Silver Heart Pro

7/24/2019 Silver Heart Pro

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Heartbeat Health Insurance Plan

Policy Wording

1. Terms & ConditionsThe insurance cover provided under thisPolicy to the Insured Person up to the SumInsured is and shall be subject to (a) theterms and conditions of this Policy and (b)the receipt of premium, and (c) Disclosure toInformation Norm (including by way of theProposal or Information Summary Sheet) forYourself and on behalf of all persons to beinsured. Please inform Us immediately ofany change in the address state of health, or

of any other changes affecting You or anyInsured Person.

2. BenefitsThe Policy covers reasonable expensesincurred towards medical treatment takenduring the Policy Period for an Illness,Accident or condition described below if thisis contracted or sustained by an InsuredPerson during the Policy Period and subjectalways to the Sum Insured, any subsidiarylimit specified in the Product Benefits Table,the terms, conditions, limitations andexclusions mentioned in the Policy andeligibility as per the insurance plan optedfor in the Product Benefits Table and asshown in the Schedule of InsuranceCertificate:

2.1. In-patient CareWe will cover Medical Expenses for:(a) Medical Practitionersfees(b) Diagnostics Tests(c) Medicines, drugs and consumables(d) Intravenous fluids, blood

transfusion, injection administrationcharges

(e)

Operation theatre charges(f) The cost of prosthetics and other

devices or equipment if implantedinternally during a SurgicalProcedure.

(g) Intensive Care Unit charges

2.2. Hospital AccommodationWe will cover Reasonable and Customarycharges for Room Rent for Hospitalaccommodation.

2.3. Pre-hospitalization Medical Expenses

We will cover Medical Expenses incurreddue to Illness up to 30 days immediatelybefore an Insured Persons admission to a

Hospital for the same Illness as long as Wehave accepted an In-patient CareHospitalisation claim under Section 2.1above. Pre-hospitalization Medical Expensescan be claimed as reimbursement only.

2.4. Post-hospitalization Medical ExpensesWe will cover Medical Expenses incurreddue to Illness up to 60 days immediatelyafter an Insured Persons discharge fromHospital for the same Illness as long as We

have accepted an In-patient CareHospitalisation claim under Section 2.1above. Post-hospitalization expenses can beclaimed as reimbursement only.

2.5. Day-Care TreatmentWe will cover Medical Expenses for Day-Care Treatment where such Treatments areundertaken by an Insured Person for In-patient Care in a Hospital/Day Care Centerfor a continuous period of less than 24hours.We will also cover the Medical Expenses forChemotherapy, Radiotherapy, Hemodialysisor any other procedure which requires aperiod of specialized observation or careafter completion of the procedure wheresuch procedure is undertaken by anInsured Person as an as an In-patient in aHospital for a continuous period of less than24 hours.Any procedure undertaken on an out-patient basis in a Hospital will not becovered.

2.6. Domiciliary TreatmentWe will cover Medical Expenses for medical

treatment taken at home if this continuesfor an uninterrupted period of 3 days andthe condition for which treatment is takenwould otherwise have necessitatedHospitalization as long as either (i) theattending Medical Practitioner confirms thatthe Insured Person could not be transferredto a Hospital or (ii) the Insured Personsatisfies Us that a Hospital bed wasunavailable.

2.7. Maternity Benefits1A. For Family Floater Policy only

We will cover Medical Expenses for thedelivery of a child and Maternity Expensessubject to the following:


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(a) This benefit is available only under aFamily Floater Policy.

(b) This benefit is available for You orYour spouse provided You and Yourspouse, both are covered under thesame Policy.

(c)

We must have received at least 3continuous annual premiums fromYou since the date ofcommencement of the first PolicyPeriod and cover will be availableunder Maternity Benefit only after24 months of continuous coveragehave elapsed since the inception ofthe first Policy with Us.

(d) Our maximum liability perpregnancy will be subject to thespecified sub-limit as shown in theProduct Benefits Table;

(e) We will cover Pre or PostHospitalisation Medical Expensesonly where the Sum Insured is morethan Rs. 10 lacs.

1B. For Family First Policy onlyWe will cover Medical Expenses forthe delivery of a child and MaternityExpenses subject to the following:

(a) This benefit is available to an adultfemale Insured Person only;

(b) The Policy has a minimum of threeadult Insured Persons including atleast one male Insured Person;

(c) We must have received at least 3

continuous annual premiums forthe Insured Person claiming thebenefit under section 2.7, since thedate of commencement of the firstPolicy Period and cover will beavailable under Maternity Benefitonly after 24 months of continuouscoverage have elapsed since theinception of the first Policy with Us;

(d) Our maximum liability for theMaternity Benefits under the Policyfor the Policy Period for all theInsured Person will be subject to the

specified sub-limit as shown in theProduct Benefits Table; and(e) We will not cover any Pre or Post

Hospitalization Medical Expenses forclaims under section 2.7.

2. We will cover Medical Expensesrelated to a Medically Necessarytermination of pregnancy subject tothe conditions mentioned in 2.7above.

3. The benefit under Sections 2.7 (1A),2.7 (1B) and 2.7(2) above may beclaimed only twice during thelifetime of the Policy including anyRenewal thereof.

4. The following expenses are notcovered under Maternity Benefit:

(a) Medical Expenses in respect of theharvesting and storage of stem cellswhen carried out as a preventivemeasure against possible future

Illnesses.(b) Medical Expenses for ectopicpregnancy. However, these expensesare covered under the In-patientCare.

2.8 New Born BabyIf We have accepted a Maternity Benefitsclaim under 2.7 above, then We will:

a Cover Medical Expenses towards themedical treatment of the Insured PersonsNew Born Baby while the Insured Person isHospitalized as an In-patient for delivery.

b Cover the New Born Baby as an InsuredPerson until the expiry date of the Policywithout the payment of any additionalpremium.

c Cover the Reasonable and CustomaryCharges for vaccination expenses of the NewBorn Baby for the vaccinations shown inAnnexure I to this Policy until the New BornBaby completes one year. If the Policy endsbefore the New Born Baby has completedone year, then, We will only cover suchvaccinations until the baby completes oneyear, and only if We have accepted the NewBorn Baby as an Insured Person at the time

of Renewal and you have paid the premiumaccordingly.

2.9 Organ DonorWe will cover Medical Expenses for an organdonors treatment for the harvesting of theorgan donated provided that:a. The donation conforms to The

Transplantation of Human OrgansAct 1994 and the organ is for theuse of the Insured Person;

b. The Insured Person has beenMedically Advised to undergo an

organ transplant;

We will not cover:(a) Pre-hospitalization or Post-

hospitalization Medical Expenses orscreening expenses of the donor orany other Medical Expenses as aresult of the harvesting from thedonor;

(b) Costs directly or indirectlyassociated with the acquisition ofthe donors organ.

2.10 Emergency ambulanceWe will cover Reasonable and CustomaryCharges for ambulance expenses incurred


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to transfer the Insured Person by surfacetransport following an Emergency to thenearest Hospital with adequate facilities if:a. The ambulance service is offered by

a healthcare or ambulance serviceprovider; and

b.

We have accepted an In-patientHospitalization claim under theprovisions of Section 2.1 above;

2.11 Health Relationship Loyalty ProgramIf the Policy is renewed with Us without anybreak, each Insured Person will becomeeligible to participate in the HealthRelationship Loyalty Program announced byUs from time to time. Under this program:a. If the Policy Period is one year, We

offer vouchers, in either electronic orphysical form, worth up to 10% ofthe last premium received foravailing certain specified servicesand products.

b. If the Policy Period is two years, Weoffer vouchers, in either electronic orphysical form, worth up to 5% of thelast premium received on thecommencement of each Policy Yearcommencing from the second PolicyYear.

The Insured Person may avail of the servicesand products specified within the periodspecified in or along with the voucher,provided that:

a.

The vouchers are used for only thosehealth services and benefitscommunicated from time to time;

b. The conditions or limitationsspecified in the vouchers areadhered to; and

c. The Policy is continuouslyRenewed.

2.12 Health CheckupWe will cover the cost of a health checkupas per Your plan eligibility as defined in theProduct Benefits Table. We will only cover

health checkups arranged by Us throughOur empanelled service providers.

2.13 Consultation and Diagnostic Tests (ForPlatinum Policyholders only)We will cover an Insured PersonsReasonable and Customary Charges forMedically Necessary consultation with aMedical Practitioner, as an OPD Treatmentto assess the Insured Persons healthcondition for any Illness. We will also payfor any Diagnostic Tests prescribed by theMedical Practitioner upto the sub-limitsshown in the Product Benefits Table.

If the Policy is renewed with Us without anybreak and there is a unutilized amount (notused by the Insured Person) under theapplicable sub-limit (as specified in theProducts Benefits Table) in a Policy Year,then We will carry forward 80% of this

unutilized amount to the immediatelysucceeding Policy Year, provided that thetotal amount (including the unutilizedamount available under this benefit) shall atno time exceed 2.5 times the amount of theentitlement in respect of this benefit underthe plan applicable to the Insured Personper the Product Benefits Table.

2.14 Child Care Benefits (For PlatinumPolicyholders only)We will cover Reasonable and CustomaryCharges for the vaccinations shown inAnnexure I to this Policy for children whoare included as Insured Persons until theyhave completed 12 years of age. We will alsocover expenses towards one consultation fornutrition and growth provided to the childduring a visit for vaccination.

2.15 Family First BenefitThis provision is applicable only toFamily First Policies:

1 Individual coverWithin the Sum Insured, there is anindividual insurance cover for each InsuredPerson which shall be up to the amount

specified in the Schedule of InsuranceCertificate for that Insured Person. Ourmaximum liability for any and all claims inrespect of an Insured Person under thePolicy during the Policy Period shall belimited to the Individual Cover amountspecified in the Schedule of InsuranceCertificate for that Insured Person.

2 Floater coverWithin the Sum Insured, there is a floaterinsurance cover up to the amount specifiedin the Schedule of Insurance Certificate.

This floater cover may be utilized only if theIndividual Cover amount of an InsuredPerson is fully exhausted and there is afurther claim under the Policy. Ourmaximum, total and cumulative liability forany and all such further claims in respect ofall Insured Persons under the Policy duringthe Policy Period shall be limited to theFloater cover amount specified in theSchedule of Insurance Certificate.

3. Co-paymentIf any Insured Person is 65 years of age or

over on the date of commencement of thecurrent Policy Year, then it is agreed thatWe will only pay 80% of any amount We


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assess for payment or reimbursement inrespect of any claim made by that InsuredPerson and the balance will be borne by theInsured Person.

4. Exclusions

We shall not be liable under this Policy forany claim in connection with or in respect ofthe following:

a. Pre-Existing DiseasesBenefits will not be available for Pre-existing Diseases until 48 months ofcontinuous coverage have elapsedsince the inception of the first Policywith Us.

b. 90 Days Waiting PeriodWe will not cover any treatmenttaken during the first 90 days sincethe date of commencement of the

Policy, unless the treatment neededis the result of an Accident orEmergency. This waiting period doesnot apply for any subsequent andcontinuous Renewals of Your Policy.

c. Specific Waiting PeriodsFor all Insured Persons who areabove 60 years of age as on the dateof commencement of the first PolicyPeriod the conditions listed belowwill be subject to a waiting period of24 months and will be covered inthe third Policy Year as long as the

Insured Person has been insuredcontinuously under the Policywithout any break:

1. Stones in the urinary system (egkidney/bladder)

2. Stones in billiary system (eg gallstones)

3. Cataract4. BPH - Benign prostatic hypertrophy5. Mennoraghia, Fibromyoma, Uterine

prolapse including any conditionrequiring Hysterectomy.

6. Piles (Haemorrhoids)

7.

Hernia (Inguinal/umbilical andgastric)8. Degenerative disorders of knee/hip9. Chronic renal failure or end stage

renal failure10. Retinopathy11. Diabetes and related treatments

d. Personal Waiting PeriodsConditions mentioned under PersonalWaiting Period in the Schedule of InsuranceCertificate will be subject to a waiting periodof 24 months and will be covered from thecommencement of the third Policy Year aslong as the Insured Person has been

insured continuously under the Policywithout any break.

e. Permanent ExclusionsWe will not be liable under anycircumstances, for any claim in connection

with or with regard to any of the followingpermanent exclusions and any suchpermanent exclusions as may be specifiedin the Schedule of Insurance Certificate

i. Addictive conditions and disorders

Treatment related to addictive conditionsand disorders, or from any kind ofsubstance abuse or misuse.

ii. Ageing and puberty

Treatment to relieve symptoms caused byageing, puberty, or other naturalphysiological cause, such as menopauseand hearing loss caused by maturing orageing.

iii. Artificial life maintenance

Artificial life maintenance, including lifesupport machine use, where such treatmentwill not result in recovery or restoration ofthe previous state of health

iv. CircumcisionCircumcision unless necessary for thetreatment of a disease or necessitated by anAccident.

v. Conflict and disaster

Treatment for any Illness or injury resultingfrom nuclear or chemical contamination,war, riot, revolution, acts of terrorism or anysimilar event (other than natural disaster orcalamity), if one or more of the followingconditions apply:1. The Insured Person put himself in

danger by entering a known area ofconflict where active fighting orinsurrections are taking place

2. The Insured Person was an activeparticipant in the above mentioned

acts or events of a similar nature.

3. The Insured Person displayed ablatant disregard for personal safety

vi. Congenital conditionsTreatment for any Congenital Anomaly.

vii. Convalescence and RehabilitationHospital accommodation when it is usedsolely or primarily for any of the followingpurposes:

1. convalescence, rehabilitation,

supervision or any other purposeother than for receiving eligible


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treatment of a type that normallyrequires a stay in Hospital.

2. receiving general nursing care orany other services that do notrequire the Insured Person to be inHospital and could be provided in

another establishment that is not aHospital

3. receiving services from a therapist orcomplementary medical practitioneror a practitioner of AlternativeTeatment.

viii. Cosmetic surgeryTreatment undergone purely for cosmetic orpsychological reasons to improveappearance, unless such treatment isMedically Necessary as a part of treatmentfor cancer or injury resulting from Accidents

or burns and is required to restorefunctionality.

ix. Dental/oral treatmentDental Treatment including surgicalProcedures for the treatment of bonedisease when related to gum disease ordamage, or treatment for, or treatmentarising from, disorders of thetempromandibular joint.

EXCEPTION: We will pay for a SurgicalProcedure for which the Insured Person isHospitalised and which is undertaken for

In-patient Care in a Hospital and carriedout by a Medical Practitioner to:

1. put a natural tooth back into a jawbone after it is knocked out ordislodged in an Accident

2. treat irreversible bone diseaseinvolving the jaw which cannot betreated in any other way, but not ifit is related to gum disease or toothdisease or damage

3. surgically remove a complicated,

buried or impacted tooth root, forexample in the case of an impactedwisdom tooth.

x. Drugs and dressings for OPD Treatmentor take-home use

drugs or surgical dressings that areprovided or prescribed in the case of OPDTreatment, or for an Insured Person to takehome on leaving Hospital, for any condition,except as included in Post-hospitalizationexpenses under clause Section 2.4 above.

xi. Eyesight

Treatment to correct refractive errors of theeye, unless required as the result of an

Accident. We will not pay for routine eyeexaminations, contact lenses, spectacles orlaser eye sight correction.

xii. Unproven/Experimental treatment

Unproven/Experimental Treatment,including medication, which in Our opinion

is experimental or has not generally beenproved to be effective.

xiii. Health hydros, nature cure, wellnessclinics etc.

Treatment or services received in healthhydros, nature cure clinics or anyestablishment that is not a Hospital.

xiv. HIV and AIDS

Any treatment for, or treatment arisingfrom, Human Immunodeficiency Virus (HIV)or Acquired Immuno Deficiency Syndrome(AIDS), including any condition that is

related to HIV or AIDS.xv. Hereditary conditions

Treatment of abnormalities, deformities,Illnesses present only because they havebeen passed down through the generationsof the family.

xvi. Items of personal comfort andconvenience, including but not limitedto:

1. Telephone, television, diet charges,(unless included in room rent)personal attendant or barber or

beauty services, baby food,cosmetics, napkins, toiletry items,guest services and similar incidentalexpenses or services.

2. Private nursing/attendants chargesincurred during Pre-Hospitalizationor Post-Hospitalization.

3. Drugs or treatment not supportedby prescription.

4. Issue of medical certificate andexaminations as to suitability foremployment or travel or any othersuch purpose.

5. Any charges incurred to procure anytreatment/Illness related documentspertaining to any period ofhospitalization/Illness.

6. External and or durablemedical/non medical equipment ofany kind used for diagnosis and ortreatment including CPAP, CAPD,Infusion pump etc.

7. Ambulatory devices such aswalkers, crutches, belts, collars,caps, splints, slings, braces,stockings of any kind, diabetic foot

wear, glucometer/thermometer andsimilar items and also any medical


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equipment which is subsequentlyused at home.

8. Nurses hired in addition to theHospitals own staff.

xvii. Alternative treatment

Any Alternative Treatment.

xviii. Psychiatric and PsychosomaticConditionsTreatment of any mental illness or sicknessor disease including a psychiatric condition,disorganisation of personality or mind, oremotions or behaviour, Parkinsons orAlzheimers disease even if caused oraggravated by or related to an Accident orIllness or general debility or exhaustion(run-down condition);

xix. Obesity

Treatment for obesity.xx. OPD Treatment

OPD treatment is not covered except thoseOPD Treatment explicitly stated as aneligible benefit for Your chosen plan.

xxi. Reproductive medicine - Birth control &Assisted reproduction

1. Any type of contraception,sterilization, termination ofpregnancy (except as provided forunder Section 2.7 above) or familyplanning.

2. Treatment to assist reproduction,including IVF treatment.

xxii. Self-inflicted injuries

Treatment for, or arising from, an injurythat is intentionally self-inflicted, includingattempted suicide.

xxiii. Sexual problems and gender issues

Treatment of any sexual problem includingimpotence (irrespective of the cause) andsex changes or gender reassignments orerectile dysfunction.

xxiv. Sexually transmitted diseases

Treatment for any sexually transmitteddisease, including Genital Warts, Syphilis,Gonorrhoea, Genital Herpes, Chlamydia,Pubic Lice and Trichomoniasis.

xxv. Sleep disorders

Treatment for sleep apnea, snoring, or anyother sleep-related breathing problem.

xxvi. Speech disorders

Treatment for speech disorders, includingstammering

xxvii. Treatment for developmental problems

Treatment for, or related to developmentalproblems, including:

1. learning difficulties, such asdyslexia;

2. behavioral problems, includingattention deficit hyperactivitydisorder (ADHD);

xxviii. Treatment received outside India

Any treatment received outside India.xxix. Unrecognised physician or Hospital:

1. Treatment provided by a MedicalPractitioner who is not recognized bythe Medical Council of India.

2. Treatment in any hospital or by anyMedical Practitioner or any otherprovider of services that We haveblacklisted as listed on Our website.

3. Treatment provided by anyone withthe same residence as an InsuredPerson or who is a member of theInsured Persons immediate family.

xxx. Unlawful ActivityAny condition as a result of Insured Personcommitting or attempting to commit abreach of law with criminal intent.

xxxi. Genetic disordersAny genetic disorders resulting from a defectin the genes.

xxxii. Any costs or expenses specified in the List of

Expenses Generally Excluded at Annexure

III.

5. Standard Terms and Conditions

a. Reasonable CareThe Insured Person shall take all reasonablesteps to safeguard against any Accident orIllnesses that may give rise to any claimunder this Policy.

b. Observance of terms and conditionsThe due observance and fulfillment of theterms, conditions and endorsements of thisPolicy in so far as they relate to anything tobe done or complied with by the InsuredPerson, shall be a Condition Precedent to

any liability to make payment under thisPolicy.

c. SubrogationThe Insured Person shall do and concur indoing and permit to be done all such actsand things as may be necessary or requiredby Us, before or after indemnification, inenforcing or endorsing any rights orremedies, or of obtaining relief or indemnity,to which We are or would become entitled orSubrogated. Neither You nor any InsuredPerson shall do any acts or things thatprejudice these Subrogation rights in anymanner. Any recovery made by Uspursuant to this clause shall first be applied


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to the amounts paid or payable by Us underthis Policy and the costs and expensesincurred by Us in effecting the recovery,whereafter We shall pay the balance amountto You.

d. Contribution

It is agreed and understood that if inaddition to this Policy, there is any otherinsurance policy in force under which aclaim for reimbursement of MedicalExpenses in respect of the Insured Personcould be made, then Insured Person maychoose the insurance policy under whichthe Insured Person wishes the claim to besettled. If, in such cases, the amountclaimed (after considering the applicableDeductibles and Co-payment) exceeds thesum insured under a single policy, theInsured Person may choose the insurance

policies under which the claim is to besettled and if this Policy is chosen then Wewill settle the claim by applying theContribution provisions.

e. Fraudulent claimsIf a claim is in any way found to befraudulent, or if any false statement, ordeclaration is made or used in support ofsuch a claim, or if any fraudulent means ordevices are used by the Insured Person orany false or incorrect Disclosure toInformation Norms or anyone acting onbehalf of the Insured Person to obtain any

benefit under this Policy, then this Policyshall be void and all claims being processedshall be forfeited for all Insured Persons andall sums paid under this Policy shall berepaid to Us by all Insured Persons whoshall be jointly liable for such repayment.

f. Free Look ProvisionYou have a period of 15 days from the dateof receipt of the Policy document to reviewthe terms and conditions of this Policy. IfYou have any objections to any of the termsand conditions, You may cancel the Policy

stating the reasons for cancellation andprovided that no claims have been madeunder the Policy, We will refund thepremium paid by You after deducting theamounts spent on any medical checkup,stamp duty charges and proportionate riskpremium for the period on cover. All rightsand benefits under this Policy shallimmediately stand extinguished on the freelook cancellation of the Policy. The free lookprovision is not applicable and available atthe time of Renewal of the Policy.

g. Portability Benefit

i. From another company to Our Policy

(i) If the proposed Insured Person wasinsured continuously and without abreak under another Indian retailhealth insurance policy with anyother Indian General Insurancecompany or stand alone Health

Insurance company,it is understoodand agreed that:

1) If You wish to exercise thePortability benefit, We should havereceived Your application and thecompleted Portability Form withcomplete documentation at least 45days before the expiry of Yourpresent period of insurance;2) This benefit is available only atthe time of renewal of the existinghealth insurance policy.

3) Portability benefit is available onlyupto the existing cover. If theproposed Sum Insured is higherthan the Sum Insured under theexpiring policy, waiting periodswould be applied on the amount ofproposed increase in Sum Insuredonly, in accordance with the existingguidelines of the InsuranceRegulatory and DevelopmentAuthority.

(4) Waiting period credits would beextended to Pre-existing Diseasesand time bound exclusions/waitingperiods in accordance with theexisting guidelines of the InsuranceRegulatory and DevelopmentAuthority.

(5) The Portability Benefit shall beapplied by Us within 15 days ofreceiving Your completedApplication and Portability Formsubject to the following:

(a) You shall give Us all additionaldocumentation and/or informationWe request;

(b)

You pay Us the applicable premiumin full;

(c) We may, subject to Our medicalunderwriting, restrict the termsupon which We may offer cover, thedecision as to which shall be in Oursole and absolute discretion;

(d) There is no obligation on Us toinsure all Insured Persons or toinsure all Insured Persons on theproposed terms, even if You havegiven Us all documentation;

(e) We have received necessary details

of medical history and claim historyfrom the previous insurance


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company for the Insured Personsprevious health insurance policythrough the IRDAs web portal.

ii. From Our existing health insurancepolicies to this Policy

(i)

If the proposed Insured Person wasinsured continuously and without abreak under another healthinsurance policy with Us, it isunderstood and agreed that:

(1) If You wish to exercise thePortability Benefit, We should havereceived Your application andcompleted Portability Form beforethe expiry of Your present period of

insurance;(2) This benefit is available only at the

time of renewal of existing healthinsurance policy.

(3) Portability Benefit is available onlyupto the existing cover. If theproposed Sum Insured is higherthan the Sum Insured under theexpiring policy, waiting periodswould be applied on the amount ofproposed increase in Sum Insuredonly, in accordance with the existing

guidelines of the InsuranceRegulatory and DevelopmentAuthority.

(4) Waiting period credits would beextended to Pre-existing Diseasesand time bound exclusions/waitingperiods in accordance with theexisting guidelines of the InsuranceRegulatory and DevelopmentAuthority.

(5) The Portability Benefit shall beapplied by Us within 15 days of

receiving Your completedApplication and Portability Formsubject to the following :

(a) You shall give Us all additionaldocumentation and/or informationWe request;

(b) You pay Us the applicable premiumin full;

(c) We may, subject to Our medicalunderwriting, restrict the termsupon which We may offer cover, thedecision as to which shall be in Our

sole and absolute discretion;

(d) There is no obligation on Us toinsure all Insured Persons or toinsure all Insured Persons on theproposed terms, even if You havegiven Us all documentation.

(e) No additional loading or charges

shall be applied by Us exclusively forporting the policy.

We reserve the right to modify oramend the terms and theapplicability of the PortabilityBenefit in accordance with theprovisions of the regulations andguidance issued by the InsuranceRegulatory and DevelopmentAuthority as amended from time totime.

h.

Cancellation/ Termination (other thanFreeLook cancellation)

1. Cancellation by You.

You may terminate this Policy by giving 7days prior written notice to Us. We shallcancel the Policy and refund the premiumfor the period as mentioned herein below,provided that no claim has been madeunder the Policy by or on behalf of anyInsured Person:

Length of time

Policy in force

Refund ofpremium

up to 30 days 75%

up to 90 days 50%

up to 180 days 25%

exceeding 180 days 0%

2. Automatic Cancellation:

a. Individual Policy:

The Policy shall automatically terminate inthe event of death of the Insured Person.

b. For Family Floater and Family First Policies:

The Policy shall automatically terminate inthe event of the death of all the InsuredPersons.

c. Refund:

A refund in accordance with the table inSection 5(h)(1) above shall be payable ifthere is an automatic cancellation of thePolicy provided that no claim has beenmade under the Policy by or on behalf ofany Insured Person.

3. Cancellation by Us:Without prejudice to the above, We mayterminate this Policy during the PolicyPeriod by sending 30 days prior written


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notice to Your address shown in theSchedule of Insurance Certificate withoutrefund of premium if in Our opinion:

i. You or any Insured Person or anyperson acting on behalf of either hasacted in a dishonest or fraudulent

manner under or in relation to thisPolicy; and/or

ii. You or any Insured Person has notdisclosed the material facts ormisrepresented in relation to thePolicy; and/or

iii. You or any Insured Person has notco operated with Us.

For avoidance of doubt, it is clarified that noclaims shall be admitted and/or paid by Usduring the notice period.

i. Territorial Jurisdiction

All benefits are available in India only, andall claims shall be payable in India in IndianRupees only.

j. Policy DisputesAny dispute concerning the interpretation ofthe terms, conditions, limitations and/orexclusions contained herein shall begoverned by Indian law and shall be subjectto the jurisdiction of the Indian Courts.

k. Renewal of PolicyThe renewal premium is payable on orbefore the due date in the amount shown inthe Schedule of Insurance Certificate or atsuch altered rate as may be reviewed andnotified by Us before completion of thePolicy Period. The amount of premium isdependent on the age of the Insured Personand the geographical locations. Thereference of age for calculating the premiumfor Family Floater Policies shall be the age ofthe eldest Insured Person. We shall allowthe enhancement in Sum Inured or scope ofcover only at the time of Renewal, providedYou submit a written request to Us at thetime of Renewal. You understand and agreethat the decision of acceptance of

enhancement of the Sum Insured or thescope of cover will solely be based on Ourdiscretion, Our underwriting policy andshall be subject to payment of applicablepremium by You for such enhanced cover.We are under no obligation to notify You ofthe Renewal date of Your Policy. We willallow a Grace Period of 30 days from thedue date of the Renewal premium forpayment to Us.

If the Policy is not renewed within the GracePeriod then We may agree to issue a freshpolicy subject to Our underwriting criteria

and no continuing benefits shall beavailable from the expired Policy.

Renewal of the Policy will not ordinarily bedenied other than on grounds of moralhazard, misrepresentation or fraud or non-cooperation by you.

l. Notices

Any notice, direction or instruction givenunder this Policy shall be in writing anddelivered by hand, post, or facsimile to

i. You/the Insured Person at theaddress specified in the Schedule ofInsurance Certificate or at thechanged address of which We mustreceive written notice.

ii. Us at the following address.Max Bupa Health InsuranceCompany LimitedD-1, 2nd Floor,Salcon Ras Vilas,District Centre, Saket,New Delhi-110 017Fax No.: 1800-3070-3333

In addition, We may send You/theInsured Person other informationthrough electronic andtelecommunications means withrespect to Your Policy from time totime.

m. Claims Procedure

(a) Cashless Hospitalization Facility for

Network Provider:

(i) The health card We provide willenable an Insured Person to accesstreatment on a cashless basis onlyat any Network Provider on theproduction of the card to theHospital prior to admission,provided that:

(1) The Insured Person has notified Usin writing at least 72 Hours before aplanned Hospitalization. In anEmergency the Insured Person

should notify Us in writing within 48hours of Hospitalization; and

(2) We have pre-authorized the In-patient or Day Care Procedure.

(ii) Cashless treatment will not beavailable if You take treatment in anNon-Network Hospital.

(iii) For cashless Facility HospitalizationWe will make the payment of theamounts assessed to be due directlyto the Network Provider. The

treatment must take place within 15days of the pre-authorization dateand pre-authorization is only valid if


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all the details of the authorizedtreatment, including dates, Hospitaland locations, match with thedetails of the actual treatmentreceived.

(iv) If pre-authorisation is not obtained

then the Cashless Facility will not beavailable and the claims procedureshall be as per (b)(ii) below.

(b) Non-Network Hospitals & All Other Claimsfor Reimbursement:

(i) In all Hospitalizations which havenot been pre-authorized, We mustbe notified within 48 hours ofadmission to the Hospital or beforedischarge from the Hospital,whichever is earlier. The notification

should be ideally provided by thePolicyholder/Insured Person. In theevent Policyholder and InsuredPerson is unwell, then thenotification should be provided byany immediate adult member of thefamily.The following information ismandated in the notification:1. Policy number.2. Name of Policyholder3. Name of Insured Person in

respect of whom the claim

has been notified.4. Name of Hospital withaddress and contactnumber.

5. Diagnosis.6. Treatment undergone

(medical / surgicalmanagement with name ofSurgical Procedureundergone, if applicable) andapproximate amount beingclaimed for

(ii) For any Illness or Accident ormedical condition that requiresHospitalization, the Insured Personshall deliver to Us the necessarydocuments listed below, at his ownexpense, within 30 days of theInsured Person's discharge fromHospital (when the claim is only inrespect of Post-hospitalization,within 30 days of the completion ofthe post-hospitalization):

(1) Claim form duly completed andsigned by the claimant.

(2) Cancelled Cheque

(3)

Self attested copy of valid age proof(Passport / Driving License / PAN

card / class X certificate / Birthcertificate)

(4) Self attested copy of identity proof(Passport / Driving License / PANcard / Voters identity card)

(5) Original Discharge summary

(6)

Original final bill from Hospital withdetailed break-up and paid receipt.(7) Original bills of medicines

purchased, or of any otherinvestigation done at an outsidehospital with reports and requisiteprescriptions.

(8) Invoice of major accessories in casebilled and utilized during treatment(if not included in the final hospitalbill).

(9) For Medicolegal cases (MLC/FIRcopy attested by the concernedhospital / police station (ifapplicable)

(10) Original self-narration of incident inabsence of MLC / FIR

(11) Original first consultation paper (incase disease is first time diagnosed).

(12) Original Laboratory Investigationreports.

(13) Original X-Ray/ MRI / Ultrasoundfilms and other Radiologicalinvestigations

(14) Indoor case paper/OT notes (ifrequired)

(iii) For any medical treatment taken

from an Non-Network Hospital Wewill only pay Medical Expenseswhich are Reasonable andCustomary Charges.

(c) For Network and Non-Network HospitalsIn all cases:(i) We reserve the right to call for:(1) Any other Necessary documentation

or information that We believe maybe required; and

(2) A medical examination by OurMedical Practitioner or for aninvestigation as often as We believe

this to be necessary. Any expensesrelated to such examinations orinvestigations shall be borne by Us.

(ii) In the event of the Insured Person'sdeath during Hospitalization, writtennotice accompanied by a copy of thepost mortem report (if any) shall begiven to Us within 14 daysregardless of whether any othernotice has been given to Us. Wereserve the right to require anautopsy.

(iii) For the purposes of Section 2, it isunderstood and agreed that if aHospital room as per the rent limitpermitted by the insurance plan


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opted for, as shown in the ProductBenefits Table, is unavailable, thenWe will only be liable to makepayment for a Hospital room that isactually occupied or as perentitlement permitted by the plan

opted for, whichever is lower.Further where Medical Expenses arelinked with room rates, MedicalExpenses as applicable to the roomthat is actually occupied or as perroom rates entitlement under theplan opted, whichever is lower, shallbe payable.

(d) All claims are to be notified to Us within atimeline as per Sections 5(m)(b)(i). In casewhere the delay in intimation is proved to begenuine and for reasons beyond the controlof the Insured Person or Nominee specifiedin the Schedule of Insurance Certificate, Wemay condone such delay and process theclaim, We reserve a right to decline suchrequests for claim process where there is nomerit for a delayed claim.

(e) Upon acceptance of a claim, the payment ofthe amount due shall be made within 30days from the date of acceptance of theclaim. In the case of delay in payment, Weshall be liable to pay interest at a rate whichis 2% above the bank rate prevalent at thebeginning of the financial year in which theclaim is reviewed by it.

(f) It is hereby agreed and understood that in

providing pre-authorisation or accepting aclaim for reimbursement under this Policyor making a payment under this Policy, Wemake no representation and/or give noguarantee and/or assume no responsibilityfor the appropriateness, quality oreffectiveness of the treatment sought orprovided.

n. Withdrawal of ProductThis product may be withdrawn at Ouroption subject to prior approval ofInsurance Regulatory and DevelopmentAuthority (IRDA) or due to a change in

regulations. In such a case We shall providean option to migrate to our other suitableretail products as available with Us.

o. Revision or ModificationThis product may be revised or modifiedsubject to prior approval of the IRDA. Insuch case We shall notify You of any suchchange at least 3 months prior to the datefrom which such revision or modificationshall come into effect, provided it is nototherwise provided by the IRDA.

p. Alteration to the PolicyThis Policy constitutes the completecontract of insurance. Any change in thePolicy will only be evidenced by a writtenendorsement signed and stamped by Us.

No one except Us can change or vary thisPolicy.

q. Change of Policy holderIf You do not renew the Policy by the duedates specified in the Schedule of InsuranceCertificate, any other adult Insured Person

may apply to renew the Policy within 30days of the end of the Policy Period providedthat We receive an application and thepremium from such Insured Person andevidence satisfactory to Us of the agreementof all other Insured Persons and You (exceptin case of death). If We accept suchapplication and the premium for therenewed Policy is paid on time, then thePolicy shall be treated as having beenrenewed without a break in cover. Coverageshall not be available for the period forwhich premium has not been received.

If the new proposed Policyholder does notfulfill the relationship conditions specified inthe definition of Family as stated in thedefinition of Family First Policy, any otheradult Insured Person may apply to renewthe Policy in accordance with the aforesaidprovision and the Policy will continue as aFamily First Policy provided that Ourunderwriting criteria for Family FirstPolicies is satisfied,

In such cases, for the purposes of the Policythe relationship between the Insured

Persons and the Policyholder shall begoverned in relation to the originalPolicyholder, notwithstanding the change inpolicyholder and the addition of anyproposed Insured Persons under the Policywill also be subject to these proposedInsured Persons satisfying the relationshiprequirements with the original Policyholderas specified in the definition of Family FirstPolicy.

r. Nomination & AssignmentYou are mandatorily required at theinception or at any time before the expiry of

the Policy to make a nomination for thepurpose of payment of claims under thePolicy in the event of death.

Any change of nomination shall becommunicated to Us in writing and suchchange shall be effective only when anendorsement on the Policy is made by Us.

In case of any Insured Person other thanYou under the Policy, for the purpose ofpayment of claims in the event of death, thedefault nominee would be You.

No assignment of this Policy or the benefits

thereunder shall be permitted.

s. Obligations in case of a minor


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If an Insured Person is less than 18 years ofage, You/adult Insured Person shall becompletely responsible for ensuringcompliance with all the terms andconditions of this Policy on behalf of thatminor Insured Person.

t. Customer Service and GrievancesReddressal:

i. In case of any query orcomplaint/grievance, You/theInsured Person may approach Ouroffice at the following address:

Customer Services DepartmentMax Bupa Health InsuranceCompany LimitedD-1, 2nd Floor,Salcon Ras Vilas,District Centre, Saket,

New Delhi-110 017Contact No: 1800-3010-3333Fax No.: 1800-3070-3333Email ID:[email protected]

ii. In case You/the Insured Person arenot satisfied with the decision of theabove office, or have not receivedany response within 10 days, Youmay contact the following official forresolution:

HeadCustomer Services

Max Bupa Health InsuranceCompany LimitedD-1, 2nd Floor,Salcon Ras Vilas,District Centre, Saket,New Delhi-110 017Contact No: 1800-3010-3333Fax No.: 1800-3070-3333Email ID:

[email protected]

iii. In case You/the Insured Person arenot satisfied with Ourdecision/resolution, You mayapproach the InsuranceOmbudsman at the addresses givenin Annexure II.

iv. The complaint should be made inwriting duly signed by thecomplainant or by his/her legalheirs with full details of thecomplaint and the contactinformation of the complainant.

v. As per provision 13(3)of theRedressal of Public Grievances Rules1998,the complaint to the

Ombudsman can be made

1. only if the grievance has beenrejected by the Grievance RedressalMachinery of the Insurer;

2. within a period of one year from thedate of rejection by the insurer;

3.

if it is not simultaneously under anylitigation.

6. Interpretations & Definitions

In this Policy the following words or phrasesshall have the meanings attributed to themwherever they appear in this Policy and forthis purpose the singular will be deemed toinclude the plural, the male gender includesthe female where the context permits:

Def. 1. Accident or Accidental means a sudden,unforeseen and involuntary event caused byexternal visible and violent means.

Def. 2.

Alternative Treatments are forms oftreatments other than treatment "Allopathy"or "modern medicine" and includesAyurveda, Unani, Sidha and Homeopathy inthe Indian context.

Def. 3. Cashless Facilitymeans a facility extendedby the insurer to the insured where thepayments, of the costs of treatmentundergone by the insured in accordancewith the policy terms and conditions, aredirectly made to the Network Provider by theinsurer to the extent pre-authorization

approved.Def. 4. Condition Precedent shall mean a policy

term or condition upon which the Insurer'sliability under the policy is conditionalupon.

Def. 5. Congenital Anomaly refers to a condition(s) which is present since birth, and whichis abnormal with reference to form,structure or position.

i) Internal Congenital Anomaly:Congenital Anomaly which is not inthe visible and accessible parts of

the body.ii) External Congenital Anomaly:

Congenital Anomaly which is in thevisible and accessible parts of thebody.

Def. 6. Contribution is essentially the right of aninsurer to call upon other insurers, liable tothe same insured, to share the cost of anindemnity claim on a rateable proportion ofSum Insured. This clause shall not apply toany benefit offered on fixed benefit basis.

Def. 7. Co-payment is a cost-sharing requirement

under a health insurance policy thatprovides that the Policyholder/insured willbear a specified percentage of the
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


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admissible claim amount. A co-paymentdoes not reduce the Sum Insured.

Def. 8. Day Care Center:A day care centre meansany institution established for Day CareTreatment of illness and/or injuries or a

medical set-up within a Hospital and whichhas been registered within the localauthorities, wherever applicable, and isunder the supervision of a registered andqualified Medical Practitioner AND mustcomply with all minimum criteria as under:-has Qualified Nursing staff under itsemployment; has qualified MedicalPractitioner (s) in charge; had a fullyequipped operation theatre of its own whereSurgical Procedures are carried outmaintains daily records of patients and willmake these accessible to the Insurancecompanys authorized personnel.

Def. 9. Day Care Treatment refers to medicaltreatment, and/or surgical procedure whichis undertaken under General or LocalAnaesthesia in a hospital/day care centre inless than 24 hrs because of technologicaladvancement, which would have otherwiserequired a hospitalization of more than 24hours.

Treatment normally taken on an OPDtreatment basis is not included in the scope

of this definition.

Def. 10. Deductible: Deductible is a cost-sharing requirement under a healthinsurance policy that provides that theInsurer will not be liable for a specifiedrupee amount in case of indemnity policiesand for a specified number of days/hours incase of hospital cash policies which willapply before any benefits are payable by theInsurer. A deductible does not reduce theSum Insured.

Def. 11. Dental Treatment is treatment

carried out by a dental practitionerincluding examinations, fillings (whereappropriate), crowns, extractions andsurgery excluding any form of cosmeticsurgery/implants.

Def. 12. Diagnostic Tests: Investigations,such as X-Ray or blood tests, to find thecause of your symptoms and medicalcondition.

Def. 13. Disclosure to Information Norm:The Policy shall be void and all premiumpaid hereon shall be forfeited to theCompany, in the event of misrepresentation,mis-description or non-disclosure of anymaterial fact.

Def. 14. Domiciliary Hospitalisation:Domiciliary treatment means medicaltreatment for a period exceeding 3 days, foran Illness/disease/injury which in the

normal course would require care andtreatment at a Hospital but is actually takenwhile confined at home under any of thefollowing circumstances: the condition ofthe patient is such that he/she is not in acondition to be removed to a hospital, or thepatient takes treatment at home on accountof non availability of room in a hospital.

Def. 15. Emergency means a severe illnessor injury which results in symptoms whichoccur suddenly and unexpectedly, andrequires immediate care by a MedicalPractitioner to prevent death or serious longterm impairment of the Insured Personshealth.

Def. 16. Emergency Care meansmanagement for a severe Illness or injurywhich results in symptoms which occursuddenly and unexpectedly, and requiresimmediate care by a Medical Practitioner toprevent death or serious long termimpairment of the Insured Persons health.

Def. 17. Family Floater Policy means aPolicy in terms of which, two or morepersons of a Family are named in theSchedule of Insurance Certificate as InsuredPersons. In a Family Floater Policy, Familymeans a unit comprising of upto fourmembers who are related to each other inthe following manner:

i)

ii) Legally married husband and wife aslong as they continues to bemarried; and/or

iii) Up-to two of their children who areless than 21 years on the date ofcommencement of the initial coverunder the Policy

Def. 18. Family First Policy means a Policy interms of which, two or more persons ofYour Family are named in the Schedule ofInsurance Certificate as Insured Persons.In a Family First Policy, Family meansYou and the persons listed below whois/are related to You in the following

manner:-


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a. Legally married spouse as long as heor she continues to be married toYou;

b. Son;c. Daughter-in-law;d. Daughter;

e. Father;f. Mother;g. Father-in-law as long as Your

spouse continues to be married toYou;

h. Mother-in-law as long as Yourspouse continues to be married toYou;

i. Grandfather;j. Grandmother;k. Grandson;l. Granddaughter.

Def. 19. Grace Period means the specified periodof time immediately following the premiumdue date during which a payment can bemade to renew or continue a policy inforce without loss of continuity benefitssuch as waiting periods and coverage ofPre-existing Diseases. Coverage is notavailable for the period for which nopremium is received.

Def. 20. Hospital means any institutionestablished for in-patient care and DayCare Treatment of sickness and / orinjuries and which has been registered as

a hospital with the local authorities,under the Clinical Establishments(Registration and Regulation) Act, 2010 orunder the enactments specified under theSchedule of Section 56(1) of the said ActOR complies with all minimum criteria asunder::

a) has at least 10 inpatient beds, inthose towns having a population ofless than 10,00,000 and 15inpatient beds in all other places;

b) has Qualified Nursing staff under

its employment round the clock;c) has qualified Medical Practitioner (s)

in charge round the clock;

d) has a fully equipped operationtheatre of its own where surgicalprocedures are carried out

e) maintains daily records of patientsand will make these accessible tothe Insurance companys authorizedpersonnel.

Def. 21. Hospitalization or Hospitalized means

the admission in a Hospital for aminimum period of 24 Inpatient Care

consecutive hours except for specifiedprocedures/treatments, where suchadmission could be for a period of lessthan 24 consecutive hours.

Def. 22. Injury: Injury means accidental physical

bodily harm excluding illness or diseasesolely and directly caused by external,violent and visible and evident meanswhich is verified and certified by a MedicalPractitioner.

Def. 23. Information Summary Sheet means therecord and confirmation of informationprovided to Us or Our representatives overthe telephone for the purposes of applyingfor this Policy.

Def. 24. Intensive Care Unit means an identifiedsection, ward or wing of a Hospital whichis under the constant supervision of adedicated Medical Practitioner(s), andwhich is specially equipped for thecontinuous monitoring and treatment ofpatients who are in a critical condition, orrequire life support facilities and wherethe level of care and supervision isconsiderably more sophisticated andintensive than in the ordinary and otherwards.

Def. 25. Illness means sickness or a disease or

pathological condition leading to theimpairment of normal physiologicalfunction which manifests itself during thePolicy Period and requires medicaltreatment.

i) Acute condition-is a disease, illness orinjury that is likely to respond quickly totreatment which aims to return theperson to his/her state of healthimmediately before suffering thedisease/illness/injury which leads tofull recovery.

ii)

Chronic condition- A chronic conditionis defined as a disease, illnesss, orinjury that has one or more of thefollowing characteristics:- it needsongoing or long-term monitoringthrough consultations, examinations,check-ups, and/or tests- it needsongoing or long-term control or relief ofsymptoms it requires yourrehabilitation or for you to bespecifically trained to cope with it- itcontinues indefinitelyit comes back oris likely to come back.

Def. 26.

Inpatient means the Insured Personsadmission to for treatment in a Hospital


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for more than 24 hours for a coveredevent.

Def. 27. InPatient Care means treatment forwhich the Insured Person has to stay in ahospital for more than 24 hours for a

covered event.

Def. 28. Insured Person means person named asinsured in the Schedule of InsuranceCertificate. Any Family member may beadded as an Insured Person during thePolicy Period if We have accepted hisapplication for insurance and issued anendorsement confirming the addition ofsuch person as an Insured Person.

Def. 29. Maternity Expenses: Maternity expense

shall include:(a). medical treatment expenses traceableto childbirth ( including complicateddeliveries and caesarean sections incurredduring hospitalization).(b). expensestowards lawful medical termination ofpregnancy during the policy period.

Def. 30. Medical Advise: Any consultation oradvice from a Medical Practitionerincluding the issue of any prescription orrepeat prescription.

Def. 31.

Medical Expenses means those expensesthat an Insured Person has necessarilyand actually incurred for medicaltreatment on account of Illness orAccident during the Policy Period on theadvice Medical Practitioner, as long asthese are no more than would have beenpayable if the Insured Person had notbeen insured and no more than otherhospitals or doctors in the same localitywould have charged for the same medicaltreatment.

Def. 32. Medical Practitioner is a person whoholds a valid registration from the MedicalCouncil of any State or Medical Council ofIndia or Council for Indian Medicine or forHomeopathy setup by the Government ofIndia or a State Government and isthereby entitled to practice medicinewithin its jurisdiction; and is acting withinthe scope and jurisdiction of license.

Def. 33. Medically Necessary: Medicallynecessary treatment is defined as anytreatment, tests, medication, or stay in

Hospital or part of a stay in Hospitalwhich:

a) is required for the medicalmanagement of the illness or injurysuffered by the insured;

b) must not exceed the level of carenecessary to provide safe, adequateand appropriate medical care in

scope, duration, or intensity;c) must have been prescribed by aMedical Practitioner;

d) must conform to the professionalstandards widely accepted ininternational medical practice or bythe medical community in India.

Def. 34. Network Provider means Hospitals orhealth care providers enlisted by aninsurer or by a TPA and insurer togetherto provide medical services to an insuredon payment by a Cashless Facility.

New Born Baby means baby born duringthe Policy Period and is aged between 1dayand 90 days, both days inclusive.

Def. 35. Notification of Claim is the process ofnotifying a claim to the insurer or TPA byspecifying the timelines as well as theaddress / telephone number to which itshould be notified.

Def. 36. Non Network means any Hospital, daycare centre or other provider that is notpart of the Network.

Def. 37. OPD Treatment is one in which theInsured Person visits a clinic/ hospital, orassociated facility like a consultationroom, for diagnosis and treatment basedon the advice of a Medical Practitioner.The Insured is not admitted as a day careor InPatient.

Def. 38. Policy means these terms and conditions,any annexure thereto and the Schedule ofInsurance Certificate (as amended fromtime to time), Your statements in the

proposal form and the InformationSummary Sheet and the policy wording(including endorsements, if any).

Def. 39. Policy Period means the period betweenthe date of commencement and the expirydate specified shown in the Schedule ofInsurance Certificate.

Def. 40. Policy Yearmeans the period of one yearcommencing on the date ofcommencement specified in the Scheduleof Insurance Certificate or anyanniversary thereof.


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Def. 41. Pre-existing Disease means anycondition, ailment or injury or relatedcondition(s) for which the Insured Personhad signs or symptoms, and / or werediagnosed, and / or received medicaladvice/ treatment, within 48 months prior

to the first Policy issued by Us.

Def. 42. Pre-hospitalization Medical Expenses

Medical Expenses incurred immediately

before the Insured Person is Hospitalised,

provided that:

I. Such Medical Expenses are incurred

for the same condition for which the

Insured Persons Hospitalisation was

required, and

II. The Inpatient Hospitalization claim

for such Hospitalization is admissible bythe Insurance Company.

Def. 43. Post-hospitalization Medical Expenses

Medical Expenses incurred immediately

after the Insured Person is Hospitalised,

provided that:

i. Such Medical Expenses are incurred forthe same condition for which the InsuredPersons Hospitalisation was required, andii. The Inpatient Hospitalization claim for

such Hospitalization is admissible by theInsurance Company.

Def. 44. Portability means transfer by anindividual health insurance policy holder(including family cover) of the creditgained for pre-existing conditions andtime-bound exclusions if he/she choosesto switch from one insurer to another.

Def. 45. Product Benefits Table means theProduct Benefits Table issued by Us andaccompanying this Policy and annexuresthereto.

Def. 46.

Qualified Nurse is a person who holds avalid registration from the NursingCouncil of India or the Nursing Council ofany state in India.

Def. 47. Reasonable and Customary chargesmeans the charges for services orsupplies, which are the standard chargesfor the specific provider and consistentwith the prevailing charges in thegeographical area for identical or similarservices among comparable providers,taking into account the nature of theillness / injury involved.

Def. 48. Renewal defines the terms on which thecontract of insurance can be renewed onmutual consent with a provision of graceperiod for treating the renewal continuousfor the purpose of all waiting periods.

Def. 49. Room rentmeans the amount charged bya hospital for the occupancy of a bed onper day (24 hours) basis and shall includeassociated medical expenses.

Def. 50. Schedule of Insurance Certificatemeans the schedule of insurancecertificate issued by Us, and, if more thanone, then the latest in time.

Def. 51. Subrogation shall mean the right of theinsurer to assume the rights of theinsured person to recover expenses paidout under the policy that may berecovered from any other source.

Def. 52. Sum Insured means the sum shown inthe Schedule of Insurance Certificatewhich represents Our maximum, total andcumulative liability for any and all claimsunder the Policy during the Policy Period.

Def. 53. Surgery or Surgical Procedure meansmanual and / or operative procedure (s)

required for treatment of an Illness orinjury, correction of deformities anddefects, diagnosis and cure of diseases,relief of suffering or prolongation of life,performed in a Hospital or day care centreby a Medical Practitioner.

Def. 54. Unproven/Experimental treatment:treatment, including drug experimentaltherapy, which is not based onestablished medical practice in India, istreatment experimental or unproven.

Def. 55. We/Our/Us means Max Bupa HealthInsurance Company Limited

Def. 56. You/Your/Policyholder means theperson named in the Schedule ofInsurance Certificate who has concludedthis Policy with Us.

Any reference to any statute shall be deemed torefer to any replacement or amendment to thatstatute.


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Annexure - IList of Covered Vaccinations

Time interval Vaccination to be done (age) Frequency

Vaccination for first

0 - 3 months

BCG (From birth to 2 weeks) 1

OPV (0,6,10 weeks) OR OPV + IPV1 3 OR 4

DPT (6 and 10 week) 2

Hepatitis - B (0 and 6 week) 2

Hib (6 and 10 week) 2

3 - 6 months

OPV (14 week ) OR OPV + IPV 2 1 OR 2

DPT (14 week) 1

HepatitisB (14 week) 1

Hib (14 week) 1

9 months Measles (+9 months) 1

12 months Chicken Pox (12 months) 1

Vaccination for Year

1 -2 years

OPV (15 and 18 months) OR OPV + 1 OR 2

DPT (1518 months) 1

Hib (1518 months) 1

MMR (1518 months) 1

Meningococcal vaccine (24 months) 1

23 years Typhoid (+2 years) 1

At 10 years TT 1

All the above vaccinations are as per WHO recommendations.


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Annexure IIList of Insurance Ombudsmen

Office of theOmbudsman

Name of theOmbudsman

Contact Details Areas of Jurisdiction

AHMEDABAD Shri P.Ramamoorthy

Insurance Ombudsman,Office of the Insurance Ombudsman,2nd Floor, Ambica House,Nr. C.U. Shah College,Ashram Road,AHMEDABAD-380 014.

Tel.:- 079-27546840Fax : [email protected]

Gujarat , UT of Dadra &Nagar Haveli, Daman andDiu

BHOPAL Insurance Ombudsman,Office of the Insurance Ombudsman,

Janak Vihar Complex,2ndFloor, 6, Malviya Nagar,Opp. Airtel, Near New Market,BHOPAL(M.P.)-462 023.


Madhya Pradesh &Chhattisgarh

BHUBANESHWAR Shri B. P. Parija Insurance Ombudsman,Office of the Insurance Ombudsman,62, Forest Park,BHUBANESHWAR-751 009.


Orissa

CHANDIGARH Shri ManikSonawane

Shri Manik SonawaneInsurance Ombudsman,Office of the Insurance Ombudsman,S.C.O. No.101-103,2nd Floor, Batra Building.

Sector 17-D,CHANDIGARH-160 017.


Punjab , Haryana,Himachal Pradesh, Jammu& Kashmir , UT ofChandigarh

CHENNAI Insurance Ombudsman,Office of the Insurance Ombudsman,Fathima Akhtar Court,4th Floor, 453 (old 312),Anna Salai, Teynampet,CHENNAI-600 018.

Tel.:- 044-24333668 /5284Fax : [email protected]

Tamil Nadu, UTPondicherry Town andKaraikal (which are part ofUT of Pondicherry)

NEW DELHI Shri Surendra PalSingh

Shri Surendra Pal SinghInsurance Ombudsman,Office of the Insurance Ombudsman,2/2 A, Universal Insurance Bldg.,Asaf Ali Road,NEW DELHI-110 002.


Delhi & Rajasthan

GUWAHATI Shri D. C.Choudhury

Shri D.C. Choudhury,Insurance Ombudsman,Office of the Insurance Ombudsman,Jeevan Nivesh, 5thFloor,Near Panbazar Overbridge, S.S. Road,GUWAHATI-781 001 (ASSAM).

Tel.:- 0361-2132204/5Fax : 0361-2732937

Assam , Meghalaya,Manipur, Mizoram,Arunachal Pradesh,Nagaland and Tripura
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


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[email protected]

HYDERABAD Insurance Ombudsman,Office of the Insurance Ombudsman,6-2-46, 1stFloor, Moin Court,A.C. Guards, Lakdi-Ka-Pool,HYDERABAD-500 004.

Tel : 040-65504123Fax: [email protected]

Andhra Pradesh, Karnatakaand UT of Yanama partof the UT of Pondicherry

KOCHI Shri R.Jyothindranathan

Insurance Ombudsman,Office of the Insurance Ombudsman,2nd Floor, CC 27/2603, Pulinat Bldg.,Opp. Cochin Shipyard, M.G. Road,ERNAKULAM-682 015.

Tel : 0484-2358759Fax : [email protected]

Kerala , UT of (a)Lakshadweep , (b) Maheapart of UT of Pondicherry

KOLKATA Ms. Manika Datta Ms. Manika DattaInsurance Ombudsman,Office of the Insurance Ombudsman,4th Floor, Hindusthan Bldg. Annexe, 4,

C.R.Avenue,Kolkatta 700 072.

Tel: 033 22124346/(40)Fax: 033 22124341Email:[email protected]

West Bengal , Bihar ,Jharkhand and UT ofAndeman & NicobarIslands , Sikkim

LUCKNOW Shri G. B. Pande Insurance Ombudsman,Office of the Insurance Ombudsman,

Jeevan Bhawan, Phase-2,6thFloor, Nawal Kishore Road,Hazaratganj,LUCKNOW-226 001.

Tel : 0522 -2231331Fax : [email protected]

Uttar Pradesh andUttaranchal

MUMBAI Insurance Ombudsman,

Office of the Insurance Ombudsman,3rd Floor, Jeevan Seva Annexe,S.V. Road, Santacruz(W),MUMBAI-400 054.

Tel : 022-26106928Fax : [email protected]

Maharashtra , Goa

OFFICE OF THE GOVERNING BODY OF INSURANCE COUNCIL

Shri M.V.V. Chalam, Secretary General The Secretary3rd Floor, Jeevan Seva Annexe, 3rdFloor, Jeevan Seva Annexe,S.V. Road, Santacruz(W), S.V. Road, Santacruz (W),

MUMBAI400 021 MUMBAI400 021.Tel:022-26106245 Tel : 022-26106980Fax : 022-26106949 Fax : [email protected]: http://www.gbic.co.in/
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]://www.gbic.co.in/http://www.gbic.co.in/http://www.gbic.co.in/mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


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Annexure III

List of Generally excluded in Hospitalisation Policy

SNO

List of Expenses Generally Excluded ("Non-

Medical")in Hospital Indemnity Policy - SUGGESTIONS

TOILETRIES/COSMETICS/ PERSONAL COMFORT OR CONVENIENCE ITEMS

1 HAIR REMOVAL CREAM Not Payable

2BABY CHARGES (UNLESSSPECIFIED/INDICATED) Not Payable

3 BABY FOOD Not Payable

4 BABY UTILITES CHARGES Not Payable

5 BABY SET Not Payable

6 BABY BOTTLES Not Payable7 BRUSH Not Payable

8 COSY TOWEL Not Payable

9 HAND WASH Not Payable

10 M01STUR1SER 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 ofthoracic 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 (

for site preparations) Payable

24EAU-DE-COLOGNE / ROOMFRESHNERS Not Payable

25 EYE PAD Not Payable

26 EYE SHEILD Not Payable

27 EMAIL / INTERNET CHARGES Not Payable

28

FOOD CHARGES (OTHER THANPATIENT'S DIET PROVIDED BYHOSPITAL) Not Payable

29 FOOT COVER Not Payable

30 GOWN Not Payable


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31 LEGGINGS

Essential in bariatric and varicose veinsurgery and should be considered for theseconditions 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

43 BED UNDER PAD CHARGES Not Payable44 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 CHARGESNot Payable ( However if CD is specificallysought 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

56HANSAPLAST/ADHESIVEBANDAGES Not Payable

57 INFANT FOOD Not Payable

58 SLINGSReasonable costs for one sling in case ofupper arm fractures should be considered

ITEMS SPECIFIC ALL Y EXCLUDED IN THE POLICIES

59WEIGHT CONTROL PROGRAMS/SUPPLIES/ SERVICES

Exclusion in policy unless otherwisespecified

60COST OF SPECTACLES/ CONTACTLENSES/ HEARING AIDS ETC.,


61

DENTAL TREATMENT EXPENSESTHAT DO NOT REQUIREHOSPITALISATION


62HORMONE REPLACEMENT

THERAPYExclusion in policy unless otherwisespecified

63 HOME VISIT CHARGES

Exclusion in policy unless otherwise

specified


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64

INFERTILITY/ SUBFERTILITY/ASSISTED CONCEPTIONPROCEDURE


65

OBESITY (INCLUDING MORBIDOBESITY) TREATMENT IF

EXCLUDED IN POLICY


specified

66PSYCHIATRIC & PSYCHOSOMATICDISORDERS


67CORRECTIVE SURGERY FORREFRACTIVE ERROR


68TREATMENT OF SEXUALLYTRANSMITTED DISEASES


69 DONOR SCREENING CHARGESExclusion in policy unless otherwisespecified

70

ADMISSION/REGISTRATION

CHARGES


specified

71

HOSPITALISATION FOREVALUATION/ DIAGNOSTICPURPOSE


72

EXPENSES FOR INVESTIGATION/TREATMENT IRRELEVANT TO THEDISEASE FOR WHICH ADMITTEDOR DIAGNOSED

Not payable - Exclusion in policy unlessotherwise specified

73

ANY EXPENSES WHEN THEPATIENT IS DIAGNOSED WITHRETRO VIRUS + OR SUFFERINGFROM /HIV/ AIDS ETC IS

DETECTED/ DIRECTLY ORINDIRECTLY Not payable as per HIV/AIDS exclusion

74STEM CELL IMPLANTATION/SURGERY and storage

Not Payable except Bone MarrowTransplantation where covered by policy

ITEMS WHICH FORM PART OF HOSPITAL SERVICES WHERE SEPARATECONSUMABLES ARE NOT PAYABLE BUT THE SERVICE IS

75WARD AND THEATRE BOOKINGCHARGES

Payable under OT Charges, not payableseparately

76ARTHROSCOPY & ENDOSCOPYINSTRUMENTS

Rental charged by the hospital payable.Purchase of Instruments not payable.

77 MICROSCOPE COVERPayable under OT Charges, not payableseparately

78SURGICAL BLADES,HARMONICSCALPEL,SHAVER

Payable under OT Charges, not payableseparately

79 SURGICAL DRILLPayable under OT Charges, not payableseparately

80 EYE KITPayable under OT Charges, not payableseparately

81 EYE DRAPEPayable under OT Charges, not payableseparately


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82 X-RAY FILMPayable under Radiology Charge s, not asconsumable

83 SPUTUM CUPPayable under Investigation Charges, notas consumable

84 BOYLES APPARATUS CHARGES Part of OT Charges, not seperately

85BLOOD GROUPING AND CROSSMATCHING OF DONORS SAMPLES Part of Cost of Blood, not payable

86 Antiseptic or disinfectant lotions Not Payable -Part of Dressing Charges

87BAND AIDS, BANDAGES, STERLILEINJECTIONS, NEEDLES,SYRINGES Not Payable -Part of 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 patien t whenprescribed , otherwise included as

Dressing Charges91 BLADE Not Payable

92 APRON

Not Payable -Part of HospitalServices/Disposable linen to be part ofOT/ICU charges

93 TORNIQUET

Not Payable (service is cha rged byhospitals,consumables can not be separately charged)

94 ORTHOBUNDLE, GYNAEC BUNDLE Part of Dressing Charges

95 URINE CONTAINER Not Payable

ELEMENTS OF ROOM CHARGE

96 LUXURY TAXActual tax levied by government is payable.Part of room charge for sublimits

97 HVAC Part of room charge not payable separately

98 HOUSE KEEPING CHARGES Part of room charge not payable separately

99SERVICE CHARGES WHERENURSING CHARGE ALSO CHARGED Part of room charge not payable separately

100TELEVISION & AIR CONDITIONERCHARGES

Payable under room charges not ifseparately levied

101 SURCHARGES Part of room charge not payable separately

102 ATTENDANT CHARGES Not Payable - P art of Room Charges

103 IM IV INJECTION CHARGES Part of nursing charges, not payable

104 CLEAN SHEET ^Part of Laundry/Housekeeping not payableseparately

105

EXTRA DIET OF PATIENT(OTHERTHAN THAT WHICH FORMS PARTOF BED CHARGE) Patient Diet provided by hospital is payable

106

BLANKET/WARMER BLANKETADMINISTRATIVE OR NON-MEDICAL CHARGES Not Payable- part of room charges

107 ADMISSION KIT Not Payable


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108 BIRTH CERTIFICATE Not Payable

109

BLOOD RESERVATION CHARGESAND ANTE NATAL BOOKINGCHARGES Not Payable

110 CERTIFICATE CHARGES Not Payable

111 COURIER CHARGES Not Payable

112 CONVENYANCE CHARGES Not Payable

113 DIABETIC CHART CHARGES Not Payable

114DOCUMENTATION CHARGES /ADMINISTRATIVE EXPENSES Not Payable

115DISCHARGE PROCEDURECHARGES Not Payable

116 DAILY CHART CHARGES Not Payable

117ENTRANCE PASS / VISITORS PASSCHARGES Not Payable

118EXPENSES RELATED TOPRESCRIPTION ON DISCHARGE

To be claimed by patient under Post Hospwhere admissible

119 FILE OPENING CHARGES Not Payable

120INCIDENTAL EXPENSES / MISC.CHARGES (NOT EXPLAINED) Not Payable

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

126PATIENT IDENTIFICATION BAND /NAME TAG Not Payable

127 WASHING CHARGES Not Payable

128 MEDICINE BOX Not Payable

129 MORTUARY CHARGESPayable upto 24 hrs,shifting cha rges notpayable

130MEDICO LEGAL CASE CHARGES(MLC CHARGES) Not Payable

EXTERNAL DURABLE DEVICES

131 WALKING AIDS CHARGES Not Payable132 BIPAP MACHINE Not Payable

133 COMMODE Not Payable

134 CPAP/ CAPD EQUIPMENTS Device Not Payable

135 INFUSION PUMP - COST Device Not Payable

136OXYGEN CYLINDER (FOR USAGEOUTSIDE THE HOSPITAL) Not Payable

137 PULSEOXYMETER CHARGES Device Not Payable

138 SPACER Not Payable

139 SPIROMETRE Device Not Payable

140 SP0 2PROB E Not Payable


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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 Payable146 SPLINT Not Payable

147 DIABETIC FOOT WEAR Not Payable

148KNEE BRACES ( LONG/ SHORT/HINGED) Not Payable

149KNEE IMMOBILIZER/SHOULDERIMMOBILIZER Not Payable

150 LUMBOSACRAL BELT

Essential and should be paid specificallyfor cases who have undergone su rg e ry oflumbar spine.

151NIMBUS BED OR WATER OR AIRBED CHARGES

Payable for any ICU p atien t requiring

more th an 3 days in ICU, all patients withparaplegia /quadripiegia for any reasonand at rea sonable cost of ap proxim ate lyRs 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 postsurgery patients of major abdominalsurgery including TAH, LSCS,incisional

hern ia repair, exploratory laparotomy forintestinal liver transplant etc.obstruction,

ITEMS PA YABLE IF SUPPORTED BY A PRESCRIPTION

156

BETADINE \ HYDROGENPEROXIDE\SPIRIT\DISINFECTANTSETC

May be payable when pre sc rib ed forpatien t, not payable for hospital use in OTor ward or for dressings in hospital

157PRIVATE NURSES CHARGES-SPECIAL NURSING CHARGES

Post hospitalization nursing charges notPayable

158

NUTRITION PLANNING CHARGES -DIETICIAN CHARGESDIET

CHARGES

Patien t Diet provided by hospital is

payable

159 SUGAR FREE TabletsPayable -Sugar free variants of admissablemedicines are not excluded

160

CREAMS POWDERS LOTIONS(Toileteries are not payable,onlyprescribed medical pharmaceuticalspayable) Payable when prescribed

161 Digestion gels Payable when prescribed

162 ECG ELECTRODES

Upto 5 electrodes are required for everycase visiting OT o r ICU. For longer stay in

ICU, may req u ire a change and at leastone set every second day must be payable.


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163 GLOVES Sterilized Gloves payable /unsterilized gloves not payable

164 HIV KIT Payable - payable Preop e ra tiv e screening

165LISTERINE/ ANTISEPTICMOUTHWASH Payable when prescribed

166 LOZENGES Payable when prescribed

167 MOUTH PAINT Payable when prescribed

168 NEBULISATION KITIf used during hospitalization is payablereasonably

169 NOVARAPID Payable when prescribed

170 VOLINI GEL/ ANALGESIC GEL Payable when prescribed

171 ZYTEE GEL Payable when prescribed

172 VACCINATION CHARGESRoutine Vaccination not Payable / PostBite Vaccination Payable

PART OF HOSPITAL'S OWN COSTS AND NOT PA YA BLE

173 AHDNot Payable - Part of Hospita l's internalCost

174 ALCOHOL SWABESNot Payable - Part of Hospita l's internalCost

175 SCRUB SOLUTION/STERILLIUMNot Payable - Part of Hospita l's internalCost

OTHERS

176 VACCINE CHARGES FOR BABY Payable as per Plan

177AESTHETIC TREATMENT /SURGERY Not Payable

178 TPA CHARGES Not Payable

179 VISCO BELT CHARGES Not Payable

180

ANY KIT WITH NO DETAILSMENTIONED [DELIVERYKIT,ORTHOKIT, RECOVERY KIT,ETC] Not Payable

181 EXAMINATION GLOVES Not Payable

182 KIDNEY TRAY Not Payable

183 MASK Not Payable

184 OUNCE GLASS Not Payable

185

OUTSTATION CONSULTANT'S/

SURGEON'S FEES

Not payable, except for telemedicine

consultations w here covered by policy

186 186 OXYGEN MASK Not Payable

187 PAPER GLOVES Not Payable

188 PELVIC TRACTION BELT

Should be payable in case of PIVI)requiring trac tion as this is generally notreused

189 REFERAL DOCTOR'S FEES Not Payable

190ACCU CHECK ( Glucometery/Strips)

Not payable prehospitilasation o r posthospitalisation / Reports and Chartsrequired / Device not payable

191 PAN CAN Not Payable192 SOFNET Not Payable


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193 TROLLY COVER Not Payable

194 UROMETER, URINE JUG Not Payable

195 AMBULANCE Payable as per Plan

196 TEGADERM / VASOFIX SAFETYPayable - maximum o f 3 in 48 hrs an dthen 1 in 24 hrs

197 URINE BAG PPayable where medicaly necessary till areasonable cost - maximum 1 per 24 hrs

198 SOFTOVAC Not Payable

199 STOCKINGSEssential for case like CABG etc. where itshould be paid.

Silver Heart Pro

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