ReAssure 2.0 - Policy Wording
ReAssure 2.0 - Policy Wording
ReAssure 2.0 - Policy Wording
0 - Policy Wordings
1. Preamble
This Policy covers Allopathic and AYUSH treatments taken in India ONLY.
2. Definitions
It is IMPORTANT You should go through the definition of some words used in the policy. Definition of these may vary from the common understanding and
colloquial meaning. If a word is not specifically defined in the following section, it’s common meaning will apply.
2.2.1. Base Sum Insured means the coverage amount for which the premium is computed and charged for this policy.
2.2.2. Insured Person is the one for whom the company has received full premium (including additional premium if any), completed the risk
assessment and issued the policy. The names of the Insured persons covered in the policy are specified in the policy document, who are also
referred as You/Your/Policyholder in this policy.
2.2.3. Partner Network means Hospital, Diagnostic Centers, Clinics, Doctors, Health Care Workers, empanelled by the Insurer and/or by a
consolidated organization to provide health related medical services.
2.2.4. Policy Year means the period of one year from the date of commencement of the policy.
3. Sum Insured(s)
The product offers you so much more! More benefits, More options and More Sum Insured. Sum Insured will be utilized as per following sequence in event of
any claim:
1. Base Sum Insured
2. Booster+ Sum Insured
3. Safeguard/Safeguard+ Sum Insured
4. ReAssure+/ReAssureX
NOTE: A limit of maximum INR 1,00,000 per claim will apply to all robotic surgeries, except for total radical prostatectomy, cardiac
surgeries, partial nephrectomy and surgeries for malignancies.
4.3. Expenses before and after hospitalization (Pre & Post hospitalization)
We will pay expenses incurred on consultations, medicines, physiotherapy, diagnostic tests for 60 days before the date of admission and 180 days
after date of discharge IF these are related to the condition for which hospitalization claim is paid.
If you donate any of your organs, we will pay for the expenses for harvesting the organ from you. We respect this noble deed. Remember, organ
donation saves many lives.
4.6. Annual Health Checkup
Available once every Policy Year, from day 1 of the policy. You can choose any test(s) from the list specified below up to your eligibility limit. The tests
MUST be booked through our digital assets (e.g. Mobile App). This benefit is available ONLY on cashless and no re-imbursement is allowed.
10 Lakhs from
Base Sum ReAssure+ ReAssure+ (this 10 Lakh will
Insured and trigger unlimited
5 Lakhs from times)
ReAssure+
10 Lakh from
10 Lakh 10 Lakh 15 Lakh Nil 12 Lakh 10 Lakh Nil 10 Lakh ReAssureX
4.9. Booster+
Don’t lose what you don’t use.
Unutilized Base Sum Insured carries forward. Maximum it will accumulate up to 3/5/10 times (based on the plan you have chosen) of the Base Sum
Insured.
Example: If you have chosen Base Sum Insured of INR 10 lakh and Titanium+ Variant, then at the end of 10 years (if you have made no claims in
these years) you will have
1.10 Crore Sum Insured (that is 10 Lakh base + 1 Crore Booster+). Don’t forget that you would have the Safeguard / Safeguard+ (this is a great
benefit. You must choose it) and ReAssure “Forever” (in case of claim) over and above the 1.10 Crore.
That’s 11 times of Base Sum Insured than what you paid for.
Optional Benefit:
4.14. Hospital Cash
We will pay for an Insured, an additional fixed amount for each day’s hospitalization for maximum up to 30 days. One day is considered as 24
continuous hours of hospitalization.
Note: we will pay if you were hospitalized for 48 hours or more continuously.
4.17. Safeguard+
4.17.1. Claim Safeguard+: We will cover non-payable items mentioned in ‘List I,II,III,IV of Annexure I’. Clause 2.1.36 for Reasonable and Customary
Charges will still apply.
4.17.2. Booster+ Safeguard+: Booster+ will not be impacted if the total claim in a policy year is up to INR 1,00,000.
4.17.3. Sum Insured Safeguard+: Preserves the value of Sum Insured. Safeguards it against inflation. We will increase the Base Sum Insured on cumulative
basis at each renewal by the rate of inflation in the previous year. Inflation rate would be the average consumer price index (CPI) of the entire
calendar year published by the Central Statistical Organization (CSO).
Note: You will lose all accumulated Sum Insured Safeguard+ if you opt out of this benefit at any point in time.
Note: You can either choose Safeguard or Safeguard+ at a given point in time.
5. Exclusions
5.1. Standard Exclusions
5.1.1. Pre-existing Diseases (Code–Excl01):
a. Expenses related to the treatment of a Pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 36 months
(48 months for Bronze, Silver & Gold Variants) of continuous coverage after the date of inception of the first Policy with Us.
b. In case of enhancement of Sum Insured the exclusion shall apply afresh to the extent of Sum Insured increase.
c. If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health
Insurance) Regulations, then waiting period for the same would be reduced to the extent of prior coverage.
d. Coverage under the Policy after the expiry of 36 months (48 months for Bronze, Silver & Gold Variants) for any Pre-existing Disease is
subject to the same being declared at the time of application and accepted by Us.
5.1.2. Specified disease/procedure waiting period (Code- Excl02)
a. Expenses related to the treatment of the listed conditions, surgeries/treatments shall be excluded until the expiry of 24 months of continuous
coverage after the date of inception of the first Policy with us. This exclusion shall not be applicable for claims arising due to an Accident
(covered from day 1) or Cancer (covered after 30-day waiting period).
b. In case of enhancement of Sum Insured the exclusion shall apply afresh to the extent of Sum Insured increase.
c. If any of the specified disease/procedure falls under the waiting period specified for pre-Existing diseases, then the longer of the two waiting
periods shall apply.
d. The waiting period for listed conditions shall apply even if contracted after the Policy or declared and accepted without a specific exclusion.
e. If the Insured Person is continuously covered without any break as defined under the applicable norms on portability stipulated by IRDAI then
waiting period for the same would be reduced to the extent of prior coverage.
f. List of specific diseases/procedures:
i. Pancreatitis and stones in biliary and urinary system
ii. Cataract, glaucoma and retinal detachment
iii. Hyperplasia of prostate, hydrocele and spermatocele
iv. Prolapse uterus or cervix, endometriosis, Fibroids, Polycystic ovarian disease (PCOD), hysterectomy (unless necessitated by Malignancy)
v. Hemorrhoids, fissure, fistula or abscess of anal and rectal region
vi. Hernia of any site or type,
vii. Osteoarthritis, joint replacement, osteoporosis, systemic connective tissue disorders, inflammatory polyarthropathies, Rheumatoid
viii. Varicose veins of lower extremities
ix. All internal or external benign neoplasms/ tumours, cyst, sinus, polyps, nodules, mass or lump
x. Ulcer, erosion or varices of gastro intestinal tract
xi. Surgical treatment for diseases of middle ear and mastoid (including otitis media, cholesteatoma, perforation of tympanic membrane),
Tonsils and adenoids, nasal septum and nasal sinuses
5.1.3. 30-day waiting period (Code- Excl03):
a. Expenses related to the treatment of any Illness within 30 days from the first Policy commencement date shall be excluded except claims
arising due to an Accident, provided the same are covered.
b. This exclusion shall not, however, apply if the Insured Person has continuous coverage for more than twelve months
c. The within referred waiting period is made applicable to the enhanced Sum Insured in the event of granting higher Sum Insured subsequently.
5.1.4. Investigation & Evaluation (Code-Excl04)
a. Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.
b. Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.
The insured person shall be allowed free look period of fifteen days (thirty days for policies
with a term of 3 years, if sold through distance marketing) from date of receipt of the
policy document to review the terms and conditions of the policy, and to return the same
if not acceptable.
lf the insured has not made any claim during the Free Look Period, the insured shall be
entitled to:
i. refund of the premium paid, less any expenses incurred by the Company on medical
examination of the insured person.
6.1.2. Cancellation Simplified for you
i. The policyholder may cancel this policy by giving 15 days' written notice and in such
an event, the Company shall refund premium for the unexpired policy period as You can cancel your policy whenever you wish.
detailed below.
In case of death of an Insured, pro-rate refund of the premium for the deceased insured will
be refunded, provided there is no history of claim.
ii. The Company may cancel the policy at any time on grounds of misrepresentation
non-disclosure of material facts, fraud by the insured person by giving 15 days'
written notice. There would be no refund of premium on cancellation on grounds of
misrepresentation, non-disclosure of material facts or fraud.
6.1.4. Possibility of Revision of Terms of the Policy Including the Premium Rates
The Company, with prior approval of IRDAI, may revise or modify the terms of the Policy Pay your renewal premium before end
including the premium rates. The Insured Person shall be notified three months before the of policy period to maintain continuity of
changes are effected. benefits. A grace period is also available to
pay the premium after policy expiry.
6.1.5. Nomination
The policyholder is required at the inception of the policy to make a nomination for the
purpose of payment of claims under the policy in the event of death of the policyholder. Any Note: You are NOT insured during the grace
change of nomination shall be communicated to the company in writing and such change period.
shall be effective only when an endorsement on the policy is made. ln the event of death
of the policyholder, the Company will pay the nominee {as named in the Policy Schedule/ Simplified for you
Policy Certificate/Endorsement (if any)} and in case there is no subsisting nominee, to the
legal heirs or legal representatives of the policyholder whose discharge shall be treated as We will cancel your policy, will not pay any
full and final discharge of its liability under the policy. claim, will not refund any premium paid and
have right to take all possible legal action
6.1.6. Fraud against you including for recovery of
lf any claim made by the insured person, is in any respect fraudulent, or if any false benefits paid earlier, if
statement, or declaration is made or used in support thereof, or if any fraudulent means • You withheld any information from us,
or devices are used by the insured person or anyone acting on his/her behalf to obtain whole or part that would have invited any
any benefit under this policy, all benefits under this policy and the premium paid shall be decision other than a ‘standard acceptance’
forfeited. of your application for insurance.
Note: Non standard decisions are:
Any amount already paid against claims made under this policy but which are found ° Loading – We ask for additional premium
fraudulent later shall be repaid by all recipient(s)/policyholder(s), who has made that ° Exclusions – We apply a additional waiting
particular claim, who shall be jointly and severally liable for such repayment to the insurer. period for health conditions or treatments
° Rejection – We hate to do this. But
For the purpose of this clause, the expression "fraud" means any of the following acts sometimes are compelled to say no to a
committed by the insured person or by his agent or the hospital/doctor/any other party customer
acting on behalf of the insured person, with intent to deceive the insurer or to induce the
insurer to issue an insurance policy: a) the suggestion, as a fact of that which is not true and
lnsured person may also approach the grievance cell at any of the company's branches with
the details of grievance. If lnsured person is not satisfied with the redressal of grievance
through one of the above methods, insured person may contact the grievance officer at:
Head – Customer Services
Niva Bupa Health Insurance Company Limited
D-5, 2nd Floor, Logix Infotech Park
opp. Metro Station, Sector 59, Noida, Uttar Pradesh, 201301
Contact No: 1860-500-8888
Fax No.: 011-41743397
Email ID: customercare@nivabupa.com
For updated details of grievance officer, kindly refer the link https://www.nivabupa.com/
customer-care/health-services/grievance-redressal.aspx
If the Insured person is not satisfied with the above, they can escalate to GRO@nivabupa.
com.
lf lnsured person is not satisfied with the redressal of grievance through above methods,
the insured person may also approach the office of lnsurance Ombudsman of the respective
area/region for redressal of grievance as per lnsurance Ombudsman Rules 2017 (at the
addresses given in Annexure II).
Grievance may also be lodged at IRDAI lntegrated Grievance Management System - https://
igms. irda.qov. in/
6.1.9. Claim settlement (Provision for Penal interest) Simplified for you
i. The Company shall settle or reject a claim, as the case may be, within 30 days from the
date of receipt of last necessary document. We will provide our decision on claim within
ii. ln the case of delay in the payment of a claim, the Company shall be liable to pay 30 days (45 days for investigated cases) from
interest to the policyholder from the date of receipt of last necessary document to the submission of all necessary claim documents.
(Explanation: “Material facts” for the purpose of this policy shall mean all relevant
information sought by the company in the proposal form and other connected documents to
enable it to take informed decision in the context of underwriting the risk)
a. Renewal Premium:
Renewal premium will alter based on Age. For Floater plan, the age of eldest insured
person will be considered for calculating the premium.
6.2.4. Claims
a. Cashless claim facility is available at our network hospitals ONLY. As list of network
hospitals is dynamic, for the latest list, refer to our website www.nivabupa.com.
b. Documents required with claim form:
Hospital / Medical records:
• Original Discharge summary with first and subsequent consultation papers.
• Original Final Hospital bill with detailed break-up and payment receipt (including
pharmacy bills).
• Laboratory investigation reports with supporting prescriptions.
• MLC/First Information Report (FIR) (in accident cases).
Policyholder documents (Nominee in case of death of Policyholder):
• KYC documents
• Cancelled cheque
IMPORTANT:
• All documents MUST be submitted within 30 days from discharge.
• For any delay in submission, You MUST provide the reasons in writing. We will
condone such delay on merits (i.e. reasons beyond your control).
• You MUST submit all claim related documents for expenses within the Deductible
amount (if applicable).
• We reserve the right to check and investigate the hospital / medical records from
any doctor, Hospital, clinic, individual or institution.
c. The expenses that are not covered or subsumed into room charges / procedure charges
/ costs of treatment are placed as Annexure I.
d. If you opt for a Hospital room which is higher than the eligible room category as
specified in your Policy Schedule, then We will pay only a pro-rated portion of the
total Associated Medical Expenses (including surcharge or taxes thereon) as per the
following formula:
(Eligible Room Rent limit / Room Rent actually incurred) * total Associated Medical
Expenses
Your premium depends upon your residential city. Please inform us immediately in case
of change in your city.
6.2.9. Assignment
The Policy can be assigned subject to applicable laws.