3.1ACCIDENT

Accident – An accident is a sudden, unforeseen and involuntary event caused by external and visible and violent means

3.2A.  “Acute condition” – Acute condition is a disease, illness or injury that is likely to respond quickly to treatment which aims to return the person to his or her state of health immediately before suffering the disease/illness/injury which leads to full recovery.

B.  “Chronic condition” – A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics –

i.it needs ongoing or long-term monitoring through consultations, examinations, check-ups and/or tests –

ii.it needs ongoing or long-term control or relief of symptoms

iii.it requires your rehabilitation or for you to be specially trained to cope with it

iv.it continues indefinitely

v.it comes back or is likely to come back.

3.3ALTERNATIVE TREATMENT

Alternative treatments are forms of treatments other than treatment “Allopathy” or “modern medicine” and includes Ayurveda, Unani, Siddha and Homeopathy in the Indian context.

3.4ANY ONE ILLNESS

Any one illness will be deemed to mean continuous period of illness and it includes relapse within 45 days from the date of last consultation with the Hospital / Nursing Home where treatment has been taken. Occurrence of the same illness after a lapse of 45 days as stated above will be considered as fresh illness for the purpose of this policy.

3.5CASHLESS FACILITY

Cashless facility means a facility extended by the insurer/TPA to the insured where the payments, of the costs of treatment undergone by the insured in accordance with the policy terms and conditions, are directly made to the network provider by the insurer/TPA to the extent pre-authorisation approved.

3.6CONGENITAL ANOMALY

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

a.Internal Congenital Anomaly

Which is not in the visible and accessible parts of the body.

b.External Congenital Anomaly

Which is in the visible and accessible parts of the body.

3.7CONDITION PRECEDENT

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

3.8CONTRIBUTION

Contribution is essentially the right of an insurer to call upon other insurers liable to the same insured to share the cost of an indemnity claim on a rateable proportion.

3.9DAY CARE CENTRE

Day Care centre means any insititution established for day care treatment of illness and/or injuries or a medical set-up within a hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified medical practitioner AND must comply with all minimum criteria as under :

a.Has qualified nursing staff under its employment

b.Has qualified Medical Practitioner(s) in charge

c.Has a fully equipped operation theatre of its own where surgical procedures are carried out-

d.Maintains daily records of patients and will make these accessible to the Insurance Company’s authorized personnel.3.10DAY CARE TREATMENT  - Day Care treatment  means the medical treatment and/or surgical procedure which is – (i).  Undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 hrs because of technological and (ii) which would have otherwise required a hospitalisation of more than 24 hours.   Treatment normally taken on an out-patient basis is not included in the scope of this definition.  

3.10DEDUCTIBLE

Deductible is a cost sharing requirement under a Health Insurance Policy that provides that the Insurer will not be liable for a specified rupee amount in case of Indemnity policies and for a specified number of days/hours in case of hospital cash policies which will apply before any benefits are payable by the insurer.  A deductible does not reduce the sum insured.

3.11DOMICILIARY HOSPITALISATION

Domiciliary Hospitalisation means medical treatment for an illness/disease/injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances :

a.The condition of the patient is such that he/she is not in a condition to be removed to a hospital or

b.The patient takes treatment at home on account of non-availability of room in a hospital.

3.12    GRACE PERIOD

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

3.13   HOSPITAL/NURSING HOME

A Hospital means any institution established for in-patient care and day care treatment of illness and/or injuries and which has been registered as a Hospital with the local authorities under the Clinical establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under

-Has qualified nursing staff under its employment round the clock.

-Has at least 10 in-patient beds in towns having a population of less than 10 lacs and at least 15 in-patient beds in all other places;

-Has qualified medical practitioner(s) in charge round the clock;

-Has a fully equipped Operation Theatre of its own where surgical procedures are carried out;

-Maintains daily records of patients and makes these accessible to the insurance company’s authorized personnel.

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

3.14         HOSPITALISATION

Means admission in a Hospital/Nursing Home for a minimum period of 24 In-patient care consecutive hours except for specified procedures/treatments, where such admission could be for a period of less than 24 consecutive hours.

3.15      ID CARD

ID card means the identity card issued to the insured person by the TPA to avail cashless facility in network hospitals.

3.16   ILLNESS

Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function which manifests itself during the policy period and required medical treatment.

3.17  INJURY

Injury means accidental physical bodily harm excluding illness or disease solely and directly caused by external, violent and visible and evident means which is verified and certified by a Medical Practitioner.

3.18  IN-PATIENT CARE

In-patient care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.

3.19  INTENSIVE CARE UNIT

The term “Intensive Care” unit means an identified section, ward or wing of a hospital which is under the constant supervision of a dedicated Medical Practitioner(s), and which is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards.

3.20  MEDICAL ADVISE

Medical Advise – Any consultation or advice from a Medical Practitioner including the issue of a any prescription or repeat prescription.

3.21MEDICAL EXPENSES

Medical expenses – Medical Expenses means those expenses that an Insured person has necessarily and actually incurred for medical treatment on account of illness or Accident on the advice of a Medical Practitioner, as long as these are no more than would have been payable if the Insured Person had not been insured and no more than other hospitals or doctors in the same locality would have charged for the same medical treatment.

3.22  MEDICALLY NECESARY

Medically Necessary treatment is defined as any treatment, tests, medication, or stay in hospital or part of a stay in hospital which

a.Is required for the medical management of the illness or injury suffered by the insured;

b.Must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration or intensity;

c.Must have been prescribed by a Medical Practitioner;

d.Must conform to the professional standards widely accepted in international medical practice or by the medical community in India.

3.23MEDICAL PRACTITIONER

A Medical Practitioner is a person who holds a valid registration from the Medical Council of any State of India or Medical Council of India or Council for Indian Medicine or for Homeopathy set up by the Government of India or a State Goverment and is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of licence.

The term Medical Practitioner would include Physician, Specialist and Surgeon.  (The Registered Practitioner should not be the insured or close family members such as parents, in-laws, spouse and children).

3.24NETWORK PROVIDER

Network Provider means the hospital/nursing home or health care providers enlisted by an insurer or by a TPA and insurer together to provide medical services to an insured on payment by a cashless facility.  The list of Network Hospitals is maintained by and available with the TPA and the same is subject to amendment from time to time.

Preferred Provider Network means a network of hospitals which have agreed to a cashless packaged pricing for certain procedures for the insured person.  The list is available with the company/TPA and subject to amendment from time to time.  Reimbursement of expenses incurred in PPN for the procedures (as listed under PPN package) shall be subject to the rates applicable to PPN package pricing.

3.25   NON-NETWORK HOSPITALS

 Non-Network – Any hospital, day care centre or other provider that is not part of the network.

3.26    NOTIFICATION OF CLAIM

Notification of claim is the process of notifying a claim to the insurer or TPA by specifying the timelines as well as the address/telephone number to which it should be notified.

3.27   PORTABILITY

Portability means transfer by an Individual Health Insurance Policyholder (including family cover) of the credit gained for pre-existing conditions and time-bound exclusions if he/she chooses to switch from one insurer to another.

3.28   PRE-EXISTING DISEASE

Any condition, ailment or injury or relation condition(s) for which you had signs or sumptoms, and/or were diagnosed, and/or received medical advice/treatment within 48 months to prior to the first policy issued by the insurer.

3.29 PRE – HOSPITALISATION MEDICAL EXPENSES

Relevant medical expenses incurred immediately 30 days before the Insured person is hospitalised provided that ;

a.Such Medical expenses are incurred for the same condition for which the Insured Person’s Hospitalisation was required; and

b.The In-patient Hospitalisation claim for such Hospitalisation is admissible by the Insurance Company

3.30  POST HOSPITALISATION MEDICAL EXPENSES

Relevant medical expenses incurred immediately 60 days after the Insured person is discharged from the hospital provided that ;

a.Such Medical expenses are incurred for the same condition for which the Insured Person’s Hospitalisation was required; and

b.The In-patient Hospitalisation claim for such Hospitalisation is admissible by the Insurance Company.

3.31QUALIFIED NURSE

QUALIFIED NURSE means a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any State in India and who is employed on recommendation of the attending Medical Practitioner.

3.32REASONABLE AND CUSTOMARY CHARGES

Reasonable and Customary charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of illness/injury involved.

3.33RENEWAL

Renewal defines the terms on which the contract of insurance can be renewed on mutual consent with a provision of grace period for treating the renewal continuous for the purpose of all waiting periods.

3.34   ROOM RENT

Room rent shall mean the amount charged by a hospital for the Occupancy of a bed on per day (24 hours) basis and shall include associated medical expenses.

3.35SUBROGATION

Subrogation shall  mean the right of the insurer to assume the rights of the insured person to recover expenses paid out under the policy that may be recovered from any other source.

3.36   SURGERY OR SURGICAL PROCEDURE”

Surgery or Surgical Procedure means manual and/or operative procedure(s) required for treatment of an illness or injury, correction of deformities and defects, diagnosis and cure of diseases, relief of suffering or prolongation of life, performed in a hospital or day care centre by a Medical Practitioner.

3.37“THIRD PARTY ADMINISTRATOR”

TPA  means a Third Party Administrator who holds a valid License from Insurance Regulatory and Development Authority to act as a THIRD PARTY ADMINISTRATOR and is engaged by the Company for the provision of health services as specified in the agreement between the Company and TPA.

3.38       UNPROVEN/EXPERIMENTAL TREATMENT

Treatment including drug experimental therapy which is not based on established medical practice in India, is treatment experimental or unproven.

The policy covers all the members of the family under a single Sum Insured. Family comprising of self, spouse and Dependent children can be covered.  The age of the proposer shall be between 18 and 80 years.

The Policy provides the following benefits.

I      Hospitalisation expenses
       1 Room, Boarding and Nursing expenses not exceeding 1% of the Sum Insured or actuals whichever is less.  
       2 ICU not exceeding 2% of the Sum Insured or actual whichever is less.
       3 Expenses incurred for Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees.
       4 Expenses incurred on Anesthetic, blood, oxygen, Operation theatre charges, surgical appliances, Medicines & drugs, dialysis, chemotheraphy, radiotheraphy, cost of artificial limbs, cost of prosthetic devices implanted during surgical procedure like Pacemaker, orthopaedic implants, infra cardiac valve replacements, vascular stents, relevant laboratory/diagnostic tests, x-ray and similar expenses that are medically necessary and hospitalization expenses (excluding cost of organ) incurred for donor in respect of organ transplant to the insured.
    
       Pre-hospitalisation expenses incurred upto 30 days prior to date of admission and Post-hospitalisation expenses incurred upto 60 days from the date of discharge.  Subject to a maximum limit of 10% of the Sum Insured.

       Expenses for the following illness restricted to –
       1 Cataract    -    10% of SI subject to maximum of Rs.25,000/-
       2 Hernia        -    15% of SI subject to maximum of Rs.30,000/-
       3 Hysterectomy    -    20% of SI subject to maximum of Rs.50,000/-
       4 Major surgeries    -    70% of SI subject to maximum of Rs.4 lac.

II             Day Care Treatment

    Certain specified Day Care procedures which require less than 24 hours hospitalization.

III       AYUSH TREATMENT
        Treatment taken in a Government Hospital or in any Institute recognized by the Government and/or accredited by Quality Council of India/National Accreditation Board on Health.

IV    Cashless facility in more than 7000 hospitals across Pan India.

V    No claim discount of 3% after three continuous claim free years and subsequent claim free years subject to maximum of 15%.

VI    Free Look period of 15 days shall be applicable at the inception of the first policy.

VII    Free Medical check-up once at the end of every three underwriting years provided no claims reported during the block and subject to policy renewed without any break. The limit applicable is 1% of the average Sum Insured during the preceding three policy periods.

VIII    Premium paid for self, spouse, dependent children and dependent parents are exempt from Income Tax under Section 80-D of the IT act as per rules in force.

For detailed terms and conditions, please see our Prospectus and Policy in our website.

All claims shall be paid in Indian Rupees only.

Upon happening of any event, notice of Intimation about the hospitalization or claim should be sent to the address of Insurer/TPA stated in the Policy.  In case of emergency hospitalization, notice of intimation to be sent within 24 hours from the time of hospitalization. 

Claim form should be collected on intimation of claim. The completed claim form along with all required/relevant hospitalization documents should be submitted to servicing TPA within 15 days from the date of discharge from the hospital.

For Cashless treatment, the Insured or the representative has to submit the Pre-authorisation Cashless form to TPA through the hospital where the treatment is taken.  No separate intimation is required if the pre-authorisation form is submitted immediately on admission.

In case of Reimbursement claims, the insured should submit documents in respect of the hospitalization expenses incurred within 15 days from the date of discharge from hospital.

• All Pre-existing diseases upto 48 months of continuous coverage.
• Any disease contracted during the first 30 days of inception of policy.
• Waiting period of 2/4 years for certain specified illness/treatment.
• Vaccination and Inoculation of any kind unless it is post-animal bite
• General debility and Run down conditions
• Circumcision, Cosmetic surgery, Plastic surgery.
• HIV/AIDS
• Psychiatric and psychosomatic disorders
• Injury arising out of drug/alcohol abuse.
• Pregnancy, ailments related thereto and child birth
• War, act of foreign enemy, ionizing radiation and nuclear weapon.
• Naturopathy
• Experimental or unproven treatment
• All external equipments
• Dental treatments

For detailed exclusions, please see policy in our website.