treatment for an Illness/Disease/Injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances:

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

14. 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.

15.  Grace Period

means the specified period of time, immediately following the premium due date during which premium payment can be made to renew or continue a policy in force without loss of continuity benefits pertaining to waiting periods and coverage of pre-existing diseases. Coverage need not be available during the period for which no premium is received.

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:

16. Hospital/Nursing Home
    1. Has qualified nursing staff under its employment round the clock
    2. 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
    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 makes these accessible to the insurance company’s authorized personnel

17. Hospitalisation

means admission in a Hospital/Nursing Home for a minimum period of 24 Inpatient 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.

means a sickness or a disease or pathological condition leading to the impairment of normal physiological function and requires medical treatment

18. Illness 
    1. 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
    2. Chronic Condition – A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics:
       • it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /or tests
       • it needs ongoing or long-term control or relief of symptoms
       • it requires rehabilitation for the patient or for the patient to be specially trained to cope with it 
       • it continues indefinitely
       • it recurs or is likely to recur.

19. 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.

20. 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.

21. 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.

22. Intensive Care Unit (ICU) 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.

Means:

23. Maternity Expenses
    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

24. Medical Advice

means any consultation or advice from a Medical Practitioner including the issuance of any prescription or follow-up prescription.

25. 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.

means any treatment, tests, medication, or stay in hospital or part of a stay in hospital which:

26. Medically Necessary Treatment
    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

27. Medical Practitioner

means a person who holds a valid registration from the Medical Council of any State 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.

28. Migration

means a facility provided to policyholders (including all members under family cover and group policies), to transfer the credits gained for pre-existing diseases and specific waiting periods from one health insurance policy to another with the same insurer.

29. Network Provider

means hospitals or health care providers enlisted by an insurer, TPA or jointly by an Insurer and TPA to provide medical services to an insured by a cashless facility.

30. New Born Baby

means baby born during the Policy Period and is aged up to 90 days

31. Non-Network Provider

means any hospital, day care centre or other provider that is not part of the network.

32. Notification Of Claim

means the process of intimating a claim to the insurer or TPA through any of the recognized modes of communication.

33. Out-Patient (OPD) 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

34. Portability

means a facility provided to the health insurance policyholders (including all members under family cover), to transfer the credits gained for, pre-existing diseases and specific waiting periods from one insurer to another insurer.

means any condition, ailment, injury or disease:

35. Pre-Existing 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.

means medical expenses incurred during pre-defined number of days preceding the hospitalisation of the Insured Person provided that

36. Pre-Hospitalisation Medical Expenses
    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.

means medical expenses incurred during pre-defined number of days immediately after the Insured Person is discharged from the hospital provided that:

37. Post-Hospitalisation Medical Expenses
    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

38. 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.

39. 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.

40. Renewal

means the terms on which the contract of insurance can be renewed on mutual consent with a provision of a 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.

41. Room Rent

means the amount charged by a Hospital towards room and boarding expenses and shall include the Associated Medical Expenses

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 from suffering and 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. 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

1. Age

means completed age in years on the Policy Commencement Date

means hospitalisation-related expenses on Surgeon, Anesthetist, Medical Practitioner, Consultants and Specialist Fees (whether paid directly to the treating doctor/surgeon or to the hospital), Anesthetics, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances and such other similar expenses which vary based on the room category occupied by the Insured Person whilst undergoing treatment in a hospital. Such Associated Medical expenses do not include:

2. Associated Medical Expenses
   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.

3. Sum Insured

means the pre-defined limit specified in the Policy Schedule

4. Break in policy

means the period of gap that occurs at the end of the existing policy term/installment premium due date, when the premium due for renewal on a given policy or installment premium due is not paid on or before the premium renewal date or grace period.

5. 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 the other which is not lower than a period of fifteen days.

6. Continuous Coverage

means uninterrupted coverage of the Insured Person under the 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.

7. Family

means the persons named in the Policy Schedule who are the Insured Person, his/her legal spouse, Dependent Children.

8. Insured Person

means person(s) named in the schedule of the Policy.

9. Material Fact

means all relevant information sought by the Company in the Proposal Form and other connected documents to enable it to take an informed decision in the context of underwriting the risk

10. Nominee

means the person named in the Policy Schedule, Policy certificate and/or endorsement (if any) who is nominated by the Policy Holder/Insured Person, to receive the benefits under this Policy as per the terms of the Policy if the Insured Person deceases.

11. Organ Donor

means any person whose organ has been made available in accordance and compliance with The Transplantation of Human Organs (Amendment) Act, 1994 and relevant rules and amendments thereof. The donated organ must be for the use of the Insured Person.

12. Policy

means these Policy wordings, the Policy Schedule and any applicable endorsements or extensions attaching to and/or forming part thereof. The Policy contains details of the benefits, exclusions, and applicable terms & conditions.

13. Policy Period

means the period for which this policy is taken and is in force as specified in the Schedule.

14. Preferred Provider Network (PPN)

means a network of hospitals which have agreed to a cashless packaged pricing for certain procedures for the Insured Person. The updated list of network providers/PPN is available on our website (https://uiic.co.in/en/tpa-ppn-network-hospitals) and the website of the TPA mentioned in the schedule and is subject to amendment from time to time.

means the form to be filled in by the prospect in written or electronic or any other format as requested by the Company and approved by the IRDAI, for furnishing all material information as required by the Insurer, to: 

15. Proposal Form
    1. Enable the Insurer to take an informed decision in the context of underwriting the risk
    2. And in the event of acceptance of the risk, to determine the rates, benefits, terms and conditions of the cover to be granted

16. Single Occupancy Standard Air-Conditioned Room

means an individual air-conditioned room for accommodating a single patient with attached wash room. This room may have a television, telephone, and a couch. Such room must be the most economical of all such air-conditioned accommodations available Offi in that hospital as single occupancy. This does not include deluxe room / suite or room with additional facilities other than those stated herein.

17. 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.

18. Total Sum Insured

means the aggregate limit of Indemnity which consists of the Sum Insured and Restored Sum Insured. It represents Our maximum, total, and cumulative liability for any and all claims made under the Policy, in respect of that Insured Person(s) (on Individual Sum Insured basis) or for all Insured Persons (on Family Floater basis) during the policy period.

19. 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

20. We/Our/Us/Company/Insurer

means United India Insurance Company Limited.

1. Eligibility 
   Eligibility based on age:
   • Adults: 18 years and 65 years.
   • Dependent Children: 91 days to 17 years, provided either or both parents are covered concurrently. In case, where both the parents of the child(ren) are already deceased, the minor child(ren) can be covered by the guardian without covering himself/herself.
   • Dependent Children up to 91 days can be covered if the optional cover of Maternity Expenses and New Born Baby Cover is purchased on payment of additional requisite premium. Children aged 18 years or above 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.
2. Policy Term
   One Year. Renewable annually.
3. Sum Insured
   Rs. 3 lacs, 4 lacs, 5 lacs, 6 lacs, 7 lacs, 8 lacs, 9 lacs, 10 lacs, 15 Lacs, 20 Lacs & 25 Lacs.

The coverages available under this Policy are described below.

1. 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

In-patient Hospitalisation Expenses Cover We will pay the Reasonable and Customary Charges for the following Medical Expenses of an Insured Person in case of Medically Necessary Treatment taken during Hospitalisation provided that the admission date of the Hospitalisation due to Illness or Injury is within the Policy Period:

1. Room, Boarding and Nursing expenses (all inclusive) incurred as provided by the Hospital/Nursing Home up to the limits provided below:

These expenses will include nursing care, RMO charges, patient’s diet charges, IV Fluids/Blood transfusion/injection administration charges and similar expenses.

2. Charges for accommodation in Intensive Care Unit (ICU)/ Intensive Cardiac Care Unit (ICCU) up to the limits provided below:

3.  The fees charged by the Medical Practitioner, Surgeon, Specialists, and anesthetists treating the Insured Person;
4. Operation theatre charges,
5. Anesthesia, 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, orthopedic implants, infra cardiac valve replacements, vascular stents, relevant laboratory/ diagnostic tests, X-Ray, dialysis, chemotherapy, radiotherapy, and such other similar medical expenses related to the treatment.

1.1 Note:

1. PROPORTIONATE PAYMENT CLAUSE: In case of admission to a room at rates exceeding the aforesaid limits in clause III.A.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.
2. No payment shall be made under clause III.A.1.iii other than as part of the hospitalisation bill. However, the bills raised by Surgeon, Anesthetist 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
3. All Day Care treatments as per definition are covered.

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 up to 25% of Sum Insured subject to a maximum of Rs. 3,00,000 per policy period;

   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 - F22; F23; F28; F29)

2. Pre-Hospitalisation and Post-Hospitalisation Expenses –

We will cover, on a reimbursement basis, the Insured Person’s:

1. Pre-hospitalisation Medical Expenses incurred due to an Illness or Injury during the period up to 30 days prior to hospitalisation; and
2. Post- hospitalisation Medical Expenses incurred due to an Illness or Injury during the period up to 60 days after the discharge from the hospital

Subject to a maximum of 10% of Sum Insured for Pre- and Post-Hospitalisation combined, provided that:

1. We have accepted a claim for primary In-patient Hospitalization above.
2. The Pre-hospitalisation and Post-hospitalisation Medical Expenses are related to the same Illness or Injury.

3. 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 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 Clause III.A.1 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

1. Pre-hospitalization Medical Expenses or Post-hospitalisation 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.

4. Restoration of Sum Insured

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

1. In case of policies on Individual Sum Insured basis, the Restored sum insured will be available only once to each Insured Person individually in a Policy Period.
2. In case of policies of Family Floater basis, the Restored Sum Insured will be available only once to the whole family on floater basis during a Policy Period.
3. Such restored Sum Insured can be utilized only for illness / disease unrelated to the illness(es) / disease(s) for which claim(s) was / were made for the same insured person.
4. The maximum liability for a claim in a Policy Year cannot exceed the Sum Insured
5. If the Restored Sum Insured is not utilized in a Policy Period, it shall not be carried forward to any subsequent Policy Period.

Note:

1. Restoration of Sum Insured is available only for Sum Insured options from Rs. 3 lakhs and above
2. The payment from the Restored Sum Insured will be done only after exhaustion of the Sum Insured.

5. Modern Treatment Methods & Advancement in Technologies

In case of an admissible claim under Clause III.A.1, expenses incurred on the following procedures (wherever medically indicated) shall be covered.

1. Uterine Artery Embolization and HIFU (High Intensity focused ultrasound)
2. Balloon Sinuplasty
3.  Deep Brain Stimulation
4. Oral Chemotherapy
5.  Immunotherapy - Monoclonal Antibody to be given as an injection
6. Intra-vitreal injections
7.  Robotic Surgeries
8. Stereotactic Radio Surgeries
9. Bronchial Thermoplasty
10. Vaporization of the Prostrate (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 hematological conditions to be covered

Note: The claims under Oral Chemotherapy and Immunotherapy-Monoclonal Antibody to be given as injection shall be treated as post-Hospitalisation claim(s). However, the time and monetary limits shall not be applied.

6. Road Ambulance Cover

We will cover the costs incurred up to:

1. 0.5% of the Sum Insured subject to a maximum of Rs. 2,500 per event and
2. 1% of the Sum Insured subject to a maximum of Rs. 5,000 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 Clause III.A.1 and the expenses are related to the same Illness or Injury. We will also cover the costs incurred on transportation of the Insured Person by road Ambulance in the following circumstances up to the limits specified above under this cover, if:

1. it is medically required to transfer the Insured Person to another Hospital or diagnostic Centre during the course of Hospitalization for advanced diagnostic treatment in circumstances where such facility is not available in the existing Hospital;
2. it is medically required to transfer the Insured Person to another Hospital during the course of Hospitalization due to lack of super specialty treatment in the existing Hospital.

7. Cost of Health Check-up

Expenses incurred towards cost of health check-up up to 1% of average Sum Insured of preceding 3 policy years, subject to a maximum of Rs. 5,000 per person for policies issued on individual sum insured basis/ Rs. 10,000 per policy period for policies issued on family floater basis for a block of every three claim-free years provided the health check-up is done at hospitals/diagnostic Centre authorised by us within a year from the date when it got due and the policy is in force. Payment under this benefit does not reduce the Total Sum Insured. In case of the policy on family 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.

Note: Payment of expenses towards cost of health check-up will not prejudice the company's right to deal with a claim in case of non-disclosure of material fact and /or Pre-Existing Diseases in terms of the policy

8. 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.

1. Optional Covers:

1. 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. 40,000 in case of normal delivery and Rs. 60,000 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 up to 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 Expenses under Clause III.B.1.a 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.

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 for Maternity and New Born Baby Cover
6. Subject to the terms & conditions, the Policy covers New Born Baby beyond 90 days only on payment of requisite premium
7. If this Option is in force in respect of the Insured Person

1. The maternity exclusion is inoperative
2. The waiting period for “Internal Congenital Anomaly” will be deemed inoperative for the New Born Baby throughout the time such baby is continuously covered under this product.

2. 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 Treatment claims. Deductible equivalent to Daily Cash Allowance for the first 24 hours Hospitalization will be levied on each Hospitalisation during the Policy Period.

1. Notification of Claim
   Upon the happening of any event which may give rise to a claim under this Policy, the Insured Person/Insured Person’s representative shall notify the TPA (if claim is processed by TPA)/company (if claim is processed by the company) in writing providing all relevant information relating to claim including plan of treatment, policy number etc. within the prescribed time limit as under:
   • Within 24 hours from the date of emergency hospitalisation required or before the Insured Person’s discharge from Hospital, whichever is earlier.
   • At least 48 hours prior to admission in Hospital in case of a planned Hospitalisation
2. Procedure for Cashless Claims
   • a. Cashless facility for treatment in network hospitals only shall be available to Insured if opted for claim processing by TPA.
   • b. Treatment may be taken in a network provider/PPN hospital and is subject to pre authorization by the TPA. Booklet containing list of network provider/PPN hospitals shall be provided by the TPA. Updated list of network provider/PPN is available on website of the company (https://uiic.co.in/en/tpa-ppn-network-hospitals) and the TPA mentioned in the schedule.
   • c. The customer may call the TPA’s toll free phone number provided in the policy copy/on the health ID card for intimation of claim and related assistance. Please keep the ID number handy for easy reference.
   • d. 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 filled and submitted to the TPA for authorization.
   • e. 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.
   • f. At the time of discharge, the Insured Person shall verify and sign the discharge papers and pay for non-medical and inadmissible expenses.
   • g. The TPA reserves the right to deny pre-authorization in case the Insured Person is unable to provide the relevant medical details.
   • h. 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
   • a. 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.
   • b. Claims for Domiciliary Hospitalisation and Pre- and Post-Hospitalisation will be settled on reimbursement basis on production of relevant claim papers and cash receipts within the prescribed time limit.
   • c. Claims for Cost of Health Check-up will be settled on reimbursement basis on production of test reports and cash receipts within the prescribed time limit.
4. Supporting Documents
   The claim is to be supported with the following original documents and submitted within the prescribed time limit:
   • a. Duly completed claim form
   • b. 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.
   • c. Medical history of the patient as recorded, bills (including break up of charges) and payment receipts duly supported by the prescription from attending medical practitioner/ hospital.
   • d. Discharge certificate/ summary from the hospital.
   • e. Cash-memos from the Diagnostic Centre(s)/ hospital(s)/ chemist(s) supported by proper prescription.
   • f. Payment receipts from doctors, surgeons and anesthetists.
   • g. Bills, receipts, Stickers of the Implants.
   • h. Any other document required by company/ TPA
   
   Note: In the event of a claim lodged as per Settlement under multiple policies clause and the original documents having been submitted to the other Insurer, the company may accept the duly certified documents listed under Clause V.B.5.iv of the policy wordings and claim settlement advice duly certified by the other Insurer subject to satisfaction of the Company.


5. Time Limit for submission of documents

Notes:

• i The company shall only accept bills/invoices/medical treatment related documents only in the Insured Person’s name for whom the claim is submitted.
• ii Waiver of clause V.B.5.v of the policy wordings 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.
• iii 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.
• iv All the documents submitted to TPA shall be electronically collected by us for settlement/denial of the claims by the appropriate authority.
• v 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. 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:

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

1. Waiting Periods

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:

1. Pre-Existing Diseases (Code – Excl01)
   • 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.
   • In case of enhancement of the Sum Insured, the exclusion shall apply afresh to the extent of the Sum Insured increase.
   • If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health Insurance) Regulations, then the waiting period for the same would be reduced to the extent of prior coverage.
   • 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. Specified Disease/Procedure Waiting Period (Code – Excl02)
   • 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.
   • In case of enhancement of the sum insured the exclusion shall apply afresh to the extent of the sum insured increase
   • 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
   • The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a specific exclusion.
   • If the Insured Person is continuously covered without any break as defined under the applicable norms on portability stipulated by IRDAI, then the waiting period for the same would be reduced to the extent of prior coverage.
   • List of specific diseases/procedures:

Table A. Two years waiting period

Table B. Four years waiting period

3. 30-Day Waiting Period (Code – Excl03)
   •  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.
   • This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve months.
   • The within-referred waiting period is made applicable to the enhanced sum insured in the event of granting a higher sum insured subsequently.

2. Standard Permanent Exclusions

The Company shall not be liable to make any payment under this Policy in respect of any expenses incurred by You in connection with or in respect of:

4. Investigation & Evaluation (Code – Excl04)
   • Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.
   • Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.

Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:

5. Rest Cure, Rehabilitation and Respite Care (Code – Excl05)
   • 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, and moving around either by skilled nurses or assistants or non-skilled persons
   • Any services for people who are terminally ill to address physical, social, emotional and spiritual needs

6. Obesity/Weight Control (Code – Excl06)

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

• Surgery to be conducted is upon the advice of the Doctor
• The surgery/Procedure conducted should be supported by clinical protocols
• The member has to be 18 years of age or older and
• Body Mass Index (BMI):
  • Greater than or equal to 40 or
  • 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
  • Obesity-related cardiomyopathy
  • Coronary heart disease
  • Severe Sleep Apnea
  • Uncontrolled Type2 Diabetes

Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.

7. Change-of-Gender treatments (Code – Excl07)

8. 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.

9. 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.

10. 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.

11. 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 on 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.

12. (Code – Excl12)

Treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof.

13. (Code – Excl13)

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.

14. (Code – Excl14)

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 a hospitalisation claim or day care procedure.

15. Refractive Error (Code – Excl15)

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

16. 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.

Expenses related to sterility and infertility. This includes:

17. Sterility and Infertility (Code – Excl17)
    • Any type of contraception, sterilization
    •  Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
    • Gestational Surrogacy
    • Reversal of sterilization

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

3. Specific Permanent Exclusions

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 Illnesses/expenses caused by ionizing radiation or contamination by radioactivity from any nuclear fuel (explosive or hazardous form) or any nuclear waste from the combustion of nuclear fuel, nuclear/chemical/biological attack.
3.  Any expenses incurred on Domiciliary Hospitalization.
4. Any expenses incurred on Out-patient treatment (OPD treatment). Procedures/treatments usually done in outpatient department are not payable under the policy even if admitted/converted as an in-patient in the hospital for more than 24 hours.
5. . Any item(s) or treatment specified in ‘List of Non-Medical Expenses under this Policy’ as per clauses in Annexure – 1, unless specifically covered under the Policy.
6. Any treatment related to sleep disorder or sleep apnoea syndrome.
7.  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.
8. Change of treatment from one system of medicine to another system unless recommended by the consultant/hospital under whom the treatment is taken.
9. Circumcision unless necessary for Treatment of an Illness or Injury not excluded hereunder or due to an Accident.
10.  Congenital External Diseases or Defects or anomalies.
11. Cost of hearing aids; including optometric therapy.
12. Cost of routine medical examination and preventive health check-up unless as provided for in clause III.A.8.
13. Dental treatment or  surgery  of  any  kind  unless  necessitated  by  disease  or  accident  and  requiring hospitalisation.
14.  Intentional self-inflicted Injury or attempted suicide.
15.  Routine eye-examination expenses, cost of spectacles, contact lenses.
16. Stem cell implantation/Surgery/Therapy, harvesting, storage or any kind of treatment using stem cells except Hematopoietic stem cells for bone marrow transplant for haematological conditions; growth hormone therapy.
17. 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.
18. Treatments other than Allopathy and AYUSH
19. 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. Please refer to clauses in Annexure-1 for the complete list of non-payable items.
20. Vaccination or inoculation of any kind unless it is post animal bite.
21.  In respect of the existing diseases, disclosed by the insured and mentioned in the policy schedule (based on insured’s consent), Insured Person is not entitled to get the coverage for specified ICD Codes

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