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HEARTBEAT HEALTH INSURANCE PLAN
&LITERATURESALES
PROSPECTUS
HEARTBEAT HEALTH INSURANCE PLAN
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HEARTBEAT HEALTH INSURANCE PLAN
OUR PARENT COMPANIES
Your search for high quality health insurance stops here.
Introducing Max Bupa Health Insurance Company Limited, a joint venture between Max India Limited and Bupa
Finance Plc U.K. We believe in nurturing long-term relationships with our customers by providing the highest levels of
quality in service.
Max India Limited: A reputation for excellence
Max Group brings expertise in insurance and
healthcare with a strong presence in Life Insurance
(through Max New York Life Insurance Company
Limited), Healthcare (through Max Healthcare Institute
Ltd.) and Clinical Research (through Max Neeman
Medical International Limited).
A Rs 8500 crore group, it has over 500 offices across
400 locations in India with more than 57,000
employees, all focused on delivering customer
satisfaction to more than 5 million customers(Source
Max India website as on March 31st, 2012)
Bupa - 65 years of Care
Established in 1947 as the British United Provident
Association, Bupa today has group revenue of
£8.0billion, 10.84 million customers in over 190
countries and employs over 52,000 people.(Source –
Bupa Annual Report published in March 2011)
Bupa Group brings in a wealth of experience in serving
customers directly in the health insurance sector across
the world. In addition, Bupa also runs care homes for
older people, operates hospitals, provides chronic
disease management services and offers out of hospital
care.
Recognition and Rewards
Max India Group: • Max New York Life was declared a “Superbrand” by Superbrands India in the 3rd edition of Consumer Superbrands 2008’ • CII-Exim Bank Award for for Business Excellence awarded to Max New York Life in 2008 • CIO 100 Award for technology implementation
Bupa: • The Health Insurance Company of the Year Award awarded at the U.K. Health Insurance Awards 2009 • Best International Private Medical Insurance provider 2008 - awarded at the U.K. Health Insurance Awards • Best Medical Insurer Company (2008, Bupa Arabia) - awarded at the Jeddah Chamber of Commerce and Industry Health Committee Awards • Best Healthcare Provider of the Year - awarded at the U.K. Corporate Adviser Awards 2009 • Best Individual Private Medical Insurance Provider awarded at the U.K Money Marketing Awards 2009
Heartbeat Health Insurance Plan
Start a healthy relationship
Heartbeat Health Insurance Plan from Max Bupa is
*(Source: www.maxindia.com)#(Source - Bupa Annual Report published in March 2012)
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the most comprehensive health insurance cover for you
and your family. It gives you the flexibility to choose just
the right cover for your needs. Apart from giving you a
comprehensive health insurance cover to suit your
needs, we are also committed to provide you the best
quality service when you need it the most.
Which is why Max Bupa is the Healthier Health
Insurance for you and your family:
• You talk to us directly, not through any third
parties. We will be there for you when you need
us. Because you should concentrate on getting
better, not chasing your claims.
• We are with you at every step of the way in your
life. For a happy occasion like the delivery of your
baby, to your child’s vaccinations, or at other
times when there is an illness in the family- we
have it covered. New born babies are
automatically covered till the next renewal
of the policy.
• You can access our cashless facility at quality
hospitals of your city, with the best medical
facilities included in our partner network.
• We cover families across life stages – from
newborns to senior citizens of any age, covering
up to 13 relationships in one policy.
• Our health relationship programme helps you to
nurture and improve your and your family’s
health.
• You can call us anytime for help on our 24/7
health line for easy and friendly access to health
advice when you need it.
• Managing our relationship - As a customer, you
can access your own page onthe Max Bupa
website to keep track of your policy details and
benefits.
• To build a relationship that lasts a lifetime, we
make all efforts to understand your health
profile during enrollment, so that when you need
us, we can provide speedy and efficient support.
• We assure you renewability of your policy for
lifetime, if you pay renewal premium within the
grace period of 30 days of expiry of your previous
policy. You should renew on or before the renewal
date of the policy to ensure you have continued
medical insurance cover even during the grace period.
• As with all health insurance policies, you may save
tax under Section 80D of the Income Tax Act
when you buy a Max Bupa health insurance
policy. (Tax benefits are subject to changes in the
tax laws, please consult your tax advisor for more
details)
Policy Design
• Max Bupa Heartbeat Health Insurance plan can be
issued to an individual customer, a family and/or
extended family.
• The family floater policy may be available in any of
the following combinations:
o 1 Adult + 1Child
o 1 Adult + 2 Children
o 1 Adult + 3 Children
o 1 Adult + 4 Children
o 2 Adults
o 2 Adults + 1Child
o 2 Adults + 2Children
o 2 Adults + 3Children
o 2 Adults + 4Children
• The family includes spouse and dependent
children and can comprise up to a unit of 6
insureds of which up to 4 can be children.
• The premium for family floater policies depends
on the age of the eldest insured customer.
• The Family First may be available in any of the
below relationships with the Proposer
a. Legally married spouse as long as he or she
continues to be married to You; b. Son;
c. Daughter-in-law; d. Daughter; e. Son-in-Law;
f. Father; g. Mother; h. Father-in-law as long as
Your spouse continues to be married to You;
i. Mother-in-law as long as Your spouse continues
to be married to You.; j. Grandfather;
k. Grandmother; l. Grandson; m. Granddaughter
• The premium for Family First policies depends on
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the individual age of each insured customer in the
Extended Family.
• This policy covers persons of any age. There is no
maximum entry age for the insured.
• The maximum entry age of any dependent as a
child in the policy is less than 21 years on the date
of commencement of the initial cover under the
Policy.
Please note all the children whose age exceeds the
maximum entry age would be given an option to
migrate to our retail health insurance offering (for
e.g. Heartbeat Health Insurance Plan, Health
Companion Health Insurance Plan, Health
Assurance) under individual plans.
• There is no maximum cover ceasing age in this
policy.
• The default policy term for all plans is one year. A
two year policy term option is also available for
Heartbeat Individual, Family Floater and Family
First plans. Avail 12.5% discount on second year
premium when you opt for 2 year policy.
• You can also choose an optional aggregate annual
deductible (top-up cover) along with Silver Sum
Insured options of Individual and Family Floater
plans.
Sum Insured
• The sum insured options:
o In case of Individual or Family Floater - range
from Rs. 2 lacs to Rs. 1 cr depending on the
plan you choose. The details of the plans are
available in the product benefits table.
o In case of Family First:
Flexible sum insured per person (one amount
chosen for all family members) as well as a
floating amount that can be utilised once the
sum assured per person is consumed. This
provides flexibility for families to decide their
optimal cover: Choose individual cover from
options given below:
• Individual Base Sum Insured Options for Silver are -
Rs 1L, 2L, Rs 3L, Rs 4L, & Rs 5L
• Individual Base Sum Insured Options for Gold - Rs
1L, Rs 2L, Rs 3L, Rs 4L, Rs 5L, Rs10L and Rs 15L
• Individual Cover Sum Insured Options (for
Platinum)- Rs5L, 10L and Rs 15L
Within the Sum Insured, there is an individual
insurance cover for each Insured Person which shall
be up to the amount specified in the Schedule for
that Insured Person. Our maximum liability for all
claims in respect of an Insured Person under the
Policy during the Policy Period shall be limited to the
Individual Cover amount specified in the Schedule
for that Insured Person.
Choose family floater cover from options given below:
Family Floater Cover Sum Insured
• For Silver – Rs. 3L, Rs. 4L, Rs. 5L, Rs. 10L & Rs. 15L
• For Gold – Rs. 3L, Rs. 4L, Rs. 5L, Rs. 10L, Rs. 15L,
Rs.20L, Rs.30L and Rs.50L
• For Platinum- Rs. 15L, Rs 20L, Rs. 30L and Rs. 50L
Within the Sum Insured, there is a floater insurance
cover up to the amount specified in the Schedule. This
floater cover may be utilized only if the Individual
Cover amount of an Insured Person is fully exhausted
and there is a further claim under the Policy. Our
maximum, total and cumulative liability for any and all
such further claims in respect of all Insured Persons
under the Policy during the Policy Period shall be
limited to the Floater Cover amount specified in the
Schedule.
Illustration for Family First Policy:
The details of the plans are available in the product
benefits table for Family First Policy.Product
Product Features and Benefits – Key Highlights
The policy covers reasonable charges incurred towards
Family Members Age Individual Sum Insured (in lacs) Father 66 2 Mother 65 2 Son 40 2
Daughter-in law 39 2 Total Individual Sum Insured 8 lacs
Family Floater Sum Insured 5 lacs
Total Sum Insured 13 lacs
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medical treatment taken during the Policy Period for an
Illness or an Accident. We cover the following expenses
1. Inpatient Care: Medical Expenses for:
(i) Medical Practitioners’ fees, Diagnostics
procedures, Medicines, drugs and
consumables, Operation theatre charges,
Intensive Care Unit, Intravenous fluids, blood
transfusion, injection administration charges
(ii) The cost of prosthetics and other devices or
equipment if implanted internally during a
Surgical Procedure.
2. Hospital Accommodation:
Reasonable charges for Room Rent for Hospital
accommodation. All Gold and Platinum Policies
can utilise Single Private rooms during
hospitalization.
For Silver sum insured options of Individual and
Family Floater plans, the Insured Persons can
choose between a shared room
category or 1% of their Sum Insured,
at the time of hospitalisation. For Silver Family
First plans, the insured persons can opt for Rs
3,000 or a shared room, depending on their
preference.
3. Pre & Post hospitalization Medical Expenses:
Medical Expenses incurred due to Illness up to
30 days period immediately before an Insured
Person’s admission to a Hospital and 60 days
immediately after an Insured Person’s
discharge from a Hospital. These are payable
for the same illness or treatment as long as we
have accepted an inpatient hospitalization
claim for that treatment or illness. These can
be claimed only as reimbursements. .
4. Day Care Treatment: Medical Expenses for
Day Care procedures/ Treatment where such
treatment are undertaken by an Insured
Person for a continuous period of less than 24
hours, in a Hospital/day care centre, will be
covered. Any procedure undertaken at the
out-patient department of a Hospital will not
be covered. Under Day Care Procedures we
will also cover Chemotherapy, Radiotherapy,
Hemodialysis, or any procedure which needs a period
of specialized observation or care after completion of
the procedure, where such procedure is undertaken by
an Insured Person as an In-patient in a Hospital for a
continuous period of less than 24 hours. Any OPD
Treatment undertaken in a Hospital will not be
covered.
5. Domiciliary Treatment: Medical Expenses for
treatment taken at home if the treatment
continues for an uninterrupted period of 3
days and the condition for which treatment is
taken would otherwise have necessitated
hospitalization as long as either (i) the
attending Medical Practitioner confirms that
the Insured Person could not be transferred to
a Hospital or (ii) Insured Person satisfies us that
a Hospital bed was unavailable.
6. Maternity Benefits:
(i) ‘In-case of Family Floater: This benefit is
available only to you or your spouse under
family floater policy, only when you and your
spouse, are both covered under the same
policy. We pay Medical Expenses for the
delivery of a child, only after 24 months of
continuous coverage since the inception of the
first Policy with Us. There is a sub-limit on
maternity expenses as shown in the Product
Benefit Table. Maternity benefits are paid only
twice during the lifetime of the Policy including
any of its renewals. We will also cover medically
necessary termination of pregnancy. We will
cover the pre-natal & post-natal Medical
Expenses for any covered delivery and
termination. However, expenses in respect of
harvesting and storage of stem cells
are not covered.
(ii) In-case of Family First: This benefit is
available only to adult females covered
under Family First Policy. We pay Medical
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Expenses for the
delivery of a child, only after 24 months of
continuous coverage since theinception of the first
Policy with Us. There is a sub-limit on maternity
expenses as shown in the Product Benefit Table for
Family First Policy. Maternity benefits are paid only
twice during the lifetime of the Policy including any
renewal thereof. We will also cover medically necessary
termination of pregnancy. We will cover the pre-natal &
post-natal Medical Expenses for any covered delivery
and termination. However, expenses in respect of
harvesting and storage of stem cells are not covered.
7. New Born Baby:
The new born baby will be covered as an insured
person from birth. We will cover medical expenses
towards the medical treatment of the Insured Person’s
new born baby while the Insured Person is Hospitalized
as an Inpatient for delivery. We also cover Reasonable
Charges for vaccination of the new born baby until the
new born baby completes one year. If the policy ends
before the baby completes one year, then we will cover
the vaccinations only if the baby has been added as an
insured person at the time of renewal.
8. Organ Donor:
Medical Expenses for an organ donor’s treatment for
harvesting of the organ provided that the Insured
Person has been medically advised to undergo an
organ transplant and the donation conforms to The
Transplantation of Human Organs Act 1994 and the
organ is for the use of the Insured Person;
We will not cover:
(a) Pre-hospitalisation or post-hospitalization Medical
Expenses or screening expenses of the donor or any
other medical expenses as a result of the harvesting
from the donor;
(b) Costs directly or indirectly associated with the
acquisition of the donor’s organ.
9. Health Checkup:
We will cover the cost of Health Check-Up arranged by
us through our empanelled service providers as per
your plan eligibility defined in the product benefit table.
10. Emergency ambulance:
Reasonable charges for ambulance expenses (by surface
transport only) incurred to transfer the Insured Person
following an Emergency, while in India, to the nearest
Hospital, if we accept the in-patient claim. For Out Of
Network Hospitalization our maximum liability for
ambulance expenses is limited to Rs.2,000/- per event.
11. Benefits on Annual Renewals
• Health Relationship Loyalty Program
If the Policy is renewed with us without any break, each
Insured Person will become eligible to participate in the
Health Relationship Loyalty Program announced by us
from time to time. It is a first-of-its kind rewards
program, which rewards customers for their relationship
with Max Bupa and the trust they have reposed in the
brand, irrespective of their claim history. The program is
also designed in a way that the customers can choose
the benefits that are most relevant to them. Under this
program, customers can opt for either of the following:
1. Earn and Redeem: Customers can earn points
worth a percentage of their last paid premium which can
be redeemed against various products and services. These
products and services can be vouchers from various
partner brands. It also includes vouchers for OPD services
within our partner hospital network if the customer wishes
to avail of the same, of the equivalent value.
a. If the Policy Period is one year, we offer
vouchers, in either electronic or physical form, worth
10% of your last premium received
b. If the Policy Period is two years, we offer
vouchers, in either electronic or physical form, worth 5% of
the last premium received on the commencement of each
Policy Year commencing from the second Policy Year.
The Insured Person may avail of the services and
products specified within the period specified in or
along with the voucher, provided that:
• The vouchers are used for health services and
benefits communicated from time to time;
• The conditions or limitations specified in the
vouchers are adhered to;
• The Policy is continuously renewed.
2 . Increase Sum Insured: The customer also has the
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option to opt-for increasing his Sum insured up to a cap
of 50% of his base sum insured. The customer will not
have an option of opting for ‘Earn n redeem’ as
mentioned above once he has opted for increasing his
Sum insured on further renewals
• The option of higher Sum Insured is applicable
for (a) individual Policy on Base Sum Insured, (b) Family
Floater Policy on Base Plan Sum Insured, and (c) Family
First Policy on individual Base Sum Insured
• We offer a 10% increase on the expiring Base Sum
Insured on each Policy Year up to a maximum of 50% of
Base Sum Insured of that Policy Year provided the Policy
is renewed continuously
Illustration:
The Loyalty additional Sum Insured is calculated as 10% of
the expiring policy’s Sum Insured at the time of renewal.
So if a customer has a base Sum Insured of Rs. 200,000
in the beginning, he earns a 10% Loyalty additional Sum
Insured of Rs. 20,000 at renewal which is added with his
base Sum Insured to take his total Sum Insured for the
next year to 220,000. Like this the Total Loyalty
additional Sum Insured can be accumulated till 50%(Rs
100,000) of the base sum insured of Rs 200,000, if the
customer renews the policy for 200,000 continuously.
However, If at the next renewal he increases his base
Sum Insured to Rs 10,00,000 from Rs. 200,000, he
gets Rs. 20,000 Loyalty additional Sum Insured, which
is10% of the expiring base Sum Insured Rs. 200,000.
This takes his total loyalty additional Sum Insured to
40,000 and his total Sum Insured for that policy to Rs.
10,40,000. The Loyalty additional Sum Insured earned
at renewal does not become a part of the base Sum
Insured for any current year. At next renewal the Loyalty
additional Sum Insured is calculated as 10% of expiring
Base Sum Insured of Rs. 10,00,000. The maximum
allowed total Loyalty additional Sum Insured can now be
50% (Rs 500,000) of Rs. 10,00,000 if the customer
renews the policy for Rs. 10,00,000 continuously
Next, If the customer reduces his base Sum Insured
back to Rs. 200,000 at next renewal, the maximum
total Loyalty Additional Sum Insured allowed will be
calculated based on the new sum Insured of Rs.
200,000 and the customer cannot avail of the higher
amounts earned earlier.
12. Consultation and Diagnostic Tests Carry Forward
(for Platinum Policyholders only): We will cover
reasonable charges for Insured Person’s medically
necessary consultation with a Medical Practitioner, as
an OPD Treatment to assess the Insured Person’s
health condition for any illness. We will also pay for
any diagnostic tests prescribed by the medical
practitioner and medicines purchased under and
supported with a Medical Practitioner’s prescription up
to the sub-limits shown in the product benefits table.
If the Policy is renewed with us without any break and
there is a unutilized amount (not used by the Insured
Person) under the applicable sub-limit (as specified in
the product benefit table) in a Policy Year, then we will
carry forward 80% of this unutilized amount to the
immediate succeeding Policy Year. The total amount
(including the unutilized amount available under this
benefit) should not exceed 2.5 times the amount of
the entitlement in respect of this benefit under the
plan applicable to the Insured Person as per the
Product Benefits Table.
Current Base Sum Insured
Loyalty Additional Sum Insured Amount
Cumulative Loyalty Additional Sum Insured Total Sum Insured
1 200,000 - - 200,000 2 200,000 20,000 20,000 220,000 3 1,000,000 20,000 40,000 1,040,000 4 1,000,000 100,000 Rs.140,000 1,140,000 5 1,000,000 100,000 240,000 1,240,000 6 200,000 100,000 100,000 300,000 7 200,000 20,000 100,000 300,000
(All Figures in INR)
Illustration of how the above carry forward works as
follows (All figures in INR):
Illustration 1: Sum Insured:
15 lacs, Out-patient benefits sub-limit Rs. 10,000/-Yr
Sub-limit carried
forward from previous
year
Fresh OPD sub-
limit for the year
Maximum allowed (2.5 times sub-
limit)
Sub-limit available
for the year
OPD claims
made in the year
Unutilized limit at the end of the
year
Sub-limit carried
forward to the next
year 1 - 10,000 25,000 10,000 - 10,000 8,000 2 8,000 10,000 25,000 18,000 - 18,000 14,400 3 14,400 10,000 25,000 24,400 2,500 21,900 17,520 4 17,520 10,000 25,000 25,000 - 25,000 20,000 5 20,000 10,000 25,000 25,000 3,000 22,000 17,600 6 17,600 10,000 25,000 25,000 25,000 20,000
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Illustration 2 (All Figures in INR): Sum Insured: 50 lacs,
Out-patient benefits sub-limit Rs. 20,000/-
13. Co-Payment
If any insured person is 65 years of age or over on the
date of commencement of current policy year, then we
will pay the percentage provided in the table below of
any assessed claim amount
Co-payment contribution table:
The above Co-pay grid means that the Percentage of
any assessed claim amount payable by Us increases by
5% for every continuous renewal.
Illustration of how the above co-pay works:
If the insured person is of the age 63 years at the time
of the first Policy Inception then the Co-pay that would
have applied at the age of 65 years would reduce as
per the table below,
It should be noted that the Co-pay is applicable only
once the insured person is 65 years or age or older.
The reduction in co-pay is a benefit being given to
customers for enrolling before the age of 65 years.
Even after turning 65 the Co-pay continues to reduce
by 5% for every Continuous renewal. So for any
customer Continuously renewing the same plan with
Us for 4 policy years the Co-pay reduces to zero.
Special Benefits to Platinum Customers
Customers who opt for the Platinum plan of the
Heartbeat with Sum Insured ranging from 15 lacs to 1
cr on Individual policies and Family Floater, and Family
First Platinum Plans get additional benefits ranging
from preventive health care, alternative therapies and
outpatient treatments, treatment outside of India,
making it an exhaustive and best quality health cover
for the entire family providing the best quality
healthcare options available. These benefits are
offered within the geographical and sum-insured
sub-limits presented in the Product Benefit table.
14. Consultation and Diagnostic Tests (for Platinum
Policyholders only): Reasonable charges towards
medically necessary consultation as an outpatient with
a doctor to assess the Insured Person’s condition. The
outpatient treatment will also include alternative
treatment like Homeopathy and Ayurveda, within the
same, up to the sub-limits prescribed. We will also pay
for any diagnostic tests and medicines prescribed by
the doctor up to the sub-limits shown in the Product
Benefit Table.
15. Child Care Benefits (for Platinum Policyholders
only): We will cover reasonable charges for specified
vaccination expenses for children who are included as
insured persons until they have completed 12 years
are covered. We will also cover expenses towards one
consultation for nutrition and growth provided to the
child during a visit for vaccination.
16. Emergency Medical Evacuation and
Hospitalization(for Platinum Policyholders only)
Year Sub-limit carried forward
from previous
year
Fresh OPD
sub-limit for the year
Maximum allowed (2.5 times sub-
limit)
Sub-limit available for the year
OPD claims
made in the year
Unutilized limit at the end of the
year
Sub-limit carried
forward to the next
year
1 - 20,000 50,000 20,000 - 20,000 16,000 2 16,000 20,000 50,000 36,000 - 36,000 28,800 3 28,800 20,000 50,000 48,800 - 48,800 39,040 4 39,040 20,000 50,000 50,000 - 50,000 40,000 5 40,000 20,000 50,000 50,000 - 50,000 40,000 6 40,000 20,000 50,000 50,000 17,500 32,500 26,000
No of Years of Continuous renewal at or later than the age of 65 years
Percentage of any assessed claim amount payable by Us
0 year 80%
1yr 85%
2 yrs 90%
3 yrs 95%
4 yrs or more 100% (No Co-payment)
No of Years of Continuous renewal
Age of the Insured person
Percentage of any assessed claim amount payable by Us when the insured person 65 years of age or older
0 yrs (First Policy Year)
63 yrs 100% (no co-pay in this policy year)
1 yr 64 yrs 100% (no co-pay in this policy year)
2 yrs 65 yrs 90% (co-pay starts at the age of 65 yrs, applicable percentage payable by Us is 80% plus the cumulative benefit of 10% for 2 Continuous renewals)
3 yrs 67 yrs 95% (co-pay keeps reducing at each Continuous renewal by 5%)
4 yrs 68 yrs 100% (co-pay reduces to zero after 4th Continuous renewal or in other words in the 5th year of Continuous coverage)
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(i) Emergency Medical Evacuation and
Hospitalization (Outside India) In case of a medical
emergency outside India we will provide assistance in
medical evacuation of the Insured Person and cover the
reasonable charges for transportation of the Insured
Person (and an attending Doctor if this is medically
necessary) following an emergency, to the nearest
Hospital which is prepared to admit the Insured Person
provided that: Necessary medical treatment cannot be
provided at a Hospital where the Insured Person is
situated at the time of emergency; and our service
provider has approved the request for Medical
Evacuation. The medical evacuation has been prescribed
by a Medical Practitioner and is medically necessary.
Further, if the Insured Person is required to be
Hospitalized in an emergency when the Insured
Person is outside India, but within those regions
specified in the Schedule of Insurance Certificate, We
will cover the following medical expenses towards
medical treatment until the Insured Person reaches a
medically stable condition:
(1) Medical Practitioner’ fees
(2) Diagnostics procedures
(3) Medicines, drugs and consumables
(4) Intravenous fluids, blood transfusion, injection
administration charges
(5) Operation theatre charges
(6) The cost of prosthetics and other devices or
equipment if implanted internally during a
Surgical Operation.
(7) Intensive Care Unit charges
(8) Reasonable charges for room rent for Hospital
accommodation
(ii) Specific Exclusions
I. We will not cover any treatment or claims
falling under any exclusions or waiting period
II. The benefit will also not be available after the
first 180 cumulative days of travel outside India
during the Policy Year.
Claims Procedure applicable to Emergency Medical
Evacuation and Hospitalization
a) Claims for Emergency Medical Evacuation
(i) In the event of an Emergency, Our Service
Provider shall be contacted immediately on the
helpline number specified in the Insured Person’s
health card.
(ii) Our Service Provider will evaluate the
necessity for evacuation of the Insured Person and if
the request for Medical Evacuation is approved, the
Service Provider shall pre-authorise the type of travel
that can be utilized to transport the Insured Person
and provide information on the nearest Hospital that
may be approached for medical treatment of the
Insured Person.
(iii) If the Service Provider pre-authorises the
Medical Evacuation of the Insured Person through an
air ambulance, the Service Provider shall also arrange
for the same to be provided to the Insured Person
unless there are any logistical constraints or the
medical condition of the Insured prevents Emergency
Medical Evacuation.
(iv) If the Service Provider pre-authorises the
Medical Evacuation of the Insured Person through air
travel and if the condition of the Insured Person
permits travel by commercial airline as certified by the
treating Medical Practitioner, the Service Provider shall
arrange one-way economy class air tickets or
equivalent by the most direct route from the place of
evacuation to the place to where the Insured Person is
being evacuated.
(v) It is agreed and understood that We shall not cover:
a. Any claims for reimbursement of the costs
incurred in the evacuation or transportation of the
Insured Person while outside India or any claims which
are not pre-authorized by Our Service Provider;
b. Any costs or expenses incurred in relation to
any persons accompanying the Insured Person, even if
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such persons are also Insured Persons.
b) Cashless Hospitalization in Emergency at Network
Hospitals:
The health card We provide will enable the Insured
Person to access medical treatment at any
Network Hospital outside India, but within those
regions specified in the Schedule of Insurance
Certificate, on a cashless basis only by the production
of the card to the Network Hospital prior to admission,
subject to the following:
(i) In the event of an Emergency, the Insured
Person or Network Hospital shall call Our Service
Provider immediately, on the helpline number
specified in the Insured Person’s health card,
requesting for a pre-authorization for the medical
treatment required.
(ii) Our Service Provider will evaluate the request
and the eligibility of the Insured Person under the Policy
and call for more information or details, if required.
(iii) Our Service Provider will communicate
directly to the Hospital whether the request for
pre-authorization has been approved or denied.
(iv) If the pre-authorization request is approved, Our
Service Provider will directly settle the claim with the
Hospital. Any additional costs or expenses incurred by
or on behalf of the Insured Person beyond the limits
pre-authorized by the Service Provider shall be borne
by the Insured Person.
(v) This benefit is available only as cashless facility
through pre-authorization by Our Service Provider. It is
agreed and understood that We shall not cover:
a. Any claims for reimbursement of the costs
incurred in relation to the Hospitalization of the
Insured Person while inside or outside India or any
claims which are not pre-authorized by Our Service
Provider;
b. Any costs or expenses incurred in relation any
persons accompanying the Insured Person during the period of
Hospitalization, even if such persons are also Insured Persons.
The Medical Emergency Evacuation service is on best
efforts basis and Max Bupa does not make any
guarantee and/or assume the responsibility for the
appropriateness, quality or effectiveness of the
treatment/facilities sought or provided by, or arranged
by the Service Provider while approving the
pre-authorization or providing the evacuation service.
For details refer to the Terms and Conditions of the
Policy Document.
17. International Treatment support for Specified
Illnesses (For Platinum Policy Holders Only)
If an Insured Person suffers a specified illness during the
Policy Period, we will cover reasonable expenses
incurred towards the treatment of the same, provided
the symptoms first occur and are diagnosed by a doctor
within India during the Policy Period after the
completion of the 90 day waiting period. The customers
can undergo treatment on a pre-authorisation basis
outside of India. The base coverage provided under all
Platinum Plans covers treatment outside India excluding
treatment in USA and Canada.
All Platinum Plan customers can enhance their
coverage to include USA and Canada by paying an
additional premium amount.
The specified illnesses covered are listed below:
i. Cancer
A malignant tumor characterized by the uncontrolled
growth and spread of malignant cells with invasion and
destruction of normal tissues. This diagnosis must be
supported by histological evidence of malignancy. The
term cancer includes leukemia, lymphoma and
sarcoma.
Specific Exclusion: All tumors in the presence of HIV
infection are excluded.
10
ii. Myocardial Infarction (Heart Attack)
The death of a portion of the heart muscle as a result
of inadequate blood supply to the relevant area.
iii. Coronary Artery Bypass Graft (CABG)The actual
undergoing of open / keyhole chest surgery for the
correction of one or more coronary arteries, which
is/are narrowed or blocked. The diagnosis must be
supported by relevant diagnostic tests and confirmed
by a cardiologist.
iv. Major Organ Transplant
The actual undergoing of a transplant of:
One or more of the following human organs: heart,
lung, liver, kidney, pancreas, that resulted from
irreversible end-stage failure of the relevant organ, or
human bone marrow using haematopoietic stem cells.
Specific Exclusions: The following are excluded:
(a) Other stem-cell transplants
(b) Where only islets of langerhans are transplanted
iv. Stroke
Any cerebrovascular incident including infarction of
brain tissue, thrombosis in an intracranial vessel,
hemorrhage and embolisation from an extra cranial
source, which would result in neurological sequelae.
Transient Ischemic Attacks (TIA) are excluded.
Treatment of the neurological sequelae is excluded
from the cover if the primary condition is not covered.
v. Surgery of Aorta:
Surgery of aorta including graft, insertion of stents or
endovascular repair.
Specific Exclusion: Wherein the surgery is required due
to underlying congenital condition.
vi. Coronary Angioplasty
Procedures done for widening a narrowed or
obstructed blood vessel of the heart wherein a stent
may or may not be inserted into the blood vessel. The
same is payable only if the procedure is done
subsequent to Myocardial infarction or Anginal attack.
vii. Primary Pulmonary Arterial Hypertension
An abnormal elevation in pulmonary artery pressure
with or without any known cause. The disease has to
be confirmed through cardiac catheter.
viii. Brain Surgery
Any brain (intracranial) surgery required of brain due
to traumatic or non traumatic reasons.
Exclusion: Surgery for treating neurocysticercosis
In addition to the exclusions mentioned specifically for
particular specific illness, all other exclusions and/or
waiting periods specified elsewhere in the Policy
Document shall apply.
Claims procedure for specified illness treatment
Cashless Hospitalization facility for network Hospitals:
i. In the event of specified illness, the Insured
Person should call Our service provider on the
helpline number mentioned in their health card,
requesting for a pre-authorization for the treatment
prior to commencement of travel abroad for
treatment;
ii. After verification of eligibility as per the Policy, our
service provider will evaluate the request and
call for more information, if required.
iii. After evaluation of all information, our service
provider will communicate the decision and details of
the Hospitals where the treatment can be undertaken
to the Insured Person. This could either be an approval
or a denial.
iv. Any additional costs or expenses incurred by or on
behalf of the Insured Person beyond the limits pre-authorized
by the Service Provider or at any non-Network Hospital shall
be borne by the Insured Person.
v. If the pre-authorization request is approved, our service
provider will directly settle the claim with the Hospital.
11
vi. This benefit is available only as cashless facility. It
is agreed and understood that We shall not cover:
a. Any claims for reimbursement of the costs
incurred in relation to the treatment of the Specified
Illness outside India or any claims which are not
pre-authorized by Our Service Provider;
b. Any costs or expenses incurred in relation to any
persons accompanying the Insured Person during any
period of treatment, even if such persons are also
Insured Persons.
c. Any costs or expenses incurred in relation to the
travel to or from the overseas location where
treatment is being taken.
d. Any costs or expenses incurred in relation to
accommodation or stay or transportation in the
overseas location where treatment is being taken.
e. Any pre-Hospitalization or post-Hospitalization
costs or expenses incurred by or on behalf of the
Insured Person.
f. Any costs or expenses incurred in relation to
transportation of repatriation of the mortal remains of
the Insured Person.
g. Any costs or expenses incurred by any organ
donor in relation to harvesting of organs.
h. Any OPD Treatment taken outside India .
Other optional benefits (Only one of the co-pays or
the deductibles can be chosen for any single policy)
18. Co-payment discount options(optional benefit)
If you are aged less than 65 years you can avail a
discount in premium calculation by opting for any one
of the below co-pay options. This will allow you to
manage your premium costs better.
i. 10% co-pay by the insured for all claims that you
submit to us, cashless or reimbursement.(Applicable
only for Individual and Family Floater)
ii. 20% co-pay by the insured for all claims that you
submit to us, cashless or reimbursement.
19. Optional Aggregate Annual Deductibles
(top-up option):
You can choose from one of three optional deductibles
of Rs 1 lac, Rs 2 Lacs and Rs 3 lacs. By doing so you
will receive a discount in the premium calculation of
your policy as per the table below,
If an annual aggregate deductible is chosen then the
Insured Person shall bear all assessed claim amounts
payable under the policy up to the deductible amount,
under his(her) policy for any Policy Year. Our liability
to make payment under the Policy in respect of any
claim made in that Policy Year will only commence
once the Deductible has been exhausted.
Any claim amount that is assessed to be payable by
Max Bupa under this policy and is borne by the
customer (even if paid for through another Health
Insurance Policy) will be accepted as reason of
deductible exhaustion.
Description (using 2 lacs deductible with 3 Lacs
Sum Insured as example)
By accepting this condition you will agree to pay
yourself or from another health insurance policy the
first 2 lac of the total claim amount assessed for
payment in one policy year. All claims will be assessed
by Us as per the Terms and Conditions of this policy.
Max Bupa will start paying claims as per the policy
Terms and Conditions once the total claim amount
assessed for payment for your policy goes above 2
Deductible Option (top-up) in INR
Available for Sum Insured (INR)
Applicable discount in premium calculation
1 lac Deductible 2 lacs & 3 lacs 25.0%
2 lac Deductible 2 lacs & 3 lacs 33.0%
3 lac Deductible 2 lacs & 3 lacs 45.0%
12
lacs. We will cover you for a Sum Insured of 3 lacs over
and above the 2 lacs deductible.
Please find below the two illustrations for the working
of the aggregate annual deductible(top-up option)
Illustration 1: When a customer already has an
health insurance policy and opts for another policy
from Max Bupa along with the annual aggregate
Deductible (top-up) Option
Heartbeat Health Insurance Plan Opted for Sum Insured:
3 Lacs, with an annual aggregate Deductible: 2 lacs
Health Insurance Policy from any other insurance
company Sum Insured: 2 Lacs
Rules:
Deductible exhaustion will be calculated without use
of Contribution clause. So the first 2 lacs of aggregate
annual claims in this example will be paid for by the
other insurer's policy.
For aggregate claim amounts above the annual
deductible,
Contribution ratio will be calculated as per the ratio of
the Sum Insured above the annual deductible in both
policies. So if the other insurers' policy has Sum Insured
Rs 2 Lacs and the deductible in Max Bupa policy is Rs 2
lacs, Max Bupa will pay 100% of the assessed claim
amount above Rs 2 lacs up to the Sum Insured.
Illustration 2: When there is an overlap of Sum
Insured between the Max Bupa policy and another
HI policy, along with the annual aggregate
Deductible (top-up) option
Heartbeat Policy Plan opted for Sum Insured: 3 Lacs
with an annual aggregate Deductible: 2 lacs
Health Insurance Policy from any other insurance
Claim Amount Assessed by Us
Deductible Exhaustion
Balance Deductible
Available Sum Insured in Heartbeat policy
Claim amount paid by the other insurance policy or the customer
Claim Amount paid by Us
At Inception
- - 200,000 300,000 - -
Claim 1 20,000 20,000 1,80,000 300,000 20,000 0 Claim 2 1,90,000 1,80,000 0 300,000 1,80,000 10,000 Claim 3 3,60,000 0 0 290,000 0 2,90,0000
(All Figures in INR)
company Sum Insured: 3 Lacs
In this case there is an overlap of coverage with the
other insurance policy. So in this case customer has an
option to choose the insurance company from which
claim to be settled.
Rules:
Deductible exhaustion will be calculated without use of
Contribution clause. So the first 2 lacs of aggregate
annual claims in this example will be paid for by the
other insurer's policy.
For aggregate claim amounts above the annual
deductible, if the customer chooses Max Bupa to settle
the claim, no contribution clause will be applied
Additional Services
• 24/7 Healthline. This facility has been put in place
to offer you access to health advice when you need it
the most.
• Relationship Managers (For Gold and Platinum
Policyholders): We may assign at our discretion, our
representative who will personally attend to your claims
settlement, leaving you free to concentrate on getting
better or looking after your loved ones.
• Second E-Opinion (For Platinum Policyholders)
for a life threatening medical condition.
• Direct Servicing – All claims are processed directly
by our own customer services team.
Waiting Periods and Exclusions:
Claims for the following are not covered:
• Pre-Existing Conditions: Benefits will not be
available for Pre-existing Conditions for Gold and
Claim Amount Assessed by Us (INR)
Deductible Exhaustion (INR)
Balance Deductible (INR)
Available Sum Insured in Heartbeat policy (INR)
Available Sum Insured in Other Insurer's policy (INR)
Claim amount paid by the other insurance policy or the customer (INR)
Claim Amount paid by Us (INR)
At Inception
- - 200,000 300,000 300,000 - -
Claim 1 20,000 20,000 1,80,000 300,000 300,000 20,000 0 Claim 2 1,80,000 1,80,000 0 300,000 2,80,000 1,80,000 0 Claim 3 2,40,000 0 0 300,000 1,00,000 0 2,40,000
(All Figures in INR)
13
Platinum plans until 24 months and for all Silver plans
until 48 months of continuous coverage have elapsed
since the inception of the first Policy with Us.
• 90 Days Waiting Period: We will not cover any
treatment taken during the first 90 days since the
commencement of the Policy, unless the treatment
needed is a result of an Accident or Emergency. This
waiting period does not apply for any subsequent and
continuous renewals of Your Policy.
• Specific Waiting Periods: For all Insured Persons
who are above 60 years of age as on the date of
commencement of the first Policy Period, the
conditions listed below will be subject to a waiting
period of 24 months and will be covered in the
third Policy Year as long as the Insured Person has
been insured continuously under the Policy without
any break:
• Stones in the urinary system (eg kidney/bladder); *
Stones in billiary system (eg gallstones);* Cataract;
*BPH - Benign prostatic hypertrophy; *
Mennoraghia, * Fibromyoma, *Uterine prolapse
including any condition requiring Hysterectomy; *
Piles (Haemorrhoids); * Hernia (Inguinal/umbilical
and gastric); * Degenerative disorders of knee/hip;
* Chronicrenal failure or end stage renal failure; *
Retinopathy; * Diabetes and related treatments
• Personal Waiting Periods: There are certain
conditions mentioned in the Schedule of insurance
certificate. These will be subject to a waiting period of
24 months and will be covered in the third Policy Year
as long as the Insured Person has been insured
continuously under the Policy without any break.
These will be applied only on select Insured Person(s)
basis their health condition which is determined only
after conducting medical tests. For example, after
conducting an ECG if the report is not normal than a
personal waiting period for heart disease will be
applied post risk assessment.
• Permanent Exclusions: Addictive conditions and
disorders; Ageing and puberty; Artificial life
maintenance; Circumcision; Conflict and disaster;
Congenital conditions; Convalescence and
rehabilitation; Cosmetic surgery; Dental/oral treatment;
Drugs and dressings for OPD treatment or take-home
use; Unproven/Experimental treatment; Eyesight;
Health hydros, nature cure, wellness clinics etc;
Hereditary conditions (specified); HIV and AIDS; Items
of personal comfort and convenience; alternative
treatment(except for Consultation and Diagnostic Tests
(For Platinum Policyholders only)); Psychiatric and
Psychosomatic conditions; Obesity; OPD treatment;
Reproductive medicine - Birth control and Assisted
reproduction; Self-inflicted injuries; Sexual problems
and gender issues; Sexually transmitted diseases; Sleep
disorders; Speech disorders; Treatment for
developmental problems; Treatment received outside
India(except for treatment undertaken under
“Emergency Medical Evacuation and Hospitalization (for
Platinum Policyholders only)” or “Specified Illness Cover
for treatment abroad (For Platinum Policyholders only)”
of the Policy Document); Unlawful activity;
Unrecognised physician or Hospital, Genetic disorders;
any other such permanent exclusions as may be
specified in the Schedule, any expenses as mentioned
below for hospitalization treatment.
14
43 BED UNDER PAD CHARGES Not Payable 44 CAMERA COVER Not Payable 45 CLINIPLAST Not Payable 46 CREPE BANDAGE Not Payable / Payable by the patient 47 CURAPORE Not Payable 48 DIAPER OF ANY TYPE Not Payable 49 DVD, CD CHARGES Not Payable (However if CD is specifically sought by Insurer / TPA then payable) 50 EYELET COLLAR Not Payable 51 FACE MASK Not Payable 52 FLEXI MASK Not Payable 53 GAUSE SOFT Not Payable 54 GAUZE Not Payable 55 HAND HOLDER Not Payable 56 HANSAPLAST/ADHESIVE Not Payable BANDAGES 57 INFANT FOOD Not Payable 58 SLINGS Reasonable costs for one sling in case of upper arm fractures should be considered
ITEMS SPECIFICALLY EXCLUDED IN THE POLICIES 59 WEIGHT CONTROL PROGRAMS/ Exclusion in policy SUPPLIES/ SERVICES unless otherwise specified 60 COST OF SPECTACLES/ CONTACT Exclusion in policy LENSES/ HEARING AIDS ETC., unless otherwise specified 61 DENTAL TREATMENT EXPENSES Exclusion in policy THAT DO NOT REQUIRE unless otherwise HOSPITALISATION specified 62 HORMONE REPLACEMENT Exclusion in policy THERAPY unless otherwise specified 63 HOME VISIT CHARGES Exclusion in policy unless otherwise specified 64 INFERTILITY/ SUBFERTILITY/ Exclusion in policy ASSISTED CONCEPTION unless otherwise PROCEDURE specified 65 OBESITY (INCLUDING MORBID Exclusion in policy OBESITY) TREATMENT IF unless otherwise EXCLUDED IN POLICY specified 66 PSYCHIATRIC & Exclusion in policy PSYCHOSOMATIC DISORDERS unless otherwise specified67 CORRECTIVE SURGERY FOR Exclusion in policy REFRACTIVE ERROR unless otherwise specified 68 TREATMENT OF SEXUALLY Exclusion in policy TRANSMITTED DISEASES unless otherwise specified 69 DONOR SCREENING CHARGES Exclusion in policy unless otherwise specified 70 ADMISSION/REGISTRATION Exclusion in policy CHARGES unless otherwise specified
LIST OF GENERALLY EXCLUDED IN HOSPITALISATION POLICY S.No. List of Expenses Generally SUGGESTIONS Excluded ("Non-Medical") in Hospital Indemnity Policy -
TOILETRIES / COSMETICS / PERSONAL COMFORT OR CONVENIENCE ITEMS
1 HAIR REMOVAL CREAM Not Payable 2 BABY CHARGES Not Payable (UNLESS SPECIFIED/INDICATED) 3 BABY FOOD Not Payable 4 BABY UTILITES CHARGES Not Payable 5 BABY SET Not Payable 6 BABY BOTTLES Not Payable 7 BRUSH Not Payable 8 COSY TOWEL Not Payable 9 HAND WASH Not Payable 10 MOISTURIZER PASTE BRUSH Not Payable 11 POWDER Not Payable 12 RAZOR Payable 13 SHOE COVER Not Payable 14 BEAUTY SERVICES Not Payable 15 BELTS/ BRACES Essential and may be paid specifically for cases who have undergone surgery of thoracic or lumbar spine. 16 BUDS Not Payable 17 BARBER CHARGES Not Payable 18 CAPS Not Payable 19 COLD PACK/HOT PACK Not Payable 20 CARRY BAGS Not Payable 21 CRADLE CHARGES Not Payable 22 COMB Not Payable 23 DISPOSABLES RAZORS CHARGES Payable (for site preparations) 24 EAU-DE-COLOGNE / Not Payable ROOM FRESHNERS 25 EYE PAD Not Payable 26 EYE SHEILD Not Payable 27 EMAIL / INTERNET CHARGES Not Payable 28 FOOD CHARGES (OTHER THAN Not Payable PATIENT'S DIET PROVIDED BY HOSPITAL) 29 FOOT COVER Not Payable 30 GOWN Not Payable 31 LEGGINGS Essential in bariatric and varicose vein surgery and should be considered for these conditions where surgery itself is payable. 32 LAUNDRY CHARGES Not Payable 33 MINERAL WATER Not Payable 34 OIL CHARGES Not Payable 35 SANITARY PAD Not Payable 36 SLIPPERS Not Payable 37 TELEPHONE CHARGES Not Payable 38 TISSUE PAPER Not Payable 39 TOOTH PASTE Not Payable 40 TOOTH BRUSH Not Payable 41 GUEST SERVICES Not Payable 42 BED PAN Not Payable
15
92 APRON Not Payable -Part of Hospital Services / Disposable linen to be part of OT/ICU charges 93 TORNIQUET Not Payable (service is charged by hospitals, consumables cannot be separately charged) 94 ORTHOBUNDLE, Part of Dressing GYNAEC BUNDLE Charges 95 URINE CONTAINER Not Payable
ELEMENTS OF ROOM CHARGE 96 LUXURY TAX Actual tax levied by government is payable. Part of room charge for sub limits 97 HVAC Part of room charge not payable separately 98 HOUSE KEEPING CHARGES Part of room charge not payable separately 99 SERVICE CHARGES WHERE Part of room charge NURSING CHARGE ALSO not payable separately CHARGED 100 TELEVISION & AIR CONDITIONER Payable under room CHARGES charges not if separately levied 101 SURCHARGES Part of room charge not payable separately 102 ATTENDANT CHARGES Not Payable - Part of Room Charges 103 IM IV INJECTION CHARGES Part of nursing charges, not payable 104 CLEAN SHEET ^ Part of Laundry / Housekeeping not payable separately 105 EXTRA DIET OF PATIENT Patient Diet provided (OTHER THAN THAT WHICH by hospital is payable FORMS PART OF BED CHARGE) 106 BLANKET/WARMER BLANKET Not Payable- part of ADMINISTRATIVE OR room charges NON-MEDICAL CHARGES 107 ADMISSION KIT Not Payable 108 BIRTH CERTIFICATE Not Payable 109 BLOOD RESERVATION CHARGES Not Payable AND ANTE NATAL BOOKING CHARGES 110 CERTIFICATE CHARGES Not Payable 111 COURIER CHARGES Not Payable 112 CONVENYANCE CHARGES Not Payable 113 DIABETIC CHART CHARGES Not Payable 114 DOCUMENTATION CHARGES / Not Payable ADMINISTRATIVE EXPENSES 115 DISCHARGE PROCEDURE Not Payable CHARGES 116 DAILY CHART CHARGES Not Payable 117 ENTRANCE PASS / VISITORS Not Payable PASS CHARGES 118 EXPENSES RELATED TO To be claimed by PRESCRIPTION ON DISCHARGE patient under Post Hosp where admissible
71 HOSPITALISATION FOR EVALUATION/ Exclusion in policy DIAGNOSTIC PURPOSE unless otherwise specified 72 EXPENSES FOR INVESTIGATION/ Not payable - TREATMENT IRRELEVANT TO THE Exclusion in DISEASE FOR WHICH ADMITTED policy unless OR DIAGNOSED otherwise specified73 ANY EXPENSES WHEN THE PATIENT Not payable as IS DIAGNOSED WITH RETRO HIV/AIDS per VIRUS + OR SUFFERING FROM exclusion /HIV/AIDS ETC IS DETECTED/ DIRECTLY OR INDIRECTLY 74 STEM CELL IMPLANTATION/ SURGERY Not Payable except and storage Bone Marrow Transplantation where covered by policy
ITEMS WHICH FORM PART OF HOSPITAL SERVICES WHERE SEPARATE CONSUMABLES ARE NOT PAYABLE BUT THE
SERVICE IS 75 WARD AND THEATRE BOOKING Payable under OT CHARGES Charges, not payable separately 76 ARTHROSCOPY & ENDOSCOPY Rental charged by the INSTRUMENTS hospital payable. Purchase of Instruments not payable. 77 MICROSCOPE COVER Payable under OT Charges, not payable separately 78 SURGICAL BLADES, HARMONIC Payable under OT SCALPEL, SHAVER Charges, not payable separately 79 SURGICAL DRILL Payable under OT Charges, not payable separately 80 EYE KIT Payable under OT Charges, not payable separately 81 EYE DRAPE Payable under OT Charges, not payable separately 82 X-RAY FILM Payable under Radiology Charges, not as consumable 83 SPUTUM CUP Payable under Investigation Charges, not as consumable 84 BOYLES APPARATUS CHARGES Part of OT Charges, not seperately 85 BLOOD GROUPING AND CROSS Part of Cost of Blood, MATCHING OF DONORS SAMPLES not payable 86 Antiseptic or disinfectant lotions Not Payable -Part of Dressing Charges 87 BAND AIDS, BANDAGES, STERLILE Not Payable -Part of INJECTIONS, NEEDLES, SYRINGES Dressing Charges 88 COTTON Not Payable -Part of Dressing Charges 89 COTTON BANDAGE Not Payable -Part of Dressing Charges 90 MICROPORE/ SURGICAL TAPE Not Payable-Payable by the patient when prescribed, otherwise included as Dressing Charges 91 BLADE Not Payable
119 FILE OPENING CHARGES Not Payable 120 INCIDENTAL EXPENSES / MISC. Not Payable CHARGES (NOT EXPLAINED) 121 MEDICAL CERTIFICATE Not Payable 122 MAINTENANCE CHARGES Not Payable 123 MEDICAL RECORDS Not Payable 124 PREPARATION CHARGES Not Payable 125 PHOTOCOPIES CHARGES Not Payable 126 PATIENT IDENTIFICATION BAND / Not Payable NAME TAG 127 WASHING CHARGES Not Payable 128 MEDICINE BOX Not Payable 129 MORTUARY CHARGES Payable upto 24 hrs, shifting charges not payable 130 MEDICO LEGAL CASE CHARGES Not Payable (MLC CHARGES)
EXTERNAL DURABLE DEVICES 131 WALKING AIDS CHARGES Not Payable 132 BIPAP MACHINE Not Payable 133 COMMODE Not Payable 134 CPAP/ CAPD EQUIPMENTS Device Not Payable 135 INFUSION PUMP - COST Device Not Payable 136 OXYGEN CYLINDER (FOR USAGE Not Payable OUTSIDE THE HOSPITAL) 137 PULSEOXYMETER CHARGES Device Not Payable 138 SPACER Not Payable 139 SPIROMETRE Device Not Payable 140 SP0 2PROB E Not Payable 141 NEBULIZER KIT Not Payable 142 STEAM INHALER Not Payable 143 ARMSLING Not Payable 144 THERMOMETER Not Payable (paid by patient) 145 CERVICAL COLLAR Not Payable 146 SPLINT Not Payable 147 DIABETIC FOOT WEAR Not Payable 148 KNEE BRACES ( LONG/ SHORT/ Not Payable HINGED) 149 KNEE IMMOBILIZER/SHOULDER Not Payable MMOBILIZER 150 LUMBOSACRAL BELT Essential and should be paid specifically for cases who have undergone surgery of lumbar spine. 151 NIMBUS BED OR WATER OR Payable for any ICU AIR BED CHARGES patient requiring more than 3 days in ICU, all patients with paraplegia /quadriplegia for any reason and at reasonable cost of approximately Rs. 200/- day 152 AMBULANCE COLLAR Not Payable 153 AMBULANCE EQUIPMENT Not Payable 154 MICROSHEILD Not Payable 155 ABDOMINAL BINDER Essential and should be paid in post surgery patients of major abdominal surgery including TAH,
LSCS, incisional hernia repair, exploratory laparotomy for intestinal obstruction, liver transplant etc.
ITEMS PAYABLE IF SUPPORTED BY A PRESCRIPTION 156 BETADINE\HYDROGEN PEROXIDE\ May be payable when SPIRIT\DISINFECTANTS ETC prescribed for patient, not payable for hospital use in OT or ward or for dressings in hospital 157 PRIVATE NURSES CHARGES- Post hospitalization SPECIAL NURSING CHARGES nursing charges not Payable 158 NUTRITION PLANNING CHARGES- Patient Diet provided DIETICIAN CHARGES DIET by hospital is payable CHARGES 159 SUGAR FREE Tablets Payable -Sugar free variants of admissable medicines are not excluded 160 CREAMS POWDERS LOTIONS Payable when prescribed (Toileteries are not payable, only prescribed medical pharmaceuticals payable) 161 Digestion gels Payable when prescribed 162 ECG ELECTRODES Upto 5 electrodes are required for every case visiting OT o r ICU. For longer stay in ICU, may require a change and at least one set every second day must be payable. 163 GLOVES Sterilized Gloves Payable /unsterilized gloves not payable 164 HIV KIT Payable - payable Pre operative screening 165 LISTERINE/ ANTISEPTIC Payable when MOUTHWASH prescribed 166 LOZENGES Payable when prescribed 167 MOUTH PAINT Payable when prescribed 168 NEBULISATION KIT If used during hospitalization is payable reasonably 169 NOVARAPID Payable when prescribed 170 VOLINI GEL/ ANALGESIC GEL Payable when prescribed 171 ZYTEE GEL Payable when prescribed 172 VACCINATION CHARGES Routine Vaccination not Payable / Post Bite Vaccination Payable
PART OF HOSPITAL'S OWN COSTS AND NOT PAYABLE 173 AHD Not Payable - Part of Hospital's internal Cost 174 ALCOHOL SWABES Not Payable - Part of
Hospital's internal Cost 175 SCRUB SOLUTION/STERILLIUM Not Payable - Part of Hospital's internal Cost
OTHERS 176 VACCINE CHARGES FOR BABY Payable as per plan 177 AESTHETIC TREATMENT/SURGERY Not Payable 178 TPA CHARGES Not Payable 179 VISCO BELT CHARGES Not Payable 180 ANY KIT WITH NO DETAILS Not Payable MENTIONED [DELIVERY KIT, ORTHOKIT, RECOVERY KIT, ETC] 181 EXAMINATION GLOVES Not Payable 182 KIDNEY TRAY Not Payable 183 MASK Not Payable 184 OUNCE GLASS Not Payable 185 OUTSTATION CONSULTANT'S/ Not payable, except SURGEON'S FEES for telemedicine consultations where covered by policy 186 OXYGEN MASK Not Payable 187 PAPER GLOVES Not Payable 188 PELVIC TRACTION BELT Should be payable in case of PIVI) requiring traction as this is generally not reused 189 REFERAL DOCTOR'S FEES Not Payable 190 ACCU CHECK (Glucometery / Strips) Not payable pre hospitilasation or post hospitalisation / Reports and Charts required / Device not payable
191 PAN CAN Not Payable 192 SOFNET Not Payable 193 TROLLY COVER Not Payable 194 UROMETER, URINE JUG Not Payable 195 AMBULANCE Payable-Ambulance from home to hospital or interhospital shifts is payable/ RTA as specific requirement is payable 196 TEGADERM / VASOFIX SAFETY Payable - maximum of 3 in 48 hrs and then 1 in 24 hrs 197 URINE BAG P Payable where medicaly necessary till a reasonable cost - maximum 1 per 24hrs 198 SOFTOVAC Not Payable 199 STOCKINGS Essential for case like CABG etc. where it should be paid.
16
92 APRON Not Payable -Part of Hospital Services / Disposable linen to be part of OT/ICU charges 93 TORNIQUET Not Payable (service is charged by hospitals, consumables cannot be separately charged) 94 ORTHOBUNDLE, Part of Dressing GYNAEC BUNDLE Charges 95 URINE CONTAINER Not Payable
ELEMENTS OF ROOM CHARGE 96 LUXURY TAX Actual tax levied by government is payable. Part of room charge for sub limits 97 HVAC Part of room charge not payable separately 98 HOUSE KEEPING CHARGES Part of room charge not payable separately 99 SERVICE CHARGES WHERE Part of room charge NURSING CHARGE ALSO not payable separately CHARGED 100 TELEVISION & AIR CONDITIONER Payable under room CHARGES charges not if separately levied 101 SURCHARGES Part of room charge not payable separately 102 ATTENDANT CHARGES Not Payable - Part of Room Charges 103 IM IV INJECTION CHARGES Part of nursing charges, not payable 104 CLEAN SHEET ^ Part of Laundry / Housekeeping not payable separately 105 EXTRA DIET OF PATIENT Patient Diet provided (OTHER THAN THAT WHICH by hospital is payable FORMS PART OF BED CHARGE) 106 BLANKET/WARMER BLANKET Not Payable- part of ADMINISTRATIVE OR room charges NON-MEDICAL CHARGES 107 ADMISSION KIT Not Payable 108 BIRTH CERTIFICATE Not Payable 109 BLOOD RESERVATION CHARGES Not Payable AND ANTE NATAL BOOKING CHARGES 110 CERTIFICATE CHARGES Not Payable 111 COURIER CHARGES Not Payable 112 CONVENYANCE CHARGES Not Payable 113 DIABETIC CHART CHARGES Not Payable 114 DOCUMENTATION CHARGES / Not Payable ADMINISTRATIVE EXPENSES 115 DISCHARGE PROCEDURE Not Payable CHARGES 116 DAILY CHART CHARGES Not Payable 117 ENTRANCE PASS / VISITORS Not Payable PASS CHARGES 118 EXPENSES RELATED TO To be claimed by PRESCRIPTION ON DISCHARGE patient under Post Hosp where admissible
71 HOSPITALISATION FOR EVALUATION/ Exclusion in policy DIAGNOSTIC PURPOSE unless otherwise specified 72 EXPENSES FOR INVESTIGATION/ Not payable - TREATMENT IRRELEVANT TO THE Exclusion in DISEASE FOR WHICH ADMITTED policy unless OR DIAGNOSED otherwise specified73 ANY EXPENSES WHEN THE PATIENT Not payable as IS DIAGNOSED WITH RETRO HIV/AIDS per VIRUS + OR SUFFERING FROM exclusion /HIV/AIDS ETC IS DETECTED/ DIRECTLY OR INDIRECTLY 74 STEM CELL IMPLANTATION/ SURGERY Not Payable except and storage Bone Marrow Transplantation where covered by policy
ITEMS WHICH FORM PART OF HOSPITAL SERVICES WHERE SEPARATE CONSUMABLES ARE NOT PAYABLE BUT THE
SERVICE IS 75 WARD AND THEATRE BOOKING Payable under OT CHARGES Charges, not payable separately 76 ARTHROSCOPY & ENDOSCOPY Rental charged by the INSTRUMENTS hospital payable. Purchase of Instruments not payable. 77 MICROSCOPE COVER Payable under OT Charges, not payable separately 78 SURGICAL BLADES, HARMONIC Payable under OT SCALPEL, SHAVER Charges, not payable separately 79 SURGICAL DRILL Payable under OT Charges, not payable separately 80 EYE KIT Payable under OT Charges, not payable separately 81 EYE DRAPE Payable under OT Charges, not payable separately 82 X-RAY FILM Payable under Radiology Charges, not as consumable 83 SPUTUM CUP Payable under Investigation Charges, not as consumable 84 BOYLES APPARATUS CHARGES Part of OT Charges, not seperately 85 BLOOD GROUPING AND CROSS Part of Cost of Blood, MATCHING OF DONORS SAMPLES not payable 86 Antiseptic or disinfectant lotions Not Payable -Part of Dressing Charges 87 BAND AIDS, BANDAGES, STERLILE Not Payable -Part of INJECTIONS, NEEDLES, SYRINGES Dressing Charges 88 COTTON Not Payable -Part of Dressing Charges 89 COTTON BANDAGE Not Payable -Part of Dressing Charges 90 MICROPORE/ SURGICAL TAPE Not Payable-Payable by the patient when prescribed, otherwise included as Dressing Charges 91 BLADE Not Payable
119 FILE OPENING CHARGES Not Payable 120 INCIDENTAL EXPENSES / MISC. Not Payable CHARGES (NOT EXPLAINED) 121 MEDICAL CERTIFICATE Not Payable 122 MAINTENANCE CHARGES Not Payable 123 MEDICAL RECORDS Not Payable 124 PREPARATION CHARGES Not Payable 125 PHOTOCOPIES CHARGES Not Payable 126 PATIENT IDENTIFICATION BAND / Not Payable NAME TAG 127 WASHING CHARGES Not Payable 128 MEDICINE BOX Not Payable 129 MORTUARY CHARGES Payable upto 24 hrs, shifting charges not payable 130 MEDICO LEGAL CASE CHARGES Not Payable (MLC CHARGES)
EXTERNAL DURABLE DEVICES 131 WALKING AIDS CHARGES Not Payable 132 BIPAP MACHINE Not Payable 133 COMMODE Not Payable 134 CPAP/ CAPD EQUIPMENTS Device Not Payable 135 INFUSION PUMP - COST Device Not Payable 136 OXYGEN CYLINDER (FOR USAGE Not Payable OUTSIDE THE HOSPITAL) 137 PULSEOXYMETER CHARGES Device Not Payable 138 SPACER Not Payable 139 SPIROMETRE Device Not Payable 140 SP0 2PROB E Not Payable 141 NEBULIZER KIT Not Payable 142 STEAM INHALER Not Payable 143 ARMSLING Not Payable 144 THERMOMETER Not Payable (paid by patient) 145 CERVICAL COLLAR Not Payable 146 SPLINT Not Payable 147 DIABETIC FOOT WEAR Not Payable 148 KNEE BRACES ( LONG/ SHORT/ Not Payable HINGED) 149 KNEE IMMOBILIZER/SHOULDER Not Payable MMOBILIZER 150 LUMBOSACRAL BELT Essential and should be paid specifically for cases who have undergone surgery of lumbar spine. 151 NIMBUS BED OR WATER OR Payable for any ICU AIR BED CHARGES patient requiring more than 3 days in ICU, all patients with paraplegia /quadriplegia for any reason and at reasonable cost of approximately Rs. 200/- day 152 AMBULANCE COLLAR Not Payable 153 AMBULANCE EQUIPMENT Not Payable 154 MICROSHEILD Not Payable 155 ABDOMINAL BINDER Essential and should be paid in post surgery patients of major abdominal surgery including TAH,
LSCS, incisional hernia repair, exploratory laparotomy for intestinal obstruction, liver transplant etc.
ITEMS PAYABLE IF SUPPORTED BY A PRESCRIPTION 156 BETADINE\HYDROGEN PEROXIDE\ May be payable when SPIRIT\DISINFECTANTS ETC prescribed for patient, not payable for hospital use in OT or ward or for dressings in hospital 157 PRIVATE NURSES CHARGES- Post hospitalization SPECIAL NURSING CHARGES nursing charges not Payable 158 NUTRITION PLANNING CHARGES- Patient Diet provided DIETICIAN CHARGES DIET by hospital is payable CHARGES 159 SUGAR FREE Tablets Payable -Sugar free variants of admissable medicines are not excluded 160 CREAMS POWDERS LOTIONS Payable when prescribed (Toileteries are not payable, only prescribed medical pharmaceuticals payable) 161 Digestion gels Payable when prescribed 162 ECG ELECTRODES Upto 5 electrodes are required for every case visiting OT o r ICU. For longer stay in ICU, may require a change and at least one set every second day must be payable. 163 GLOVES Sterilized Gloves Payable /unsterilized gloves not payable 164 HIV KIT Payable - payable Pre operative screening 165 LISTERINE/ ANTISEPTIC Payable when MOUTHWASH prescribed 166 LOZENGES Payable when prescribed 167 MOUTH PAINT Payable when prescribed 168 NEBULISATION KIT If used during hospitalization is payable reasonably 169 NOVARAPID Payable when prescribed 170 VOLINI GEL/ ANALGESIC GEL Payable when prescribed 171 ZYTEE GEL Payable when prescribed 172 VACCINATION CHARGES Routine Vaccination not Payable / Post Bite Vaccination Payable
PART OF HOSPITAL'S OWN COSTS AND NOT PAYABLE 173 AHD Not Payable - Part of Hospital's internal Cost 174 ALCOHOL SWABES Not Payable - Part of
Hospital's internal Cost 175 SCRUB SOLUTION/STERILLIUM Not Payable - Part of Hospital's internal Cost
OTHERS 176 VACCINE CHARGES FOR BABY Payable as per plan 177 AESTHETIC TREATMENT/SURGERY Not Payable 178 TPA CHARGES Not Payable 179 VISCO BELT CHARGES Not Payable 180 ANY KIT WITH NO DETAILS Not Payable MENTIONED [DELIVERY KIT, ORTHOKIT, RECOVERY KIT, ETC] 181 EXAMINATION GLOVES Not Payable 182 KIDNEY TRAY Not Payable 183 MASK Not Payable 184 OUNCE GLASS Not Payable 185 OUTSTATION CONSULTANT'S/ Not payable, except SURGEON'S FEES for telemedicine consultations where covered by policy 186 OXYGEN MASK Not Payable 187 PAPER GLOVES Not Payable 188 PELVIC TRACTION BELT Should be payable in case of PIVI) requiring traction as this is generally not reused 189 REFERAL DOCTOR'S FEES Not Payable 190 ACCU CHECK (Glucometery / Strips) Not payable pre hospitilasation or post hospitalisation / Reports and Charts required / Device not payable
191 PAN CAN Not Payable 192 SOFNET Not Payable 193 TROLLY COVER Not Payable 194 UROMETER, URINE JUG Not Payable 195 AMBULANCE Payable-Ambulance from home to hospital or interhospital shifts is payable/ RTA as specific requirement is payable 196 TEGADERM / VASOFIX SAFETY Payable - maximum of 3 in 48 hrs and then 1 in 24 hrs 197 URINE BAG P Payable where medicaly necessary till a reasonable cost - maximum 1 per 24hrs 198 SOFTOVAC Not Payable 199 STOCKINGS Essential for case like CABG etc. where it should be paid.
92 APRON Not Payable -Part of Hospital Services / Disposable linen to be part of OT/ICU charges 93 TORNIQUET Not Payable (service is charged by hospitals, consumables cannot be separately charged) 94 ORTHOBUNDLE, Part of Dressing GYNAEC BUNDLE Charges 95 URINE CONTAINER Not Payable
ELEMENTS OF ROOM CHARGE 96 LUXURY TAX Actual tax levied by government is payable. Part of room charge for sub limits 97 HVAC Part of room charge not payable separately 98 HOUSE KEEPING CHARGES Part of room charge not payable separately 99 SERVICE CHARGES WHERE Part of room charge NURSING CHARGE ALSO not payable separately CHARGED 100 TELEVISION & AIR CONDITIONER Payable under room CHARGES charges not if separately levied 101 SURCHARGES Part of room charge not payable separately 102 ATTENDANT CHARGES Not Payable - Part of Room Charges 103 IM IV INJECTION CHARGES Part of nursing charges, not payable 104 CLEAN SHEET ^ Part of Laundry / Housekeeping not payable separately 105 EXTRA DIET OF PATIENT Patient Diet provided (OTHER THAN THAT WHICH by hospital is payable FORMS PART OF BED CHARGE) 106 BLANKET/WARMER BLANKET Not Payable- part of ADMINISTRATIVE OR room charges NON-MEDICAL CHARGES 107 ADMISSION KIT Not Payable 108 BIRTH CERTIFICATE Not Payable 109 BLOOD RESERVATION CHARGES Not Payable AND ANTE NATAL BOOKING CHARGES 110 CERTIFICATE CHARGES Not Payable 111 COURIER CHARGES Not Payable 112 CONVENYANCE CHARGES Not Payable 113 DIABETIC CHART CHARGES Not Payable 114 DOCUMENTATION CHARGES / Not Payable ADMINISTRATIVE EXPENSES 115 DISCHARGE PROCEDURE Not Payable CHARGES 116 DAILY CHART CHARGES Not Payable 117 ENTRANCE PASS / VISITORS Not Payable PASS CHARGES 118 EXPENSES RELATED TO To be claimed by PRESCRIPTION ON DISCHARGE patient under Post Hosp where admissible
71 HOSPITALISATION FOR EVALUATION/ Exclusion in policy DIAGNOSTIC PURPOSE unless otherwise specified 72 EXPENSES FOR INVESTIGATION/ Not payable - TREATMENT IRRELEVANT TO THE Exclusion in DISEASE FOR WHICH ADMITTED policy unless OR DIAGNOSED otherwise specified73 ANY EXPENSES WHEN THE PATIENT Not payable as IS DIAGNOSED WITH RETRO HIV/AIDS per VIRUS + OR SUFFERING FROM exclusion /HIV/AIDS ETC IS DETECTED/ DIRECTLY OR INDIRECTLY 74 STEM CELL IMPLANTATION/ SURGERY Not Payable except and storage Bone Marrow Transplantation where covered by policy
ITEMS WHICH FORM PART OF HOSPITAL SERVICES WHERE SEPARATE CONSUMABLES ARE NOT PAYABLE BUT THE
SERVICE IS 75 WARD AND THEATRE BOOKING Payable under OT CHARGES Charges, not payable separately 76 ARTHROSCOPY & ENDOSCOPY Rental charged by the INSTRUMENTS hospital payable. Purchase of Instruments not payable. 77 MICROSCOPE COVER Payable under OT Charges, not payable separately 78 SURGICAL BLADES, HARMONIC Payable under OT SCALPEL, SHAVER Charges, not payable separately 79 SURGICAL DRILL Payable under OT Charges, not payable separately 80 EYE KIT Payable under OT Charges, not payable separately 81 EYE DRAPE Payable under OT Charges, not payable separately 82 X-RAY FILM Payable under Radiology Charges, not as consumable 83 SPUTUM CUP Payable under Investigation Charges, not as consumable 84 BOYLES APPARATUS CHARGES Part of OT Charges, not seperately 85 BLOOD GROUPING AND CROSS Part of Cost of Blood, MATCHING OF DONORS SAMPLES not payable 86 Antiseptic or disinfectant lotions Not Payable -Part of Dressing Charges 87 BAND AIDS, BANDAGES, STERLILE Not Payable -Part of INJECTIONS, NEEDLES, SYRINGES Dressing Charges 88 COTTON Not Payable -Part of Dressing Charges 89 COTTON BANDAGE Not Payable -Part of Dressing Charges 90 MICROPORE/ SURGICAL TAPE Not Payable-Payable by the patient when prescribed, otherwise included as Dressing Charges 91 BLADE Not Payable
119 FILE OPENING CHARGES Not Payable 120 INCIDENTAL EXPENSES / MISC. Not Payable CHARGES (NOT EXPLAINED) 121 MEDICAL CERTIFICATE Not Payable 122 MAINTENANCE CHARGES Not Payable 123 MEDICAL RECORDS Not Payable 124 PREPARATION CHARGES Not Payable 125 PHOTOCOPIES CHARGES Not Payable 126 PATIENT IDENTIFICATION BAND / Not Payable NAME TAG 127 WASHING CHARGES Not Payable 128 MEDICINE BOX Not Payable 129 MORTUARY CHARGES Payable upto 24 hrs, shifting charges not payable 130 MEDICO LEGAL CASE CHARGES Not Payable (MLC CHARGES)
EXTERNAL DURABLE DEVICES 131 WALKING AIDS CHARGES Not Payable 132 BIPAP MACHINE Not Payable 133 COMMODE Not Payable 134 CPAP/ CAPD EQUIPMENTS Device Not Payable 135 INFUSION PUMP - COST Device Not Payable 136 OXYGEN CYLINDER (FOR USAGE Not Payable OUTSIDE THE HOSPITAL) 137 PULSEOXYMETER CHARGES Device Not Payable 138 SPACER Not Payable 139 SPIROMETRE Device Not Payable 140 SP0 2PROB E Not Payable 141 NEBULIZER KIT Not Payable 142 STEAM INHALER Not Payable 143 ARMSLING Not Payable 144 THERMOMETER Not Payable (paid by patient) 145 CERVICAL COLLAR Not Payable 146 SPLINT Not Payable 147 DIABETIC FOOT WEAR Not Payable 148 KNEE BRACES ( LONG/ SHORT/ Not Payable HINGED) 149 KNEE IMMOBILIZER/SHOULDER Not Payable MMOBILIZER 150 LUMBOSACRAL BELT Essential and should be paid specifically for cases who have undergone surgery of lumbar spine. 151 NIMBUS BED OR WATER OR Payable for any ICU AIR BED CHARGES patient requiring more than 3 days in ICU, all patients with paraplegia /quadriplegia for any reason and at reasonable cost of approximately Rs. 200/- day 152 AMBULANCE COLLAR Not Payable 153 AMBULANCE EQUIPMENT Not Payable 154 MICROSHEILD Not Payable 155 ABDOMINAL BINDER Essential and should be paid in post surgery patients of major abdominal surgery including TAH,
LSCS, incisional hernia repair, exploratory laparotomy for intestinal obstruction, liver transplant etc.
ITEMS PAYABLE IF SUPPORTED BY A PRESCRIPTION 156 BETADINE\HYDROGEN PEROXIDE\ May be payable when SPIRIT\DISINFECTANTS ETC prescribed for patient, not payable for hospital use in OT or ward or for dressings in hospital 157 PRIVATE NURSES CHARGES- Post hospitalization SPECIAL NURSING CHARGES nursing charges not Payable 158 NUTRITION PLANNING CHARGES- Patient Diet provided DIETICIAN CHARGES DIET by hospital is payable CHARGES 159 SUGAR FREE Tablets Payable -Sugar free variants of admissable medicines are not excluded 160 CREAMS POWDERS LOTIONS Payable when prescribed (Toileteries are not payable, only prescribed medical pharmaceuticals payable) 161 Digestion gels Payable when prescribed 162 ECG ELECTRODES Upto 5 electrodes are required for every case visiting OT o r ICU. For longer stay in ICU, may require a change and at least one set every second day must be payable. 163 GLOVES Sterilized Gloves Payable /unsterilized gloves not payable 164 HIV KIT Payable - payable Pre operative screening 165 LISTERINE/ ANTISEPTIC Payable when MOUTHWASH prescribed 166 LOZENGES Payable when prescribed 167 MOUTH PAINT Payable when prescribed 168 NEBULISATION KIT If used during hospitalization is payable reasonably 169 NOVARAPID Payable when prescribed 170 VOLINI GEL/ ANALGESIC GEL Payable when prescribed 171 ZYTEE GEL Payable when prescribed 172 VACCINATION CHARGES Routine Vaccination not Payable / Post Bite Vaccination Payable
PART OF HOSPITAL'S OWN COSTS AND NOT PAYABLE 173 AHD Not Payable - Part of Hospital's internal Cost 174 ALCOHOL SWABES Not Payable - Part of
Free Look & Cancellation:
1. Free Look Provision: You have a period of 15 days
from the date of receipt of the Policy document to
review the terms and conditions of this Policy. If You
have any objections to any of the terms and
conditions, You may cancel the Policy stating the
reasons for cancellation and provided that no claims
have been made under the Policy, We will refund the
premium paid by You after deducting the amounts
spent on stamp duty charges and proportionate risk
premium for the period on cover. All rights and
benefits under this Policy shall immediately stand
extinguished on the free look cancellation of the
Policy. The free look provision is not applicable and
available at the time of Renewal of the Policy.
2. Cancellation/Termination (other than Free
Look cancellation): You may terminate this Policy by
giving 7 days’ prior written notice to us. We shall
cancel the Policy and refund the premium for the
balance of the Policy Period as per the table below,
provided that no claim has been filed under the Policy
by or on behalf of any Insured Person:
Length of time Policy in force Refund of
premium
up to 30 days 75%
up to 90 days 50%
up to 180 days 25%
exceeding 180 days 0%
Without prejudice to the above, We may terminate
this Policy during the Policy Period by sending 30 days
prior written notice to Your address shown in the
Schedule of Insurance Certificate without refund of
premium if:
a) You or Any Insured Person or any person acting
on behalf of either has acted in a dishonest and
fraudulent manner, under or in relation to this Policy
b) You or any Insured Person has not disclosed the
Hospital's internal Cost 175 SCRUB SOLUTION/STERILLIUM Not Payable - Part of Hospital's internal Cost
OTHERS 176 VACCINE CHARGES FOR BABY Payable as per plan 177 AESTHETIC TREATMENT/SURGERY Not Payable 178 TPA CHARGES Not Payable 179 VISCO BELT CHARGES Not Payable 180 ANY KIT WITH NO DETAILS Not Payable MENTIONED [DELIVERY KIT, ORTHOKIT, RECOVERY KIT, ETC] 181 EXAMINATION GLOVES Not Payable 182 KIDNEY TRAY Not Payable 183 MASK Not Payable 184 OUNCE GLASS Not Payable 185 OUTSTATION CONSULTANT'S/ Not payable, except SURGEON'S FEES for telemedicine consultations where covered by policy 186 OXYGEN MASK Not Payable 187 PAPER GLOVES Not Payable 188 PELVIC TRACTION BELT Should be payable in case of PIVI) requiring traction as this is generally not reused 189 REFERAL DOCTOR'S FEES Not Payable 190 ACCU CHECK (Glucometery / Strips) Not payable pre hospitilasation or post hospitalisation / Reports and Charts required / Device not payable
191 PAN CAN Not Payable 192 SOFNET Not Payable 193 TROLLY COVER Not Payable 194 UROMETER, URINE JUG Not Payable 195 AMBULANCE Payable-Ambulance from home to hospital or interhospital shifts is payable/ RTA as specific requirement is payable 196 TEGADERM / VASOFIX SAFETY Payable - maximum of 3 in 48 hrs and then 1 in 24 hrs 197 URINE BAG P Payable where medicaly necessary till a reasonable cost - maximum 1 per 24hrs 198 SOFTOVAC Not Payable 199 STOCKINGS Essential for case like CABG etc. where it should be paid.
17
18
material facts or misrepresented in relation to the
Policy; and/or
c) You or any Insured Person has not co-operated
with Us.
For avoidance of doubt, it is clarified that no claims
shall be admitted and/or paid during the notice period
by Us in relation to the Policy.
The Policy will be automatically terminated in the
following circumstances:
a. Individual Policy:
The Policy shall automatically terminate in the event of
death of the Insured Person.
b. Family Floater Policy:
The Policy shall automatically terminate in the event of
death of all the Insured Persons.
c. Refund:
Refund as per table above under
cancellation/termination shall be payable in case of an
automatic cancellation of the Policy provided that no
claim has been filed under the Policy by or on behalf of
any Insured Person.
Portability Benefit
From another company to Our Policy
If the proposed Insured Person was insured
continuously and without a break under another
Indian retail health insurance policy with any other
Indian Insurance company, the customer can avail the
portability benefit provided they have submitted the
application with complete documentation 21 days
before the expiry of their present period of Insurance,
at the time of renewal. The benefit will be available up
to the existing cover. If the Sum Insured is more than
that of the last issued policy, waiting periods will be
applied on the increased Sum Insured amount.
This benefit shall be applied by Us within 45 days of
receiving Your completed Application and Portability
Form and is is subject to submission of all
information/documentation requested, payment of
premium in full and case acceptance is subject to
medical underwriting. We would also need the
database and claim history from the previous
insurance company for review. No additional loading
or charges shall be applied by Us exclusively for
porting the policy.
From Our existing health insurance policies to this
Policy
If the proposed Insured Person was insured
continuously and without a break under another
health insurance policy with Us, they can port to
another policy at the time of renewal, provided the
application and completed Portability Form is received
before the expiry of the present period of insurance.
The benefit will be available only up to the existing
sum insured, and waiting periods will apply on any
additional sum insured. The terms and conditions of
acceptance of a portability application remain the
same as above
The portability benefit guidelines may be modified by
us from time to time depending on the guidance
issued by the Insurance Regulatory and Development
Authority as amended from time to time.
Notification
You will inform Us immediately of any change in the
address, nature of job, state of health, or of any other
changes affecting You or any Insured Person through
the format Annexure A.
We shall allow the enhancement in Sum Assured or
scope of cover only at the time of Renewal, provided
You intimate Us at the time of Renewal. The decision
of acceptance of enhancement of the sum insured or
the scope of cover will be based on our underwriting
policy and shall be subject to payment of applicable
premium for such enhanced cover.
Renewal Information:
Renewal Premium: The renewal premium is payable
on or before the due date as shown in the Schedule.
The premium may change on renewal and will be
notified by Us before completing the Policy Period. The
19
amount of premium is dependent on the age of the
Insured Person and the geographical locations. The
reference of age for calculating the premium for Family
Floater Policies shall be the age of the eldest Insured
Person, and for Family First policies it shall be the
individual age of each Insured Person of the Family.
There will not be any loading at the time of Renewal on
individual claims experience of the Insured Person.
We will allow a grace period of 30 days from the due
date of the renewal premium for payment to us. If the
Policy is not renewed within the grace period then we
may issue a fresh policy subject to Our underwriting
criteria but any new policy issued shall not benefit
from any of the continuity benefits (for example for
Pre-Existing Conditions). Renewal of the Policy will not
ordinarily be denied other than on grounds of moral
hazard, misrepresentation and fraud. Please note that
coverage is not available for the period for which no
premium is received.
For avoidance of doubt, it is clarified that no claims
shall be admitted and/or paid during the Grace period
by Us in relation to the Policy.
2. Waiting Period: The Waiting Periods mentioned in
the policy wording will get reduced by 1 year (2 years
if the expiring policy has a 2 year policy tenure) with
every continuous renewal of your Heartbeat Health
Insurance Policy.
3. This is a life-long renewal product unless the
Insured Person or anyone acting on behalf of an
Insured Person has acted in a dishonest or fraudulent
manner or has misrepresented under or in relation to
this policy or the Policy poses a moral hazard.
4. Maximum Age: There is no maximum coverage
ceasing age in this policy
5. No underwriting on renewal: There will be no
underwriting on policy renewal, without break. The
first year underwriting results will continue to apply
and carry forward.
6. Change in the coverage of the policy including
Sum Insured or additional members in Family Floater
and Family First policies, can be applied for at the time
of renewal. These changes shall be accepted subject to
the renewal terms and as per our underwriting policy.
Obligations in case of a minor
If an Insured Person is less than 18 years of age, the
proposer/adult Insured Person shall be completely
responsible for ensuring compliance with all the terms
and conditions of this Policy on behalf of that minor
Insured Person.
Claims Procedure(Does not apply to Emergency
Medical Evacuation and Hospitalization and
Specified Illness Cover for treatment abroad)
• Cashless Hospitalization Facility for Network
Hospitals: We will provide cashless hospitalization
facility at our network hospitals. We pre-authorise all
cashless in-patient and day care procedure, if
intimated to us in writing 72 hours before
hospitalization (andwithin 48 hours after
hospitalization for emergency). Under cashless
Hospitalization, claims are paid directly to the Network
Hospital and the treatment must take place within 15
days of pre-authorization.
• Out Of Network Hospitals & All Other Claims for
Reimbursement: We will reimburse expenses incurred
outside network hospitals or cases where
pre-authorisation has not been done within the
network hospitals. However, we must be notified in
writing within 48 hours of admission to the hospital,
ideally by the Policy holder/insured person or if
unable, by any immediate adult of the family. All
claims will be adjudicated within 30 days after the
occurrence of the event and further submission of
necessary documents by the Insured Person. To claim
re-imbursements for any Illness or Accident or medical
condition that requires Hospitalization, the Insured
Person should provideus the documents listed below,
within 30 days of the Insured Person's discharge from
Hospital:
(1) Claim form duly completed and signed by the Customer.
(2) Cancelled Cheque
20
(3) Self attested copy of valid age proof (Passport /
Driving License / PAN card / class X certificate / Birth
certificate)
(4) Self attested copy of identity proof (Passport /
Driving License / PAN card / Voters identity card)
(5) Original Discharge summary
(6) Original final bill from Hospital with detailed
break-up and paid receipt.
(7) Original bills of medicines purchased, or of any
other investigation done outside hospital with reports
and requisite prescriptions. .
(8) Invoice of major accessories in case billed and
utilized during treatment (if not included in the final
hospital bill).
(9) For Medicolegal cases (MLC/FIR copy attested by
the concerned hospital / police station (if applicable).
(10) Original self-narration of incident in absence of
MLC / FIR.
(11) Original first consultation paper (in case
disease is first time diagnosed).
(12) Original Laboratory Investigation reports.
(13) Original X-Ray/ MRI / Ultrasound films and
other Radiological investigations
(14) Indoor case paper/OT notes (if required)
- Details of any other insurance policy that may
respond to the claim.
We might request for any other documents or
information that we believe may be required;
• For any medical treatment taken from an
Non-Network Hospital we will pay Reasonable charges
towards medical expenses.
• You are also advised to refer to the list of
unrecognized hospitals, which is available at our
website (www.maxbupa.com).
Nomination Facility: You are mandatorily required at
the inception of the Policy, to make a nomination for
the purpose of payment of claims.
Withdrawal of Product
This product may be withdrawn post receiving prior
approval from Insurance Regulatory and Development
Authority or due to a change in regulations. In such a
case We will provide You an option to migrate to our
other suitable retail product as available with Us.
Revision or Modification
Max Bupa in future may revise or modify this product
post clearance of the authority basis the guidelines
issued by them. We will notify You of any such change
atleast 3 months prior to the date when such revision
or modification will come into effect.
Premium:
• Premium is dependent on age of the insured
and 3 geographical zones.
• Annual premium in INR (excluding service tax
and applicable cess) as per rate tables.
Disclosure:
• All customers’ personal information collected
or held by Max Bupa may be used by Max Bupa for
processing the claims and analysis related to
insurance / reinsurance business.
Product Benefits Tables
Attached as Annexure
How to Buy Max Bupa Policy
The Max Bupa policy is sold, through various channels
like internal telesales team, Max Bupa direct sales
person or independent advisor, our website
www.Maxbupa.com, licensed brokers, agents and any
other channels approved by IRDA.
Sum Insured
(Rs)
Premiums applicable for different ages for a standard healthy life (Rs. per annum) For 25 years
For 30 years
For 40 years
For 50 years
For 60 years
For 65 years
For 70 years
200,000 (Min)
3,204 3,366 4,235 7,340 12,042 16,166 21,103
10000000 (Max)
52,319 53,273 62,955 80,729 105,306 128,410 162,028
21
1. Every Customer will be assigned a unique customer
identification number on the Max Bupa system
2. A Max Bupa proposal form is completed. The
Customer will be required to provide;
• Insureds’ name, date of birth, and address, as well
as proof of ID as necessary.
• As above for all dependants to be covered by the policy.
• Selection of Heartbeat product and sum insured
• Any existing health insurance policy details and
claims history, if applicable.
• Disclosure of any pre-existing medical conditions
with details.
• Medical history report for the proposed insured, if
necessary.
• Height, weight and BMI for the proposed insured.
• Signature and date on application, wherever applicable.
• Premium payment collected and receipted
3. An underwriting process will be followed for every
proposal form submitted, regardless of the distribution
channel.
Checks are made internally to ensure four key
questions in the proposal form are completed, viz;
• Within the last 2 years have you consulted a
doctor or healthcare professional?
• Within the last 7 years have you been to a hospital
for an operation and/or an investigation (e.g. scan,
x-ray, biopsy or blood tests)?
• Do you take tablets, medicines or drugs on a
regular basis?
• Within the last 3 months have you experienced
any health problems or medical conditions which you
have not seen a doctor for?
For telesales, the information about the customer is
gathered on a telephone call instead of a proposal
form. The same four questions are asked on the
telephone and call recorded.
If all questions are answered with “NO” the proposal
form is processed accordingly with acceptance and
issuance of policy certificate.
If the applicant answers “YES” to any of these
questions they will proceed to a further line of enquiry
directly with the Underwriter, providing answers to the
following questions;
• Do you have circulatory disorders e.g. varicose
veins, high cholesterol, deep vein thrombosis, high
blood pressure, venous ulcers?
• Do you have glandular disorders e.g. diabetes,
thyroid, hormonal problems?
• Do you have breathing or respiratory disorders
e.g. asthma, bronchitis, chest infections?
• Do you have ear, nose, throat or eye problems e.g.
hay fever, tonsillitis, sinusitis, cataracts, eye infections,
deafness, ear infections?
• Do you have stomach, intestine, liver or gall
bladder problems e.g. peptic ulcer, colitis, indigestion,
irritable bowel, hepatitis, piles, hernias?
• Do you have cancer, tumors growth, cysts or moles?
• Do you have skin problems e.g. eczema rashes,
psoriasis, acne?
• Do you have brain or nervous system disorders
e.g. migraines, headaches, multiples sclerosis, epilepsy,
nerve pain, fits?
• Do you have muscle or skeletal problems e.g.
arthritis, cartilage and ligament problems, back and
neck problems, sprains, gout, sciatica?
• Do you have urinary problems e.g. bladder or
prostate problems, urinary infections, incontinence,
cystitis?
• Do you have blood disorders e.g. anemia,
abnormal blood tests, HIV/AIDS, leukemia?
• Do you have dental problems e.g. wisdom teeth
problems, abscesses or gingivitis?
• Do you have allergies of any nature?
22
• Do you have undiagnosed symptoms e.g. chest
pain, fatigue, weight loss, dizziness, joint pain, change
in bowel habit, shortness of breath, abdominal pain,
rectal bleeding?
• Are you or any prospective customer taking any
medicines, prescribed or otherwise?
• Has anyone to be covered ever had any past history
of joint replacements, heart conditions or strokes?
• Is there any other information relating to your
health that has not been prompted by the questions
listed above?
If the answer to any of the above questions is “YES”
then further medical assessment and review may be
requested by the Underwriter.
Upon full assessment of clinical and historical facts,
the Underwriter, with possibly second opinion, has
discretion to decide if the proposal submitted presents
a future risk.
Pre-policy health check-up requirements:
For specific ages and sum assured, a medical checkup
is required as part of the underwriting process. The
table below indicates where a medical checkup is
initially required with the proposal form:
Total rated up Sum Insured to be calculated for all
proposed individuals (Individual Sum Insured + Family
floater sum insured + Sum insured under previous or
simultaneous similar product category) to ascertain
the exact medicals to be triggered as per the medical
grid below.
For e.g. A Family First Policy has following members
covered:
Member Individual Cover Sum
Insured (Lacs)
Total Rated up Sum Insured per member for triggering medicals
(Lacs)
Proposer (Self) 2 7
Spouse 2 7
Father 2 7
Mother 2 7
Son 2 7
Family floater Cover Sum Insured
5Lacs
The table below indicates where a medical checkup is
initially required with the proposal form.
* Individual plan – Individual proposal where proposed
insured is below one year of age will be declined unless
the proposed insured is part of a family which is
insured with us.
Family Floater and Family First plans – Discharge
Summary and/or MER will be called for.
The medical check-up are spread in levels depending
on the plan and Age
TMT will be triggered as per Underwriter’s discretion
on case to case basis depending upon the health risk
profile of proposed insured(s). We may require you to
undertake further medical tests based on our
assessment of your health.
These tests will be valid for a period of 3 months (6
months for sub-standard life). The tests can be
conducted only through a Max Bupa empanelled
provider. In case the proposal is accepted the costs of
these tests will be borne by Us for gold and platinum
variants; however for silver variant you will have to
bear 50% of the cost of these tests.
For High Deductible Policies,
For Pre-policy Medicals tests, Sum Insured would be
considered as mentioned above i.e. the Sum Insured
Age (in Years) Individual Plan Family Floater Plan Family First Plan Below 1 Decline* Discharge Summary* No Check-up* Upto 39 No Check-up No Check-up No Check-up 40-44 Level 3 No Check-up No Check-up 45-59 Level 3 Level 3 No Check-up 60 and above Level 3 Level 3 Level 3
Category Tests Level 3 MER, RUA,Hba1c, TCHOL,GGT,HDL, SCREAT,SGOT,SGPT, ECG
23
applied for individual lives.
For e.g. If a proposer chooses Heartbeat Silver plan of
Sum Insured Rs 3 lacs with a deductible option of Rs 1
lac, then Sum Insured considered for triggering
medicals (if any) is Rs 3 lacs (total rated up Sum
insured).
4. Three potential options will be determined by the
Underwriter.
• No Risk - accept application with no condition
exclusion(s)
• Potential Risk – accept application, but special
conditions and exclusion(s) apply.
• Risk – decline policy cover. Max Bupa may decline
policy cover where potential risk cannot be quantified
through the use of best knowledge and expertise. Max
Bupa will consider past medical history, pathological
conditions, acquired disease conditions, deformity or
disability, terminal conditions, and/or a combination
thereof to determine if a risk is uninsurable.
5. All proposals accepted by Max Bupa are internally
processed and enrolled onto the Max Bupa system,
and premium payments are cleared.
6. Customer receives a welcome kit and a follow up
welcome outbound customer service call where the
proposed risk has been accepted by Max Bupa
7. The welcome kit will be delivered direct to the
Customers home.
8. Where proposals are not accepted due to
unacceptable risk then they too receive
communications from Max Bupa advising of the same
and specific reasons for the cover denied.
What to do next: If you wish to know more about Max
Bupa’s Heartbeat Health Insurance plan and/or would like a
personal quote, speak to our specially trained sales team or
your local advisor. They’ll take time to fully understand your
requirements and help you to select the right plan for you.
Phone 1800 3010 3333 (Toll Free) or 3300 3333
24
Policy Number
Name of the
Insured
Date of birth/Age
Relationship with Primary
Insured
City of residence
Previous Occupation or Nature of Work
New Occupation or Nature of Work
Annexure A
Format to be filled up by the proposer for change in occupation of the Insured
Place: _____________ Proposer’s Signature__________________
Date: ______________ Name:__________ Designation__________
(DD/MM/YYYY)
HB/
SP/0
41
4/V
3Registered Office : Max House, 1 Dr. Jha Marg, Okhla, New Delhi 110020Corporate Office :Block B1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi -110044
www.maxbupa.com
What to do next
Phone:1800 3010 3333 (Toll Free) or 011-3300 3333
Web: www.maxbupa.com
If you wish to know more about Group Health Insurance plan and/or
would like a personal quote, speak to our specially trained sales team
or your local advisor. They will take time to fully understand your
requirements and help you select the right plan.
Disclaimer: This is only a summary of the product features and is for reference purpose only. For more details on terms and
conditions, exclusions, waiting period and risk factors, please read sales brochure carefully before concluding a sale. The details
of benefits available shall be as described in the policy document, and will be subject to the policy terms, risk factors, conditions
and exclusions. Please call our customer service on the numbers / contact details as provided above if you require any further
information or clarification.
Insurance is a subject matter of solicitation ‘Max’, Max Logo are registered trademarks of Max India Limited “Bupa” and the
HEARTBEAT logo are the registered service marks of the The British United Provident Association Limited. All these marks are
being used under license by Max Bupa Health Insurance Company Limited. UAN No. MB/WB/2014-2015/304 and IRDA
Registration no. 145. For more details on terms and conditions, exclusions, waiting period and risk factors, please read sales
brochure carefully before concluding a sale.
Statutory Warning: Prohibition of rebates (under section 41 of Insurance Act 1938); no person shall allow or offer to allow
either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any kind
of risk relating to life or property, in India, any rebate of the whole or part of the commission payable or any rebate of the
premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such
rebate as may be allowed in accordance with the publishable prospectus or the tables of the insurer. Any person making default
in complying with the provision of this section shall be punishable with fine, which may extend to five hundred rupees.