GHI IDC ESC - 2020-21 - Final

Tailor-Made Group Health Insurance Policy
(Employees, Spouse, Children)

Policy Number
Insured: ORACLE INDIA PRIVATE LIMITED
SCHEDULE
1. Policy No.
2. Period Of Insurance 01/06/2020 to 31/05/2021

3. Sum Insured Total Sum Insured INR
4. Premium INR
5. GST (@ 18%) INR
6. Total INR
7. Broker Code BRC0000019
Marsh India Insurance Brokers Pvt. Ltd.
8. Name of Insured M/s. Oracle India Pvt.Ltd-IDC
9. Address of Insured No.3, Bannerghatta Road, Bangalore – 560 029

10. Details of the Insured INR 8 lacs per family on Family Floater Basis
Family Definition: 1 + 4 - Employee + legal Spouse +

3 dependent Children below 25 yrs
No. of Employee : , Spouse & Children : Total Lives –

11. Policy Coverage As per Annexure attached
12. Name of the TPA M/S. Medi Assist India TPA Private Limited
13. Address of the TPA Medi Assist Insurance TPA Pvt. Ltd
Tower D, 4th Floor, IBC Knowledge Park,
4/1, Dairy Circle, Bannerghatta Road,
Bangalore – 560 029
14. GST Regn. No. 29AAACO0158L1ZA
15. Date of Proposal and
Declaration
In witness whereof this policy has been signed at United India Insurance Co. Ltd, Divisional
Office-III, Bangalore on this 01st Day of June 2019 .
UNITED INDIA INSURANCE COMPANY LIMITED
AUTHORISED SIGNATORY
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Policy Number
POLICY
1 WHEREAS the insured designated in the Schedule hereto has by a proposal and
declaration dated as stated in the Schedule which shall be the basis of this Contract
and is deemed to be incorporated herein has applied to UNITED INDIA INSURANCE
COMPANY LTD. (hereinafter called the COMPANY) for the insurance hereinafter set
forth in respect of Employees/Members (including their eligible family members)
named in the Schedule hereto (hereinafter called the INSURED PERSON) and has paid
premium as consideration for such insurance.
1.1 NOW THIS POLICY WITNESSES that subject to the terms, conditions, exclusions and
definitions contained herein or endorsed, or otherwise expressed hereon the
Company undertakes that if during the period stated in the Schedule or during the
continuance of this policy by renewal any insured person shall contract any disease
or suffer from any illness (hereinafter called DISEASE) or sustain any bodily injury
through accident (hereinafter called INJURY) and if such disease or injury shall
require any such insured Person, upon the advice of a duly qualified
Physician/Medical Specialist/Medical practitioner (hereinafter called MEDICAL
PRACTITIONER) or of a duly qualified Surgeon (hereinafter called SURGEON) to incur
hospitalisation/domiciliary hospitalisation expenses for medical/surgical treatment
at any Nursing Home/Hospital in India as herein defined (hereinafter called
HOSPITAL) as an inpatient, the Company will pay through TPA to the Hospital /
Nursing Home or Insured the amount of such expenses as are reasonably and
necessarily incurred in respect thereof by or on behalf of such Insured Person but
not exceeding the Sum Insured in aggregate in any one period of insurance stated
in the schedule hereto.
Coverage
1.2 In the event of any claim (s) becoming admissible under this scheme, the company
will pay through TPA to the Hospital / Nursing Home or insured person the amount
of such expenses as would fall under different heads mentioned below, and as are
reasonably and necessarily incurred thereof by or on behalf of such insured person
but not exceeding the Sum Insured in aggregate mentioned in the schedule hereto.
A. Room, Boarding and Nursing expenses as provided by the Hospital/Nursing

Home not exceeding 1% of the sum insured per day or the actual amount
whichever is less. This also includes nursing care, RMO charges, IV
Fluids/Blood transfusion/injection administration charges and similar
expenses.
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Policy Number
B. Intensive Care Unit (ICU) expenses not exceeding 2% of the sum insured per
day or actual amount whichever is less.
C. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees.
D. Anesthetic, Blood, Oxygen, Operation Theatre Charges, surgical appliances,
Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Cost of Artificial
Limbs, cost of prosthetic devices implanted during surgical procedure like
pacemaker, orthopedic implants, infra cardiac valve replacements, vascular
stents, relevant laboratory/diagnostic tests, X-ray and such similar expenses
that are medically necessary.
E. All Hospitalisation expenses (excluding cost of organ) incurred on donor in
respect of organ transplant to the insured.
Note:
1. The amount payable under 1.2 C & D above shall be at the rate applicable to the
entitled room category. In case the Insured person opts for a room with rent higher
than the entitled category as in 1.2 A above, the charges payable under 1.2 C & D
shall be limited to the charges applicable to the entitled category. This will not be
applicable in respect of medicines & drugs and implants.
2. No payment shall be made less than 1.2 C other than as part of the
hospitalisation bill.
1.2.1 Expenses in respect of the following specified illnesses/surgeries will be restricted as

detailed below:
Hospitalisation Benefits LIMITS per surgery RESTRICTED TO
a. Cataract, Hernia, a. Actual expenses incurred or 25% of the sum

Hysterectomy insured whichever is less
b. Actual expenses incurred or 70% of the Sum
b. Major surgeries* Insured whichever is less
* Major surgeries include Cardiac surgeries, Brain Tumor surgeries, Pacemaker implantation
for sick sinus syndrome, Cancer surgeries, Hip, Knee, joint replacement surgery, Organ
Transplant.
* The above limits specified are applicable per hospitalization/surgery.
1.3 Pre and Post Hospitalisation expenses payable in respect of each hospitalisation shall
be the actual expenses incurred subject to a maximum of 10% of the Sum Insured.
1.4 In addition to the above, the following would apply to claims arising out of persons
aged more than 60 years
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Policy Number
TO BE SETTLED WITH A CO-PAY ON 80:20

EXPENSES ON MAJOR ILLNESSES
BASIS. The co-pay of 20% will be applicable
CHARGED AS A TOTAL PACKAGE
on the admissible claim amount.
1.5 Expenses on Hospitalisation for minimum period of 24 hours are admissible.

However, this time limit is not applied to specific treatments, such as
1. Adenoidectomy 13. Radiotherapy 24. Inguinal/ventral/

Umbilical/femoral
hernia
2. Appendectomy 14. Lithotripsy 25. Parenteral
chemotherapy
3. Ascitic/Pleural tapping 15. Incision and drainage 26. Polypectomy
of abcess
4. Auroplasty 16. Varicocelectomy 27. Septoplasty
5. Coronary angiography 17. Wound suturing 28. Piles/fistula
6. Coronary angioplasty 18. FESS 29. Prostate
7. Dental surgery 19. Haemo dialysis 30. Sinusitis
8. Dilatation & Curettage 20. 31. Tonsillectomy
Fissurectomy/Fistulectomy
9. Endoscopies 21. Mastoidectomy 32. Liver aspiration
10. Excision of 22. Hydrocele 33. Sclerotherapy
Cyst/granuloma /Lump
11. Eye surgery 23. Hysterectomy 34. Varicose Vein Ligation
12. Fracture/dislocation
exclu-ding hairline
fracture
Or any other surgeries/procedures agreed by the TPA/Company which require less

than 24 hours hospitalisation and for which prior approval from TPA/Company is
mandatory. This condition will also not apply in case of stay in hospital of less than 24
hours provided -
1 The treatment is such that it necessitates hospitalisation and the procedure involves
specialized infrastructural facilities available in hospitals.
2 Due to technological advances hospitalisation is required for less than 24 hours only.
3 They are carried out in Day Care Centre networked by TPAs where requirement of
minimum number of beds is overlooked but having (i) fully equipped Operation
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Policy Number
Theatre, (ii) fully qualified Day Care Staff (c) fully qualified Surgeons/Post-Operative
attending Doctors.
Note 1: Procedures/treatments usually done in outpatient department are not payable

under the policy even if converted as an in-patient in the hospital for more than 24
hours or carried out in Day Care Centres.
Note 2: When treatment such as dialysis, Chemotherapy, Radiotherapy.etc is taken in
the hospital / nursing home/Day-care centre and the insured is discharged on the
same day the treatment will be considered to be taken under hospitalisation benefit
section.
1.6 For AYUSH Treatment, hospitalisation expenses are admissible only when the treatment
has been undergone 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.
1.7 Company's Liability for all claims admitted in respect of any/all insured person/s
during the period of insurance shall not exceed the Sum Insured stated in the
schedule.
2. DEFINITIONS:
2.1 ACCIDENT:
An accident is a sudden, unforeseen and involuntary event caused by external,

visible and violent means.
2.2
A. “Acute condition” – Acute condition is a disease, illness or injury that is likely to
respond quickly to treatment which aims to return the person to his or her
state of health immediately before suffering the disease/illness/injury which
leads to full recovery.
B. “Chronic condition” – A chronic condition is defined as a disease, illness, or
injury that has one or more of the following characteristics –
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.
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Policy Number
2.3 ALTERNATIVE TREATMENTS:
Alternative Treatments are forms of treatment other than treatment “Allopathy” or

“modern medicine and includes Ayurveda, unani,siddha and homeopathy in the Indian
Context.
2.4 ANY 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.
2.5 CASHLESS FACILITY:

Cashless facility “means a facility extended by the insurer to the insured where the
payments, of the cost of treatment undergone by the insured in accordance with the
policy terms and conditions, or directly made to the network provider by the insurer to
the extent preauthorisation approved.
2.6 CONGENITAL 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
2.7 CONDITION PRECEDENT:

Condition Precedent shall mean a policy term or condition upon which the Insurer’s
liability under the policy is conditional upon.
2.8 CONTRIBUTION:
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.
2.9 DAYCARE CENTRE:

A day care centre means any institution established for day care treatment of illness
and/ or injuries or a medical setup within a hospital and which has been registered with
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Policy Number
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;-
- has qualified nursing staff under its employment
- has all qualified medical practitioner(s) in charge
- has a fully equipped operation theatre of its own where surgical procedures are
carried out.
- maintains daily records of patients and will make these accessible to the insurance
companies authorized personnel.
2.10 DAY CARE TREATMENT:

Day care Treatment refers to 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 hours because of technological advancement, and
ii. Which would have otherwise required a hospitalisation of more than 24 hours.
Treatment normally taken on an outpatient basis is not included in the scope of this
definition.
2.11 DEDUCTIBLE:
Deductible is the 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 specifies 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.
2.13 DOMICILIARY HOSPITALIZATION:

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.
2.15 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.
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Policy Number
2.16 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.
2.17 HOSPITALIZATION:
Hospitalization means admission in a Hospital/Nursing Home for a minimum period of
24 consecutive hours of inpatient care except for specified procedures/treatments,
where such admission could be for a period of less than 24 consecutive hours
2.18 ID CARD:
ID Card means the identity card issued to the insured person by the TPA to avail
cashless facility in network hospitals.
2.19 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 requires medical treatment.
2.20 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.
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Policy Number
2.21 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.
2.22 INTENSIVE CARE UNIT:

Intensive Care Unit means an identifies 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.
2.23 MATERNITY EXPENSES:
Maternity expenses/treatment shall include:
a) Medical treatment expenses traceable to childbirth (including complicated deliveries
and caesarean sections incurred during hospitalization).
b) Expenses towards lawful medical termination of pregnancy during the policy period.
2.24 MEDICAL ADVICE:

Any consultation or advice from a medical practitioner/doctor including the issue of any
prescription or repeat prescription.
2.25 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.
2.26 MEDICALLY NECESSARY:

Medically necessary treatment is defined as any treatment, test, medication or stay in
hospital or part of a stay in a hospital which
- is required for the medical management of the illness or injury suffered b y the
insured;
- must not exceed the level of care necessary to provide safe, adequate and
appropriate medical care in scope, duration or intensity;
- must have been prescribed by a medical practitioner;
- must confirm to the professional standards widely accepted in international medical
practice or by the medical community in India.
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Policy Number
2.27 MEDICAL PRACTITIONER:
Medical Practitioner is a person who holds a valid registration from the Medical Council
of any State or Medical Council of India or Council for Indian Medicine or the
homeopathy set up by the Government of India or a State Government and is thereby
entitled to practice medicine within its jurisdiction; and is acting within the scope and
jurisdiction of his license. 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.)
2.28 NETWORK PROVIDER:

Network Provider means hospitals 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.
2.29 NEW BORN BABY:

A new born baby means baby born during the Policy Period aged between one day and
90 days, both days inclusive.
2.30 NON NETWORK:

Any hospital ,day care centre or other provider that is not part of the network.
2.31 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.
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Policy Number
2.32 OPD TREATMENT:

OPD Treatment is one in which the insured visits a clinic/hospital or associated facility
like a consultation room for diagnosis and treatment based on the advice of medical a
practitioner. The insured is not admitted as a day care or in-patient.
2.33 PRE-EXISTING DISEASE:

Pre Existing Disease is any condition, ailment or injury or related condition(s) for which
you had signs or symptoms, and/or were diagnosed, and/or received medical
advice/treatment, within 48 months prior to the first policy issued by the insurer.
2.34 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.
2.35 PRE – HOSPITALISATION MEDICAL EXPENSES:

Medical expenses incurred immediately 30 days before the insured person is
hospitalized will be considered as part of a claim as mentioned under Item 1.2 above
provided that;
i. such medical expenses are incurred for the same condition for which the insured
person’s hospitalization was required and
ii. the inpatient hospitalization claim for such hospitalization is admissible by the
insurance company.
2.36 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.
2.37 QUALIFIED NURSE:

Qualified Nurse is a person who holds a valid registration from the Nursing Council of
India or the Nursing Council of any state in India and/or who is employed on
recommendation of the attending medical practitioner.
2.38 REASONABLE AND CUSTOMARY CHARGES:

Reasonable 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
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Policy Number
geographical area for identical or similar services, taking into account the nature of the
illness/injury involved.
2.39 RENEWAL:
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.
2.40 ROOM RENT:

Room Rent shall mean the amount charged by the hospital for the occupancy of a bed
on per day (24 hours) basis and shall include associated medical expenses.
2.41 SUBROGATION:
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.
2.42 SURGERY:
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.
2.43 THIRD PARTY ADMINISTRATOR

TPA means a Third Party Administrator who holds a valid Licence 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.
2.44 UNPROVEN/EXPERIMENTAL TREATMENT:

Unproven/Experimental treatment is treatment, including drug Experimental therapy,
which is not based on established medical practice in India.
3. COVERAGES:
3.1 Expenses on Hospitalisation for minimum period of 24 hours are admissible.

However, this time limit is not applied to specific treatments, i.e, Dialysis,
Chemotherapy, Radiotherapy; Eye Surgery, Dental Surgery, Lithotripsy (Kidney Stone
removal), D & C, Tonsillectomy taken in the Hospital / Nursing Home and the Insured
is discharged on the same day, the treatment will be considered to be taken under
hospitalization Benefit. This condition will also not apply in case of stay in hospital of
less than 24 hours provided -
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Policy Number
1) The treatment is such that it necessitates hospitalization and the procedure

involves specialized infrastructural facilities available in hospitals.
2) Due to technological advances hospitalization is required for less than 24 hours
only.
3) They are carried out in Day Care Centre networked by TPAs where requirement
of minimum number of beds is overlooked but having (i) fully equipped Operation
Theatre, (ii) fully qualified Day Care Staff (c) fully qualified Surgeons/Post-
Operative attending Doctors.
Note: Procedures/treatments usually done in outpatient department are not payable

under the policy even if converted as an in-patient in the hospital for more than 24
hours or carried out in Day Care Centre.
1 Adenoidectomy 19 FESS
2 Appendectomy 20 Haemo dialysis
3 Ascitic/Pleural tapping 21 Fissurectomy / Fistulectomy
4 Auroplasty 22 Mastoidectomy
5 Coronary angiography 23 Hydrocele
6 Coronary angioplasty 24 Hysterectomy
7 Dental surgery 25 Inguinal/ventral/
umbilical/femoral hernia
8 D&C 26 Parenteral chemotherapy
9 Endoscopies 27
Polypectomy
10 Excision of Cyst/granuloma/lump 28
Septoplasty
11 Eye surgery 29
Piles/ fistula
12 Fracture/dislocation excluding hairline 30 Prostrate
fracture
13 Radiotherapy 31 Sinusitis
14 Lithotripsy 32 Tonsillectomy
15 Incision and drainage of abcess 33 Liver aspiration
16 Colonoscopy 34 Sclerotherapy
17 Varicocelectomy 35 Varicose Vein Ligation
18 Wound suturing
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Policy Number
Note: Procedures/treatments usually done in outpatient department are not payable under
the policy even if converted as an in-patient in the hospital for more than 24 hours or
carried out in Day Care Centre.
3.2 Domiciliary Hospitalisation means medical treatment for a period exceeding three
days for such 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.
Subject however that domiciliary hospitalisation benefits shall not cover:

i) Expenses incurred for pre and post hospital treatment and
ii) Expenses incurred for treatment for any of the following diseases:-
a. Asthma
b. Bronchitis
c. Chronic Nephritis and Nephritic Syndrome
d. Diarrhoea and all type of Dysenteries including Gastroenteritis
e. Diabetes Mellitus and Insipidus
f. Epilepsy
g. Hypertension
h. Influenza, Cough and Cold
i. All Psychiatric or Psychosomatic Disorders
10) Pyrexia of unknown Origin for less than 10 days
11) Tonsillitis and Upper Respiratory Tract infection including Laryngitis and
pharangitis
12) Arthritis, Gout and Rheumatism
Liability of the company under this clause is restricted as stated in the Schedule
attached hereto
4. EXCLUSIONS:
The company shall not be liable to make any payment under this policy in respect of any
expenses whatsoever incurred by any Insured Person in connection with or in respect of:
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Policy Number
4.1 Any Pre-existing condition(s) as defined in the policy, until 48 months of continuous
coverage of such insured person have elapsed since inception of his/her first policy
with the Company.
4.2 Any disease other than those stated in clause 4.3 below, contracted by the Insured
person during the first 30 days from the commencement date of the policy. This
exclusion shall not however, apply in case of the Insured person having been covered
under an Insurance scheme with our Company for a continuous period of preceding
12 months without any break.
4.3 During the first two years of the operation of the policy, the expenses on treatment
of diseases such as Cataract, Benign Prostatic Hyperthrophy, Hysterectomy for
Menorrhagia, or Fibromyoma, Hernia, Hydrocele, Congenital internal disease, Fistula
in anus, piles, Sinusitis and related disorders, Gall Bladder Stone removal, Gout &
Rheumatism, Calculus Diseases are not payable. Internal Congenital Disease means
anomaly which is not visible and accessible parts of the body.
4.4 During the first four years of the operation of the policy, the expenses related to
treatment of Joint Replacement due to Degenerative Condition and age-related
Osteoarthritis & Osteoporosis are not payable.
If these diseases mentioned in Exclusion no.4.3 and 4.4 (other than Congenital
Internal Diseases) are pre-existing at the time of proposal they will not be covered
even during subsequent period of renewal subject to the pre-existing disease
exclusion clause. If the Insured is aware of the existence of congenital internal
disease before inception of the policy, the same will be treated as pre-existing.
4.5 Injury / disease directly or indirectly caused by or arising from or attributable to War,
invasion, Act of Foreign enemy, War like operations (whether war be declared or not).
4.6 a. Circumcision unless necessary for treatment of a disease not excluded hereunder
or as may be necessitated due to an accident.
b. Vaccination or inoculation.
c. Change of life or cosmetic or aesthetic treatment of any description such as
correction of eyesight, etc,
d. Plastic surgery other than as may be necessitated due to an accident or as part of
any illness.
4.7 Cost of spectacles and contact lenses, hearing aids.
4.8 Dental treatment or surgery of any kind unless necessitated by accident and
requiring hospitalisation.
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Policy Number
4.9 Convalescence, general debility; run-down condition or rest cure, Obesity treatment
and its complications including morbid obesity, Congenital external disease/defects
or anomalies, treatment relating to all psychiatric and psychosomatic disorders,
infertility, Sterility, Venereal disease, intentional self-injury and use of intoxication
drugs / alcohol.
4.10 All expenses arising out of any condition directly or indirectly caused to or
associated with Human T-Cell Lymphotropic Virus Type III (HTLB - III) or
lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or Variation
Deficiency Syndrome or any syndrome or condition of a similar kind commonly
referred to as AIDS.
4.11 Charges incurred at Hospital or Nursing Home primarily for diagnosis x-ray or
Laboratory examinations or other diagnostic studies not consistent with or incidental
to the diagnosis and treatment of positive existence of presence of any ailment,
sickness or injury, for which confinement is required at a Hospital / Nursing Home.
4.12 Expenses on vitamins and tonics unless forming part of treatment for injury or
diseases as certified by the attending physician
4.13 Injury or Disease directly or indirectly caused by or contributed to by nuclear weapon

/ materials.
4.14 Treatment arising from or traceable to pregnancy, childbirth, miscarriage, abortion or
complications of any of these including caesarean section, except abdominal
operation for extra uterine pregnancy (Ectopic pregnancy), which is proved by
submission of Ultra Sonographic report and Certification by Gynaecologist that it is
life threatening one if left untreated.
4.15 Naturopathy Treatment, acupressure, acupuncture, magnetic therapies, experimental

and unproven treatments/ therapies. Treatment including drug Experimental
therapy, which is not based on established medical practice in India, is treatment
experimental or unproven.
4.16 External and or durable Medical / Non-medical equipment of any kind used for
diagnosis and or treatment including CPAP, CAPD, Infusion pump etc. Ambulatory
devices i.e., walker, crutches, Belts, Collars, Caps, Splints, Slings, Braces, Stockings,
elastocrepe bandages, external orthopaedic pads, sub cutaneous insulin pump,
Diabetic foot wear, Glucometer / Thermometer, alpha / water bed and similar related
items etc., and also any medical equipment, which is subsequently used at home etc.
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Policy Number
4.17 Genetic disorders and Stem Cell implantation/surgery.
4.18 Change of treatment from one system of medicine to another unless recommended
by the consultant/hospital under whom the treatment is taken.
4.19 Treatment for Age related Macular Degeneration (ARMD), treatment such as Rotational
Field Quantum magnetic Resonance (RFQMR), Enhanced External Counter Pulsation
(EECP), etc.
4.20 All non-medical expenses including convenience items for personal comfort such as
charges for telephone, television, ayah, private nursing/barber or beauty services,
died charges, baby food, cosmetics, tissue paper, diapers, sanitary pads, toiletry
items and similar incidental expenses.
4.21 Any kind of Service charges, Surcharges, Admission Fees/Registration Charges,

Luxury Tax and similar charges levied by the hospital
5. CONDITIONS:
5.1 Contract: the proposal form, declaration pre-acceptance health check-up and the policy
issued shall constitute the complete contract of insurance.
5.2 Every notice or communication regarding hospitalization or claim to be given or made

under this Policy shall be delivered in writing at the address of the TPA office as shown
in the Schedule. Other matters relating to the policy may be communicated to the policy
issuing office.
5.3 The premium payable under this Policy shall be paid in advance. No receipt for Premium
shall be valid except on the official form of the company signed by a duly authorized
official of the company. The due payment of premium and the observance and
fulfilment of the terms, provisions, conditions and endorsements of this Policy by the
Insured Person in so far as they relate to anything to be done or complied with by the
Insured Person shall be a condition precedent to any liability of the Company to make
any payment under this Policy. No waiver of any terms, provisions, conditions and
endorsements of this policy shall be valid unless made in writing and signed by an
authorized official of the Company.
5.4 Notice of claim: Upon the happening of any event which may give rise to a claim under
this Policy notice with full particulars shall be sent to the TPA named in the schedule
17
Policy Number
immediately and in case of emergency hospitalization within 24 hours from the time of
Hospitalisation/Domiciliary Hospitalisation
5.5 All supporting documents relating to the claim must be filed with TPA within 15 days
from the date of discharge from the hospital. In case of post-hospitalisation, treatment
(limited to 60 days), all claim documents should be submitted within 7 days after
completion of such treatment.
Note: Waiver of this Condition may be considered in extreme cases of hardship where it is
proved to the satisfaction of the Company that under the circumstances in which the
insured was placed it was not possible for him or any other person to give such
notice or file claim within the prescribed time-limit.
5.6 The Insured Person shall obtain and furnish the TPA with all original bills, receipts and
other documents upon which a claim is based and shall also give the TPA/ Company
such additional information and assistance as the TPA/Company may require in dealing
with the claim.
5.7 Any medical practitioner authorized by the TPA / Company shall be allowed to examine
the Insured Person in case of any alleged injury or disease leading to Hospitalisation if
so required.
5.8 The Company shall not be liable to make any payment under this policy in respect of any
claim if such claim be in any manner fraudulent or supported by any fraudulent means
or device whether by the Insured Person or by any other person acting on his behalf.
5.9 DISCLOSURE TO INFORMATION NORM
The Policy shall be void and all premium paid hereon shall be forfeited to the Company,
in the event of misrepresentation, misdescription or non-disclosure of any material fact.
5.10 If at the time when any claim arises under this Policy, there is in existence any other
insurance (other than Cancer Insurance Policy in collaboration with Indian Cancer
Society), whether it be effected by or on behalf of any Insured Person in respect of
whom the claim may have arisen covering the same loss, liability, compensation, costs
or expenses, the Company shall not be liable to pay or contribute more than its
rateable proportion of any loss, liability, compensation costs or expenses. The
benefits under this Policy shall be in excess of the benefits available under Cancer
Insurance Policy.
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Policy Number
5.11 The Policy may be renewed by mutual consent and in such event the renewal
premium shall be paid to the Company on or before the date of expiry of the Policy
or of the subsequent renewal thereof. The Company shall not be bound to give
notice that such renewal premium is due, provided however that if the insured shall
apply for renewal and remit the requisite premium before the expiry of this policy,
renewal shall not normally be refused, unless the Company has reasonable
justification to do so.
5.12 ENHANCEMENT OF SUM INSURED
The insured may seek enhancement of Sum Insured in writing at or before payment of
premium for renewal, which may be granted at the discretion of the Company. However,
notwithstanding enhancement, for claims arising in respect of ailment, disease or injury
contracted or suffered during a preceding policy period, liability of the company shall be
only to the extent of the Sum Insured under the policy in force at the time when it was
contracted or suffered during the currency of such renewed policy or any subsequent
renewal thereof.
Any such request for enhancement must be accompanied by a declaration that the
insured or any other insured person in respect of whom such enhancement is sought is
not aware of any symptoms or other indications that may give rise to a claim under the
policy. The Company may require such insured person/s to undergo a Medical
examination to enable the company to take a decision on accepting the request for
enhancement in the Sum Insured.
5.13 Cancellation Clause:
The Company may at any time cancel this Policy by sending the Insured 15 days notice
by registered letter at the insured’s last known address and in such event the Company
shall refund to the Insured a pro-rata premium for unexpired Period of Insurance. The
Company shall, however, remain liable for any claim, which arose prior to the date of
cancellation. The Insured may at any time cancel this Policy and in such event the
Company shall allow refund of premium at Company's short period rate only (Table
given here below) provided no claim has occurred up to the date of cancellation.
PERIOD ON RISK RATE OF PREMIUM TO BE CHARGED

Upto one month 1/4 th of the annual rate
Upto three months 1/2 of the annual rate
Upto six months 3/4th of the annual rate
Exceeding six months Full annual rate.
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Policy Number
5.14 If any dispute or difference shall arise as to the quantum to be paid under the policy
(liability being otherwise admitted) such difference shall independently of all other
questions be referred to the decision of a sole arbitrator to be appointed in writing by
the parties or if they cannot agree upon a single arbitrator within 30 days of any party
invoking arbitration, the same shall be referred to a panel of three arbitrators,
comprising of two arbitrators, one to be appointed by each of the parties to the
dispute/difference and the third arbitrator to be appointed by such two arbitrators and
arbitration shall be conducted under and in accordance with the provisions of the
Arbitration and Conciliation Act, 1996.
It is clearly agreed and understood that no difference or dispute shall be referable to

arbitration as herein before provided, if the Company has disputed or not accepted
liability under or in respect of this Policy.
It is hereby expressly stipulated and declared that it shall be a condition precedent to

any right of action or suit upon this policy that award by such arbitrator/arbitrators of
the amount of the loss or damage shall be first obtained.
5.15 If the TPA, as per terms and conditions of the policy or the Company shall disclaim
liability to the Insured for any claim hereunder and if the Insured shall not within 12
calendar months from the date or receipt of the notice of such disclaimer notify the
TPA/ Company in writing that he does not accept such disclaimer and intends to recover
his claim from the TPA/Company then the claim shall for all purposes be deemed to
have been abandoned and shall not thereafter be recoverable hereunder.
5.16 All medical/surgical treatments under this policy shall have to be taken in India and
admissible claims thereof shall be payable in Indian currency. Payment of claim shall
be made through TPA to the Hospital/Nursing Home or the Insured Person as the case
may be.
5.17 Low Claim Ratio Discount (Bonus)
Low Claim Ratio Discount at the following scale will be allowed on the total premium
at renewal only depending upon the incurred claim ratio for the entire group insured
under the Group Mediclaim Insurance Policy for the preceding 3 completed years
excluding the year immediately preceding the date of renewal where the Group
Mediclaim Insurance Policy has not been in force for 3 completed years, such shorter
period of completed years excluding the year immediately preceding the date of
renewal will be taken in to account
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Policy Number
Incurred Claim ratio under Discount %

the group policy
Not exceeding 60% 5%
Not exceeding 50% 15 %
5.18 High Claims Ratio Loading (MALUS)
The total premium payable at renewal of the Group Policy will be loaded at the
following scale depending upon the incurred claims ratio for the entire group
insured under the Group Mediclaim Insurance Policy for the preceding year
(immediately preceding the date of renewal).
Incurred claims ratio under Loading

this group policy
Between 70% and 100% 25 %
Between 101% and 125 % 55 %
Between 126 % and 150 % 90 %
Between 151 % and 175 % 120 %
Between 176 and 200 150%
Over 200 % Cover to be reviewed
Note:
1. Low Claim Ratio Discount (Bonus) or High Claim Ratio loading (Malus) will be
applicable to the Premium at renewal of the Policy depending on the incurred
claims Ratio for the entire Group Insured.
2. Incurred claim would mean claims paid plus claims outstanding in respect of the
entire group insured under the policy during the relevant period.
The insured shall throughout the period of insurance keep and maintain a proper
record of register containing the names of all the insured persons and other relevant
details as are normally kept in any institution/ Organisation. The insured shall
declare to the company any additions in the number of insured persons as and when
arising during the period of insurance and shall pay the additional premium as
agreed.
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Policy Number
It is hereby agreed and understood that, that this insurance being a Group Policy
availed by the Insured covering Members, the benefit thereof would not be available
to Members who cease to be part of the group for any reason whatsoever.
Such members may obtain further individual insurance directly from the Company
and any claims shall be governed by the terms thereof.
6 MATERNITY EXPENSES BENEFIT EXTENSION: (Wherever applicable)
This is an optional cover, which can be obtained on payment of 10% of total basic
premium for all the Insured Persons under the Policy.
Option for Maternity Benefits has to be exercised at the inception of the Policy period
and no refund is allowable in case of Insured's cancellation of this option during
currency of the policy.
The hospitalization expenses in respect of the new born child can be covered within
the Mother’s Maternity expenses. The maximum benefit allowable under this clause
will be up to Rs. 40,000/- or the sum insured opted by the group whichever is lower.
Special conditions applicable to Maternity expenses Benefit Extension:

1. These Benefits are admissible only if the expenses are incurred in Hospital /
Nursing Home as in-patients in India
2. A waiting period of 9 months is applicable for payment of any claim relating
to normal delivery or caesarean section or abdominal operation for extra
uterine pregnancy. The waiting period may be relaxed only in case of delivery,
miscarriage or abortion induced by accident or other medical emergency.
3. Claim in respect of delivery for only first two children and / or operations
associated therewith will be considered in respect of any one Insured Person
covered under the policy or any renewal thereof. Those Insured Persons who
are already having two or more living children will not be eligible for this
benefit.
4. Expenses incurred in connection with voluntary medical termination of
pregnancy during the first 12 weeks from the date of conception are not
covered.
5. Pre-natal and postnatal expenses are not covered unless admitted in Hospital
/ Nursing Home and treatment is taken there.
Note: When group policy is extended to include Maternity Expenses Benefit, the
exclusion No.4.14 of the policy stands deleted.
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Policy Number
10 IMPORTANT NOTICE
The Company may revise any of the terms, conditions and exceptions of this insurance
including the premium payable on renewal in accordance with the guidelines/rules framed
by the Insurance Regulatory and Development Authority (IRDA). We shall notify you of such
changes at least three months before the revision are to take effect.
The Company may also withdraw the insurance as offered hereunder after following the due
process as laid down by the IRDA and we shall offer to cover you under such revised/new
covers for which we shall have obtained from the Authority at such terms, conditions,
exceptions and premium that the IRDA may have approved.
Issuing office
For United India Insurance Company Limited
Divisional Office III
No. 93, 1st Floor, T K N Mansion, K H Road,
BANGALORE – 560 027
Duly Constituted Attorney
23
Policy Number
ANNEXURE TO POLICY NO.
It is hereby declared and agreed that the coverage under the above policy stands amended
as under :-
1. Sum insured INR 8 lacs on family floater basis covered for employee + legal spouse +
3 dependent children.
Family definition: 1 + 4- employee + spouse + 3 dependent children covered in the

policy (Below 25 yrs age for children)
2 Pre – existing diseases stand covered.
Deletion of exclusion clause no 4.1.
3. 30 days, first year, second year and fourth year exclusions stand deleted.
Deletion of exclusion clause numbers 4.2, 4.3 and 4.4.
4. Pre and post hospitalization expenses are restricted up to 30 days prior to date of
admission and 60 days from the date of discharge respectively. No sublimit is
applicable for pre & post hospitalization claim.
5. The limits under clause 1.2a, 1.2b, 1.2.1, 1.3 and 1.4 of the policy stands deleted
Note 1 on clause no 1.2 stands deleted
6. The exclusion under clause no 4.1, 4.2, 4.3, 4.4 , 4.5, 4.10, 4.13, 4.14, 4.17 & 4.19
stands deleted -only ARMD covered including but limited to cover for avastin injection,
Intravitreal accentrix injection
7. Waiver of 9 months waiting period for maternity expenses
8. Maternity expenses are covered with a sublimit of INR 75,000.
If both claimant and spouse are employed in oracle, the maximum payable amount
against maternity would be up to the combined maternity limit (up to INR 150,000
subject to co-pay conditions).
All children irrespective of the number shall be covered in the event of the mother
delivering twins or more children in the second maternity irrespective of the no. of
children being one or two, from the first maternity.
All female members are entitled to cost of 2 successful deliveries or associated

procedures up to the maternity sub limit irrespective of living children in the family.
Life threatening conditions during period will be part of sum assured not to be
restricted to maternity limit.
If insured already has 2 or more living children, then children from second maternity
not covered.
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Policy Number
Coverage in case of twins, triplets or more:
All children irrespective of the number shall be covered in the event of the mother
delivering twins or more children for the first two deliveries with living children.
For maternity claims, if one of the spouse working at oracle and insured in the
program and the other is insured with some other company, the employee may first
claim up to INR 75,000 from oracle policy and the balance, if required from the other
company.
Alternatively if the employee chooses to first claim from other company policy, then
the balance can be claimed from the oracle policy subject to the maternity sub limit of
INR 75,000.
Pre and Post-hospitalization Expenses under Maternity:
1. Expenses (IPD and OPD) for Pre-Natal before 8 months from date of delivery, and
Post Natal up to 60 days from date of delivery are covered within the maternity
sublimit of INR 75,000. Pharmacy is excluded from OPD coverage.
2. Well baby charges - covered up to 5,000 within the maternity limit
3. Pre-natal claims to be submitted along with the maternity claim (irrespective of

policy period) and total payout shall be restricted to INR 75,000 per delivery.
9. Expenses incurred in respect of new born baby would be covered from day one subject
to the insurers being intimated about the birth of the child within 90 days of birth.
If the baby has to be hospitalized for any illness, disease or injury for eg. If the baby
has jaundice or some other medical problem then the family floater sum insured would
apply.
10. Internal congenital diseases covered.
External congenital diseases stand covered for members whose age is less than 6
years.
12. Hospitalization expenses arising out of terrorist activities stand covered.
13. Co-payment:
Employees – Nil
Spouse and children – 10% of the admissible claim amount
(if the applicable claim amount after deducting the claim co pay is greater than the
sum insured then claim settled would be up to sum insured)
Admissible expenses are arrived after deducting non-payables, then co-pay to be
25
Policy Number
deducted, the balance is payable up to SI / defined limit like maternity, dental

treatment and such similar capped ailments
14. Dental treatment is covered up to a floater amount of INR 12,000 for ESC. For
members who are enrolled as single individuals (i.e. spouse or children are not
enrolled), will have a coverage upto INR 5,000. Crown/cap treatments are also covered
as a part of the policy, upto the sublimit.
Cleaning, scaling and cosmetic treatments are not payable under dental
treatment/claims.
15. There is no corporate buffer
16. Employees would be covered under critical illness hospitalization expenses up to a
maximum of INR 1,500,000 (15 lacs) per employee per annum over and above the
existing group medical insurance policy coverage. The total payout shall not exceed
critical illness buffer of INR 15,000,000 (1.5 crore) per annum for employees IDC Ltd.,
IN and OSSI entities.
Spouse and children would be covered under critical illness hospitalization expenses
up to a combined floater of INR 1,000,000 (10 lacs) per annum over and above the
existing group medical insurance policy coverage. The total payout shall not exceed
critical illness buffer of INR 10000,000 (1 crore) per annum, for spouse and children
combined for IDC Ltd., IN and OSSI entities.
This additional critical illness amount will be allowed only after the existing GMC limits
are exhausted.
The critical illness coverage will be applicable for life-threatening medical conditions
including but not limited to major ailments such as:
1. Cancer
2. Myocardial Infarction (Heart attack)
3. Open Chest CABG
4. Open Heart Replacement or Heart Valve(s) surgery
5. Coma
6. Kidney Failure
7. Stroke
8. Major Organ / Bone Marrow transplant
9. Paralysis
10. Motor Neuron disease
11. Multiple Sclerosis
12. Angioplasty
13. Benign Brain Tumor
14. Blindness
26
Policy Number
15. Deafness
16. Lung failure
17. Liver failure
18. Loss of Speech
19. Loss of Limbs
20. Major Head Trauma
21. Pulmonary Hypertension
22. Third Degree Burns
23. Accident related hospitalization.
24. Aorta graft surgery & Coronary artery bypass surgery
17. All supporting documents relating to the claim must be filed with the TPA within 60
days from the date of discharge from the hospital. In case of post-hospitalization,
treatment (limited to 60 days), all claim documents should be submitted within 7 days
after completion of post hospitalization treatment.
18. Ambulance cover up to INR 3,000 per person per policy period in case of emergency.
Eg. From one hospital to another hospital / diagnostic centre for better care /
diagnosis. From home to hospital
19. Enhanced day care procedures and standard day care surgeries/ treatments / any
minor surgery requiring lesser than 24 hrs of treatment such as per attached list in the
subsequent sheet and any hospitalization less than 24 hrs treatment availed due to
advancement of technology is covered which is approved by IMA regulations.
20. Medical expenses for donors of organs covered within the family SI. However, cost of
organ is not covered.
21. Payment of medical expenses in case treatment of fracture / dislocation of bones or
joints for lesser than 24 hour hospitalization cases within the GMC cover (Hairline
fracture is an exclusion). Payment of medical expenses related to fracture
injuries/dislocation of bone joints under less than 24 hours hospitalization clause.
22. Treatment for correction of eyesight power beyond or equal to (+) /(-) 4.5 covered
( Lasik surgery)
23. Cyber knife treatment covered up to sum insured as per applicable policy terms &
conditions
24. Cataract cover with multifocal lens ( Rs. 50,000 capping per eye)
25. Robotic surgery stands covered up to sum insured for any medical contingency &
treatment, which other will stand covered as per the applicable policy terms. Usage of
robotic surgery approach will not result in capping.
26. Annual premium of the members are as mentioned below :-

Per employee / legal spouse / dependent children – INR 5,526 excluding service tax
per member
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Policy Number
27. Domiciliary hospitalization stands covered

29. Admissibility of expenses towards biodegradable stent is covered up to sum insured as
per the applicable policy terms & conditions.
30. Ayurvedic/ AYUSH treatment (AYUSH treatment covers Ayurveda, Unani, Siddha and
Homeopathy)
Below guidelines to be followed:
1. For AYUSH treatment, hospitalization expenses are admissible only when the
treatment has been undergone 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.
2. Prior intimation and approval of 72 hrs required for all AYUSH claims. Nature of
treatment and the treating doctor’s advice on the hospitalization procedure to be
taken in advance.
3. Treatment to be supported by diagnostic tests done by the treating doctor.
The AYUSH rates will be restricted to the government prescribed rates.

31. Any sub limits for room rent, nursing and surgeon’s fee etc are waived off.
32. Proportional deduction on opting higher room rent than eligibility is not applicable.
33. Emergency hospitalization (as per the treating doctor) to be covered under the policy
even though there is no active line of treatment for IPD cases only. Diagnostic cases (in
case of any claim from oracle employees / dependents where an active line of
treatment is not present but certain diagnostic tests are carried out to rule out the
presence of any condition / ailment due to an emergency hospitalization, has to be
referred to insurance company by TPA for a favorable consideration of the claim
amount subject to referring all such claim files to insurer for approval on case to case
basis depending on merits.) However, Medical emergency shall be determined as per
medical / treatment protocols (a mere certification by the treating doctor will not
suffice)
34. Treatments for Genetic Diseases are covered for all types of treatments except for
cosmetic purposes. Treatments that are under clinical trial in India are not covered.
35. Stem Cell Therapy/ Bone Marrow transplant will stand covered for all ailments but not
limited to marrow such as leukemia, lymphoma, and multiple myeloma and certain
blood disease such as Sickle Cell Anaemia, Thalassaemia.
36. Policy to cover expense incurred towards an advanced form of medical procedure or
technology as prescribed by the treating doctor to treat any medical condition that
otherwise stand covered and limit for same will be as applicable in policy terms. Claim
should not be denied / restricted on the grounds of usage of any advancement in
medical science and technology, subject to such a form of procedure and technology
not being an experimental/ clinical trial in India subject to the mandated IRDA
guidelines.
37. HIV/ AIDS exclusion will stand waived for any IPD treatments related HIV/ AIDS and/ or
28
Policy Number
caused by reduced immunity levels on account of same.

38. Exclusion of External device will be waived off specifically for but not limited to Bionic
Ear, Prosthetic Implant, ICL Implant covered. The cost of medical surgery and the cost
of device will stand covered in the policy.
39. Infertility treatment
Treatment for infertility is covered up to INR 75,000 on a family floater basis for
employee and spouse. This is separate from maternity benefit.
Medical expenses are covered for diagnostic infertility services to determine the cause
of infertility, treatment and procedures, as in-patient hospitalization, day care or OPD
treatment.
Cover is offered but not limited to fertility hormones, artificial insemination, and
surgery and assisted reproductive technology (ART).
Exclusions: infertility services for persons who have undergone voluntary sterilization
procedures, and infertility services for women with natural menopause.
40. Mental illness & psychiatric treatment
All types of treatment procedures and consultations for mental illnesses and
psychiatric treatments are covered, as below.
 Hospitalization (IPD) coverage of up to INR 100,000.
 Additional OPD coverage up to INR 30,000 for all types of diagnostics, treatment,
therapy, consultation and prescribed drugs administered as part of the treatment
within the hospital/clinic.
 For OPD coverage, expenses for ongoing medications/pharmacy administered
outside of hospital/clinic are not payable.
 The treatment must be administered under the direct control of a hospital or
registered psychiatrist doctor
41. Obesity/ Weight Control: Expenses related to the surgical treatment of obesity that
does not fulfil all the below conditions:
1. Surgery to be conducted is upon the advice of the Doctor
2. The surgery/Procedure conducted should be supported by clinical protocols
3. The member has to be 18 years of age or older and
4. Body Mass Index (BMI): a. greater than or equal to 40 or b. greater than or equal to
35 in conjunction with any of the following severe comorbidities following failure of
less invasive methods of weight loss: i. Obesity-related cardiomyopathy ii. Coronary
heart disease iii. Severe Sleep Apnea iv. Uncontrolled Type2 Diabetes
42. Sex reassignment surgery (SRS)

Sexual reassignment surgery is covered up to a sublimit of INR 75,000 for employees
only.
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Policy Number
43. Treatment/Therapy coverage for Differently Abled members

All types of treatment procedures and consultations are covered for differently abled
members, as below.
 Hospitalization (IPD) coverage of up to INR 100,000.
 Additional OPD coverage up to INR 30,000 for all types of diagnostics, treatment,
therapy, consultation and prescribed drugs administered as part of the treatment
within the hospital/clinic.
 For OPD coverage, expenses for ongoing medications/pharmacy administered
outside of hospital/clinic are not payable.
 All categories of disability, including genetic and physical disabilities including but
not limited to the hearing impaired, speech impaired, blind or orthopedically
disabled are covered..
44. CRTD & Pacemaker
Replacement of battery for either of CRTD or Pacemaker is covered up to a sublimit of
INR 500,000.
45. Transgenders are covered in the policy
46. Payment of medical expenses in case treatment of fracture / dislocation of bones or
joints for lesser than 24-hour hospitalization cases within the GMC cover (sprain,
hairline fracture to be included). Payment of medical expenses related to fracture
injuries/dislocation of bone joints under less than 24 hours hospitalization clause.
List of Day Care Procedures:
Microsurgical Operations on the Middle Ear

1. Stapedotomy
2. Stapedectomy
3. Revision of a stapedectomy
4. Other operations on the auditory ossicles
5. Myringoplasty (Type -I Tympanoplasty)
6. Tympanoplasty (closure of an eardrum perforation/reconstruction of the auditory ossicles)
7. Revision of a tympanoplasty
8. Other microsurgical operations on the middle ear
Other operations on the middle & internal ear
9. Myringotomy
10. Removal of a tympanic drain
11. Incision of the mastoid process and middle ear
12. Mastoidectomy
13. Reconstruction of the middle ear
14. Other excisions of the middle and inner ear
15. Fenestration of the inner ear
16. Revision of a fenestration of the inner ear
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Policy Number
17. Incision (opening) and destruction (elimination) of the inner ear

18. Other operations on the middle and inner ear
Operations on the nose & the nasal sinuses
19. Excision and destruction of diseased tissue of the nose
20. Operations on the turbinates (nasal concha)
21. Other operations on the nose
22. Nasal sinus aspiration
Operations on the eyes
23. Incision of tear glands
24. Other operations on the tear ducts
25. Incision of diseased eyelids
26. Excision and destruction of diseased tissue of the eyelid
27. Operations on the canthus and epicanthusv
28. Corrective surgery for entropion and ectropion
29. Corrective surgery for blepharoptosis
30. Removal of a foreign body from the conjunctiva
31. Removal of a foreign body from the cornea
32. Incision of the cornea
33. Operations for pterygium
34. Other operations on the cornea
35. Removal of a foreign body from the lens of the eye
36. Removal of a foreign body from the posterior chamber of the eye
37. Removal of a foreign body from the orbit and eyeball
38. Operation of cataract
Operations on the skin & subcutaneous tissues
39. Incision of a pilonidal sinus
40. Other incisions of the skin and subcutaneous tissues
41. Surgical wound toilet (wound debridement) and removal of diseased tissue of the skin and
subcutaneous tissues
42. Local excision of diseased tissue of the skin and subcutaneous tissues
43. Other excisions of the skin and subcutaneous tissues
44. Simple restoration of surface continuity of the skin and subcutaneous tissues
45. Free skin transplantation, donor site
46. Free skin transplantation, recipient site
47. Revision of skin plasty
48. Other restoration and reconstruction of the skin and subcutaneous tissues.
49. Chemosurgery to the skin.
50. Destruction of diseased tissue in the skin and subcutaneous tissues
Operations on the tongue
51. Incision, excision and destruction of diseased tissue of the tongue
52. Partial glossectomy
53. Glossectomy
54. Reconstruction of the tongue
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Policy Number
55. Other operations on the tongue

Operations on the salivary glands & salivary ducts
56. Incision and lancing of a salivary gland and a salivary duct
57. Excision of diseased tissue of a salivary gland and a salivary duct
58. Resection of a salivary gland
59. Reconstruction of a salivary gland and a salivary duct
60. Other operations on the salivary glands and salivary ducts
Other operations on the mouth & face
61. External incision and drainage in the region of the mouth, jaw and face
62. Incision of the hard and soft palate
63. Excision and destruction of diseased hard and soft palate
64. Incision, excision and destruction in the mouth
65. Plastic surgery to the floor of the mouth
66. Palatoplasty
67. Other operations in the mouth
Operations on the tonsils & adenoids
68. Transoral incision and drainage of a pharyngeal abscess
69. Tonsillectomy without adenoidectomy
70. Tonsillectomy with adenoidectomy
71. Excision and destruction of a lingual tonsil
72. Other operations on the tonsils and adenoids
Operations on the digestive tract

80. Incision and excision of tissue in the perianal region
81. Surgical treatment of anal fistulas
82. Surgical treatment of haemorrhoids
83. Division of the anal sphincter (sphincterotomy)
84. Other operations on the anus
85. Ultrasound guided aspirations
86. Sclerotherapy etc.
87. Appendectomy
Operations on the female sexual organs
87. Incision of the ovary
88. Insufflation of the Fallopian tubes
89. Other operations on the Fallopian tube
90. Dilatation of the cervical canal
91. Conisation of the uterine cervix
92. Other operations on the uterine cervix
93. Incision of the uterus (hysterotomy)
94. Therapeutic curettage
95. Culdotomy
96. Incision of the vagina
97. Local excision and destruction of diseased tissue of the vagina and the pouch of Douglas
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Policy Number
98. Incision of the vulva

99.Operations on Bartholin’s glands (cyst)
Operations on the prostate & seminal vesicles
100. Incision of the prostate
101. Transurethral excision and destruction of prostate tissue
102. Transurethral and percutaneous destruction of prostate tissue
103. Open surgical excision and destruction of prostate tissue
104. Radical prostatovesiculectomy
105. Other excision and destruction of prostate tissue
106. Operations on the seminal vesicles
107. Incision and excision of periprostatic tissue
108. Other operations on the prostate
Operations on the scrotum & tunica vaginalis testis
109. Incision of the scrotum and tunica vaginalis testis
110. Operation on a testicular hydrocele
111. Excision and destruction of diseased scrotal tissue
112. Plastic reconstruction of the scrotum and tunica vaginalis testis
113. Other operations on the scrotum and tunica vaginalis testis
Operations on the testes
114. Incision of the testes
115. Excision and destruction of diseased tissue of the testes
116. Unilateral orchidectomy
117. Bilateral orchidectomy
118. Orchidopexy
119. Abdominal exploration in cryptorchidism
120. Surgical repositioning of an abdominal testis
121. Reconstruction of the testis
122. Implantation, exchange and removal of a testicular prosthesis
123. Other operations on the testis
Operations on the spermatic cord, epididymis und ductus deferens
124. Surgical treatment of a varicocele and a hydrocele of the spermatic Cord
125. Excision in the area of the epididymis
126. Epididymectomy
127. Reconstruction of the spermatic cord
128. Reconstruction of the ductus deferens and epididymis
Operations on the penis
130. Operations on the foreskin
131. Local excision and destruction of diseased tissue of the penis
132. Amputation of the penis
133. Plastic reconstruction of the penis
134. Other operations on the penis
Operations on the urinary system
33
Policy Number
135. Cystoscopical removal of stones

Other Operations
136. Lithotripsy
137. Coronary angiography
138. Haemodialysis
139. Radiotherapy for Cancer
140. Cancer Chemotherapy
141. Ascitic/Pleural tapping
142. Auroplasty
143. Coronary Angioplasty
144. Dental Surgery
145. D&C
146. Endoscopies
147. Excision of cysts/granuloma/lump
148. Eye surgery
149. Fracture/dislocation excluding hairline fracture
150. Colonoscopy
151. FESS
152. Inguinal/ventral/umbilical/femoral hernia
153. Polypectomy
154. Piles/fistula
155. Sinusitis
156. Liver aspiration
157. Varicose Vein Ligation
158. Wound suturing
159. Septoplasty
160. Incision and drainage of abcess
161. fissureectomy/Fistulectomy
162. Varicocelectomy
FOR UNITED INDIA INSURANCE COMPANY LIMITED
AUTHORISED SIGNATORY
34

GHI IDC ESC - 2020-21 - Final

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Tailor-Made Group Health Insurance Policy

(Employees, Spouse, Children)

2. Period Of Insurance 01/06/2020 to 31/05/2021

9. Address of Insured No.3, Bannerghatta Road, Bangalore – 560 029

Family Definition: 1 + 4 - Employee + legal Spouse +

No. of Employee : , Spouse & Children : Total Lives –

UNITED INDIA INSURANCE COMPANY LIMITED

A. Room, Boarding and Nursing expenses as provided by the Hospital/Nursing

1.2.1 Expenses in respect of the following specified illnesses/surgeries will be restricted as

Hospitalisation Benefits LIMITS per surgery RESTRICTED TO

a. Cataract, Hernia, a. Actual expenses incurred or 25% of the sum

TO BE SETTLED WITH A CO-PAY ON 80:20

1.5 Expenses on Hospitalisation for minimum period of 24 hours are admissible.

1. Adenoidectomy 13. Radiotherapy 24. Inguinal/ventral/

Or any other surgeries/procedures agreed by the TPA/Company which require less

Note 1: Procedures/treatments usually done in outpatient department are not payable

An accident is a sudden, unforeseen and involuntary event caused by external,

2.3 ALTERNATIVE TREATMENTS:

Alternative Treatments are forms of treatment other than treatment “Allopathy” or

2.4 ANY ONE ILLNESS:

2.5 CASHLESS FACILITY:

2.6 CONGENITAL ANOMALY:

2.7 CONDITION PRECEDENT:

2.9 DAYCARE CENTRE:

2.10 DAY CARE TREATMENT:

2.13 DOMICILIARY HOSPITALIZATION:

2.15 GRACE PERIOD:

2.16 HOSPITAL / NURSING HOME:

2.21 IN PATIENT CARE:

2.22 INTENSIVE CARE UNIT:

2.24 MEDICAL ADVICE:

2.25 MEDICAL EXPENSES:

2.26 MEDICALLY NECESSARY:

2.27 MEDICAL PRACTITIONER:

2.28 NETWORK PROVIDER:

Preferred Provider Network means a network of hospitals which have agreed to a

2.29 NEW BORN BABY:

2.30 NON NETWORK:

2.31 NOTIFICATION OF CLAIM:

2.32 OPD TREATMENT:

2.33 PRE-EXISTING DISEASE:

2.35 PRE – HOSPITALISATION MEDICAL EXPENSES:

2.36 POST HOSPITALISATION MEDICAL EXPENSES:

2.37 QUALIFIED NURSE:

2.38 REASONABLE AND CUSTOMARY CHARGES:

2.40 ROOM RENT:

2.43 THIRD PARTY ADMINISTRATOR

2.44 UNPROVEN/EXPERIMENTAL TREATMENT:

3.1 Expenses on Hospitalisation for minimum period of 24 hours are admissible.

1) The treatment is such that it necessitates hospitalization and the procedure

Note: Procedures/treatments usually done in outpatient department are not payable

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

Subject however that domiciliary hospitalisation benefits shall not cover:

4.7 Cost of spectacles and contact lenses, hearing aids.

4.13 Injury or Disease directly or indirectly caused by or contributed to by nuclear weapon

4.15 Naturopathy Treatment, acupressure, acupuncture, magnetic therapies, experimental

4.17 Genetic disorders and Stem Cell implantation/surgery.

4.21 Any kind of Service charges, Surcharges, Admission Fees/Registration Charges,

5.2 Every notice or communication regarding hospitalization or claim to be given or made