HealthRecharge PolicyDocument

Max Bupa Health Recharge –
Policy Terms & Conditions
1. Preamble ii. Any non-melanoma skin carcinoma unless there is

This ‘Health Recharge’ policy is a contract of insurance between evidence of metastases to lymph nodes or beyond;
You and Us which is subject to payment of full premium in advance iii. Malignant melanoma that has not caused invasion
and the terms, conditions and exclusions of this Policy. This Policy beyond the epidermis;
has been issued on the basis of the Disclosure to Information iv. All tumors of the prostate unless histologically
Norm, including the information provided by You in the Proposal classified as having a Gleason score greater than 6 or
Form and / or the Information Summary Sheet. having progressed to at least clinical TNM classification
T2N0M0
Please inform Us immediately of any change in the address or any v. All Thyroid cancers histologically classified as T1N0M0
other changes affecting You or any Insured Person which would (TNM Classification) or below;
impact the benefits, terms and conditions under this Policy. vi. Chronic lymphocytic leukaemia less than RAI stage 3
vii. Non-invasive papillary cancer of the bladder
In addition, please note the list of exclusions is set out in Section histologically described as TaN0M0 or of a lesser
6 of this Policy. classification
viii. All Gastro-Intestinal Stromal Tumors histologically
2. Definitions classified as T1N0M0 (TNM Classification) or below
For the purposes of interpretation and understanding of this Policy, and with mitotic count of less than or equal to 5/50
We have defined some of the important words used in the Policy HPFs;
which will have the special meaning accorded to these terms for ix. All tumors in the presence of HIV infection.
the purposes of this Policy. For the remaining language and words V. Cashless Facility means a facility extended by the insurer to
used, the usual meaning as described in standard English language the insured where the payments, of the costs of treatment
dictionaries shall apply. The words and expressions defined in the undergone by the insured in accordance with the policy
Insurance Act 1938, IRDA Act 1999, regulations notified by the terms and conditions, are directly made to the network
IRDAI and circulars and guidelines issued by the IRDAI, together provider by the insurer to the extent pre-authorization is
with their amendment shall carry the meanings given therein. approved.
VI. Condition Precedent shall mean a Policy term or condition
Note: Where the context permits, the singular will be deemed upon which the Insurer’s liability under the Policy is
to include the plural, one gender shall be deemed to include the conditional upon.
other genders and references to any statute shall be deemed to VII. Congenital Anomaly means a condition which is present
refer to any replacement or amendment of that statute. since birth, and which is abnormal with reference to form,
structure or position.
2.1. Standard Definitions a. Internal Congenital Anomaly: Congenital Anomaly
which is not in the visible and accessible parts of the
I. Accident or Accidental means a sudden, unforeseen and body.
involuntary event caused by external, visible and violent b. External Congenital Anomaly: Congenital Anomaly
means. which is in the visible and accessible parts of the body.
II. AYUSH Treatment refers to the medical and / or VIII. Co-payment means a cost-sharing requirement under a
hospitalization treatments given under Ayurveda, Yoga health insurance policy that provides that the Policyholder/
and Naturopathy, Unani, Sidha and Homeopathy systems. insured will bear a specified percentage of the admissible
III. Associated Medical Expenses shall include Room Rent, claim amount. A Co-payment does not reduce the Sum
nursing charges, Medical Practitioners’ fees and operation Insured.
theatre charges. IX. Cumulative Bonus means any increase or addition in the
IV. Cancer means a malignant tumor characterized by the Sum Insured granted by the insurer without an associated
uncontrolled growth and spread of malignant cells with increase in premium.
invasion and destruction of normal tissues. This diagnosis X. Day Care Center means any institution established for
must be supported by histological evidence of malignancy. Day Care Treatment of Illness and/or Injuries or a medical
The term cancer includes leukemia, lymphoma and set-up with a Hospital and which has been registered with
sarcoma. the local authorities, wherever applicable, and is under
The following are excluded: the supervision of a registered and qualified Medical
i. All tumors which are histologically described as Practitioner AND must comply with all minimum criterion
carcinoma in situ, benign, pre-malignant, borderline as under:
malignant, low malignant potential, neoplasm of a. has Qualified Nursing staff under its employment;
unknown behavior, or non-invasive, including but b. has qualified Medical Practitioner(s) in charge;
not limited to: Carcinoma in situ of breasts, Cervical c. has a fully equipped operation theatre of its own
dysplasia CIN-1, CIN - 2 and CIN-3. where Surgical Procedures are carried out;
d. maintains daily records of patients and will make these
Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

accessible to the insurance company’s authorized where Surgical Procedures are carried out;
personnel. e. maintains daily records of patients and makes these
XI. Day Care Treatment refers to medical treatment, and/or accessible to the Insurance company’s authorized
Surgical Procedure which is: personnel.
a. undertaken under General or Local Anaesthesia in a XIX. Hospitalization or Hospitalized means the admission in a
Hospital/Day Care Center in less than 24 hrs because Hospital for a minimum period of 24 consecutive Inpatient
of technological advancement, and Care hours except for specified procedures/treatments,
b. which would have otherwise required a Hospitalization where such admission could be for a period of less than 24
of more than 24 hours. consecutive hours.
Treatment normally taken on an OPD basis is not XX. ICU (Intensive Care Unit) Charges means the amount
included in the scope of this definition. charged by a Hospital towards ICU expenses which shall
XII. Deductible means a cost-sharing requirement under a include the expenses for ICU bed, general medical support
health insurance policy that provides that the Insurer services provided to any ICU patient including monitoring
will not be liable for a specified rupee amount in case of devices, critical care nursing and intensivist charges.
indemnity policies and for a specified number of days/ XXI. Illness means a sickness or a disease or pathological
hours in case of hospital cash policies which will apply condition leading to the impairment of normal physiological
before any benefits are payable by the insurer. A deductible function and requires medical treatment.
does not reduce the Sum Insured. (a) Acute condition - Acute condition is a disease, illness
XIII. Dental Treatment means a treatment related to teeth or or injury that is likely to respond quickly to treatment
structures supporting teeth including examinations, fillings which aims to return the person to his or her state
(where appropriate), crowns, extractions and Surgery. of health immediately before suffering the disease/
XIV. Disclosure to Information Norm means the Policy shall illness/ injury which leads to full recovery
be void and all premium paid thereon shall be forfeited (b) Chronic condition - A chronic condition is defined as a
to the Company, in the event of misrepresentation, mis- disease, illness, or injury that has one or more of the
description or non-disclosure of any material fact. following characteristics:
XV. Domiciliary Hospitalization means medical treatment for i. it needs ongoing or long-term monitoring through
an Illness/disease/Injury which in the normal course would consultations, examinations, check-ups, and /or
require care and treatment at a Hospital but is actually tests
taken while confined at home under any of the following ii. it needs ongoing or long-term control or relief of
circumstances: symptoms
a. the condition of the patient is such that he/she is not iii. it requires rehabilitation for the patient or for the
in a condition to be removed to a Hospital, or patient to be specially trained to cope with it
b. the patient takes treatment at home on account of iv. it continues indefinitely
non availability of room in a Hospital. v. it recurs or is likely to recur
XVI. Emergency means a medical condition or symptom XXII. Injury means Accidental physical bodily harm excluding
resulting from Illness or Injury which arises suddenly and Illness or disease solely and directly caused by external,
unexpectedly and requires immediate care and treatment violent and visible and evident means which is verified and
by a Medical Practitioner to prevent death or serious long certified by a Medical Practitioner.
term impairment of the Insured Person’s health. XXIII. Intensive Care Unit means an identified section, ward or
XVII. Grace Period means the specified period of time wing of a Hospital which is under the constant supervision
immediately following the premium due date during which of a dedicated Medical Practitioner(s), and which is
a payment can be made to Renew or continue a policy in specially equipped for the continuous monitoring and
force without loss of continuity benefits such as Waiting treatment of patients who are in a critical condition, or
Periods and coverage of Pre-existing Diseases. Coverage require life support facilities and where the level of care
is not available for the period for which no premium is and supervision is considerably more sophisticated and
received. intensive than in the ordinary and other wards.
XVIII. Hospital means any institution established for Inpatient XXIV. Inpatient Care means treatment for which the Insured
Care and Day Care Treatment of Illness and / or Injuries Person has to stay in a Hospital for more than 24 hours for
and which has been registered as a Hospital with the local a covered event.
authorities under the Clinical Establishments (Registration XXV. Medical Advice means any consultation or advice from
and Regulation) Act, 2010 or under the enactments a Medical Practitioner including the issuance of any
specified under the Schedule of Section 56(1) of the said prescription or follow-up prescription.
Act OR complies with all minimum criteria as under: XXVI. Medical Expenses means those expenses that an Insured
a. has Qualified Nursing staff under its employment Person has necessarily and actually incurred for medical
round the clock; treatment on account of Illness or Accident on the advice
b. has at least 10 Inpatient beds in towns having a of a Medical Practitioner, as long as these are no more
population of less than 10,00,000 and at least 15 than would have been payable if the Insured Person had
Inpatient beds in all other places; not been insured and no more than other Hospitals or
c. has qualified Medical Practitioner(s) in charge round doctors in the same locality would have charged for the
the clock; same medical treatment.
d. has a fully equipped operation theatre of its own XXVII. Medical Practitioner means a person who holds a valid

registration from the Medical Council of any State or XXXVI. Portability means the right accorded to an individual
Medical Council of India or Council for Indian Medicine health insurance policyholder (including family cover), to
or for Homeopathy set up by the Government of India or transfer the credit gained for Pre-existing conditions and
a State Government and is thereby entitled to practice time bound exclusions, from one insurer to another or
medicine within its jurisdiction; and is acting within the from one plan to another plan of the same insurer.
scope and jurisdiction of his licence. XXXVII. Qualified Nurse means a person who holds a valid
XXVIII. Medically Necessary Treatment means any treatment, registration from the Nursing Council of India or the
tests, medication, or stay in Hospital or part of a stay in Nursing Council of any state in India.
Hospital which: XXXVIII. Reasonable and Customary Charges means the charges
a. is required for the medical management of the Illness for services or supplies, which are the standard charges
or Injury suffered by the insured; for the specific provider and consistent with the prevailing
b. must not exceed the level of care necessary to provide charges in the geographical area for identical or similar
safe, adequate and appropriate medical care in scope, services, taking into account the nature of the Illness /
duration, or intensity; Injury involved.
c. must have been prescribed by a Medical Practitioner; XXXIX. Renewal means the terms on which the contract of
d. must conform to the professional standards widely insurance can be renewed on mutual consent with
accepted in international medical practice or by the a provision of Grace Period for treating the renewal
medical community in India. continuous for the purpose of gaining credit for pre-
XXIX. Network Provider means Hospital enlisted by an insurer, existing diseases, time bound exclusions and for all Waiting
TPA or jointly by an insurer and TPA to provide medical Periods.
services to an insured by a Cashless Facility. XL. Room Rent means the amount charged by a Hospital
XXX. Notification of Claim means the process of intimating a towards Room and Boarding expenses and shall include
claim to the insurer or TPA through any of the recognized the Associated Medical Expenses.
modes of communication. XLI. Surgery or Surgical Procedure means manual and / or
XXXI. Non-Network means any Hospital, Day Care Center or operative procedure (s) required for treatment of an Illness
other provider that is not part of the network. or Injury, correction of deformities and defects, diagnosis
XXXII. OPD Treatment means the one in which the Insured visits and cure of diseases, relief from suffering or prolongation
a clinic / Hospital or associated facility like a consultation of life, performed in a Hospital or Day Care Center by a
room for diagnosis and treatment based on the advice of a Medical Practitioner.
Medical Practitioner. The Insured is not admitted as a day
care or In-patient. 2.2. Specific Definitions
XXXIII. Pre-existing Disease I. Age means age as on last birthday.
Pre-existing Disease means any condition, ailment, injury or II. Base Sum Insured means the amount stated in the Policy
disease: Schedule.
a) That is/are diagnosed by a physician within 48 months III. Bone Marrow Transplant is the actual undergoing of a
prior to the effective date of the policy issued by the transplant of human bone marrow using haematopoietic
insurer or its reinstatement or stem cells. The undergoing of a transplant has to be
b) For which medical advice or treatment was confirmed by a specialist medical practitioner. The
recommended by, or received from, a physician within following will be excluded:
48 months prior to the effective date of the policy i. Other stem-cell transplants
issued by the insurer or its reinstatement. ii. Where only islets of langerhans are transplanted
XXXIV. Pre-hospitalization Medical Expenses means medical IV. Break in Policy means the period of gap that occurs at the
expenses incurred during pre-defined number of days end of the existing policy term, when the premium due
preceding the hospitalization of the Insured Person, for renewal on a given policy is not paid on or before the
provided that: premium renewal date or within 30 days thereof.
a. Such Medical Expenses are incurred for the V. Critical Illness, an Illness, medical event or Surgical
same condition for which the Insured Person’s Procedure specifically defined in Section 4.2.
Hospitalization was required, and VI. Diagnostic Services means those diagnostic tests and
b. The Inpatient Hospitalization claim for such exploratory or therapeutic procedures required for the
Hospitalization is admissible by the Insurance detection, identification and treatment of a medical
Company. condition.
XXXV. Post-hospitalization Medical Expenses means medical VII. Evidence Based Clinical Practice means process of making
expenses incurred during pre-defined number of days clinical decisions for Inpatient Care using current best
immediately after the Insured Person is discharged from evidence in conjugation with clinical expertise.
the Hospital, provided that: VIII. e-Consultation means opinion from a Medical Practitioner
a. Such Medical Expenses are for the same condition who holds a valid registration from the medical council of
for which the Insured Person’s Hospitalization was any state or medical council of India or council for Indian
required, and medicine or for homeopathy set up by the Government
b. The Inpatient Hospitalization claim for such of India or a state government and is thereby entitled
Hospitalization is admissible by the Insurance to practice medicine within its jurisdiction; and is acting
Company. within the scope and jurisdiction of his license.

IX. Family Floater Policy means a Policy described as such in XXII. Policy Schedule means a certificate issued by Us, and, if
the Policy Schedule where the family members (two or more than one, then the latest in time. The Policy Schedule
more) named in the Policy Schedule are Insured Persons contains details of the Policyholder, Insured Persons, the
under this Policy. Only the following family members can Sum Insured and other relevant details related to the
be covered under a Family Floater Policy: coverage.
a. Primary Insured Person; and/or XXIII. Primary Insured Person means the Policyholder if he/
b. Primary Insured Person’s legally married spouse (for she is covered under the Policy as an Insured Person. In
as long as she/he continues to be married to the case Policyholder is not an Insured Person, then Primary
Primary Insured Person); and/or Insured Person will be the eldest Insured Person covered
c. Primary Insured Person’s children who are less than under the Policy.
25 years of Age on the commencement of the Policy XXIV. Reimbursement means settlement of claims paid directly
Period (a maximum 4 children can be covered under by Us to the Policyholder/Insured Person.
the Policy as Insured Persons). XXV. Service Provider means any person, organization,
X. First Policy means for the purposes of this Policy the institution that has been empanelled with Us to provide
Policy Schedule issued to the Policyholder at the time services specified under the benefits to the Insured Person.
of inception of the first Policy mentioned in the Policy XXVI. Single Private Room means an air conditioned room in
Schedule with Us. a Hospital where a single patient is accommodated and
XI. Health Recharge means and includes ‘Niva Bupa Health which has an attached toilet (lavatory and bath). Such
Recharge’ policy. room type shall be the most basic and the most economical
XII. Information Summary Sheet means the information and of all accommodations available as a single room in that
details provided to Us or Our representatives over the Hospital.
telephone for the purposes of applying for this Policy XXVII. Standby Services are services of another Medical
which has been recorded by Us and confirmed by You. Practitioner requested by treating Medical Practitioner
XIII. Individual Policy means a Policy described as such in the and involving prolonged attendance without direct (face-
Policy Schedule where the individual named in the Policy to-face) patient contact or involvement.
Schedule is the Insured Person under this Policy. XXVIII. Sum Insured means the total of the Base Sum Insured and
XIV. Insured Event means any event specifically mentioned as Loyalty Addition as per Section 3.11 (if applicable) which
covered under this Policy. is Our maximum, total and cumulative liability for any and
XV. Insured Person means person(s) named as insured persons all claims during the Policy Year in respect of all Insured
in the Policy Schedule. Person(s) which is specified in the Policy Schedule.
XVI. IRDAI means the Insurance Regulatory and Development XXIX. Survival Period means the period, if any, specified under
Authority of India. the Policy after the occurrence of an Insured Event that
XVII. Medical Record means the collection of information as the Insured Person has to survive before a claim becomes
submitted in claim documentation concerning a Insured admissible under the Policy.
Person’s Illness or Injury that is created and maintained XXX. Waiting Period means a time-bound exclusion period
in the regular course of management, made by Medical related to condition(s) specified in the Policy Schedule or
Practitioners who have knowledge of the acts, events, the Policy which shall be served before a claim related to
opinions or diagnoses relating to the Insured Person’s such condition(s) becomes admissible.
Illness or Injury, and made at or around the time indicated XXXI. We/Our/Us means Niva Bupa Health Insurance Company
in the documentation. Limited.
XVIII. Mental Illness means a substantial disorder of thinking, XXXII. You/Your/Policyholder means the person named in the
mood, perception, orientation or memory that grossly Policy Schedule who has concluded this Policy with Us.
impairs judgment, behaviour, capacity to recognise reality
or ability to meet the ordinary demands of life, mental 3. Benefits covered under the Policy
conditions associated with the abuse of alcohol and
drugs, but does not include mental retardation which is a The benefits available under this Policy are described below.
condition of arrested or incomplete development of mind
of a person, specially characterised by subnormality of a. The Policy covers Reasonable and Customary Charges incurred
intelligence. towards medical treatment taken by the Insured Person
XIX. Policy means these terms and conditions, the Policy during the Policy Period for an Illness, Injury or condition as
Schedule (as amended from time to time), Your statements described in the sections below and contracted or sustained
in the Proposal and the Information Summary Sheet and during the Policy Period. The benefits listed in the sections
any endorsements attached by Us to the Policy from time below will be payable subject to the terms, conditions and
to time. exclusions of this Policy and the availability of the Sum
XX. Policy Period is the period between the inception Insured and any sub-limits for the benefit as maybe specified
date and the expiry date of the Policy as specified in the in the Policy Schedule. You have to mandatorily choose an
Policy Schedule or the date of cancellation of this Policy, annual aggregate claim Deductible amount, options of these
whichever is earlier. Deductible amounts are provided in the section ‘Product
XXI. Policy Year means the period of one year commencing Benefit Table’.
on the date of commencement specified in the Policy b. All the benefits (including optional benefits) which are
Schedule or any anniversary thereof. available under the Policy along with the respective limits

/ amounts applicable based on the Sum Insured have been II. Pre-hospitalization Medical Expenses
summarized in the Product Benefit Table in Annexure I.
c. All claims under the Policy must be made in accordance with What is covered:
the process defined under Section 7.2 (XII) (Claim Process & We will indemnify on Reimbursement basis only, the Insured
Requirements). Person’s Pre-hospitalization Medical Expenses incurred in respect
d. All claims paid under any benefit except for those admitted of an Illness or Injury.
under Section 3.9 (e-Consultation), Section 4.1 (Personal
Accident Cover) and Section 4.2 (Critical Illness Cover) shall Conditions:
reduce the Sum Insured for the Policy Year in which the a. We have accepted a claim under Section 3.1 (Inpatient Care)
Insured Event in relation to which the claim is made has been or Section 3.4 (Day Care Treatment) or Section 3.5 (Domiciliary
occurred, unless otherwise specified in the respective section. Hospitalization) or Section 3.6 (Alternative Treatments).
Thereafter only the balance Sum Insured after payment of b. Pre-hospitalization Medical Expenses are incurred for the
claim amounts admitted shall be available for future claims same condition for which We have accepted the Inpatient
arising in that Policy Year. Care or Day Care Treatment or Domiciliary Hospitalization or
Alternative Treatments claim.
I. Inpatient Care c. The expenses are incurred after the inception of the First
Policy with Us. If any portion of these expenses is incurred
What is covered: before the inception of the First Policy with Us, then We
We will indemnify the Medical Expenses incurred for one or more shall be liable only for those expenses incurred after the
of the following due to the Insured Person’s Hospitalization during commencement date of the First Policy, irrespective of the
the Policy Period following an Illness or Injury. : initial waiting period.
i. Room Rent; d. Pre-hospitalization Medical Expenses incurred on
ii. Room boarding and nursing charges during Hospitalization physiotherapy will also be payable provided that such
as charged by the Hospital where the Insured Person availed physiotherapy is prescribed in writing by the treating Medical
medical treatment; Practitioner as Medically Necessary Treatment and is directly
iii. Medical Practitioners’ fees, excluding any charges or fees for related to the same condition that led to Hospitalization.
Standby Services; e. Any claim admitted under this Section 3.2 shall reduce the
iv. Investigative tests or diagnostic procedures directly related to Sum Insured for the Policy Year in which In-patient Care or Day
the Insured Event which lead to the current Hospitalization; Care Treatment or Domiciliary Hospitalization or Alternative
v. Medicines, drugs as prescribed by the treating Medical Treatments claim has been incurred.
Practitioner related to the Insured Event that led to the
current Hospitalization; Sub-limit:
vi. Intravenous fluids, blood transfusion, injection administration a. We will pay above mentioned Pre-hospitalization Medical
charges and /or allowable consumables; Expenses only for period up to 60 days immediately preceding
vii. Operation theatre charges; the Insured Person’s admission for Inpatient Care or Day
viii. The cost of prosthetics and other devices or equipment, if Care Treatment or Domiciliary Hospitalization or Alternative
implanted internally during Surgery; Treatments.
ix. Intensive Care Unit Charges.
III. Post-hospitalization Medical Expenses
Conditions:
a. The Hospitalization is for Medically Necessary Treatment and What is covered:
advised in writing by a Medical Practitioner. We will indemnify on Reimbursement basis only, the Insured
b. If the Insured Person is admitted in a Hospital room where Person’s Post-hospitalization Medical Expenses incurred following
the room category opted or Room Rent incurred is higher an Illness or Injury.
than the eligibility as specified in the Policy Schedule, then
We shall be liable to pay only a pro-rated portion of the total Conditions:
Associated Medical Expenses (including surcharge or taxes a. We have accepted a claim under Section 3.1 (Inpatient Care)
thereon) as per the following formula: or Section 3.4 (Day Care Treatment) or Section 3.5 (Domiciliary
(Eligible Room Rent limit / Room Rent actually incurred) * Hospitalization) or Section 3.6 (Alternative Treatments).
total Associated Medical Expenses b. Post-hospitalization Medical Expenses are incurred for the
Associated Medical Expenses shall include Room Rent, same condition for which We have accepted the Inpatient
nursing charges, Medical Practitioners’ fees and operation Care, Day Care Treatment or Domiciliary Hospitalization or
theatre charges. Alternative Treatments claim.
c. We will pay the consultation charges for any Medical c. The expenses incurred shall be as advised in writing by the
Practitioner visiting the Insured Person only if: treating Medical Practitioner.
i. The Medical Practitioner’s treatment or advice has been d. Post-hospitalization Medical Expenses incurred on
specifically sought by the Hospital; and physiotherapy will also be payable provided that such
ii. The consultation charges are included in the Hospital’s physiotherapy is prescribed in writing by the treating Medical
bill Practitioner as Medically Necessary Treatment and is directly
related to the same condition that led to Hospitalization.
e. Any claim admitted under this Section 3.3 shall reduce the

Sum Insured for the Policy Year in which In-patient Care or Day para-surgical treatment procedures and interventions are
Care Treatment or Domiciliary Hospitalization or Alternative carried out by AYUSH Medical Practitioner(s) comprising of
Treatments claim has been incurred. any of the following:
i. Central or state government AYUSH Hospital; or
Sub-limit: ii. Teaching Hospital attached to AYUSH college recognized
a. We will pay Post-hospitalization Medical Expenses only for by the Central Government / Central Council of Indian
up to 90 days immediately following the Insured Person’s Medicine / Central Council of Homeopathy; or
discharge from Hospital or Day Care Treatment or Domiciliary iii. AYUSH Hospital, standalone or co-located with in-patient
Hospitalization or Alternative Treatments. healthcare facility of any recognized system of medicine,
registered with the local authorities, wherever applicable
IV. Day Care Treatment and is under the supervision of a qualified registered
AYUSH Medical Practitioner and must comply with all the
What is covered: following criterion:
We will indemnify the Medical Expenses incurred on the Insured a) Having at least five in-patient beds;
Person’s any Day Care Treatment during the Policy Period following b) Having qualified AYUSH Medical Practitioner in
an Illness or Injury. charge round the clock;
c) Having dedicated AYUSH therapy sections as
Conditions: required and/or has equipped operation theatre
a. The Day Care Treatment is advised in writing by a Medical where surgical procedures are to be carried out;
Practitioner as Medically Necessary Treatment. d) Maintaining daily records of the patients and
b. If We have accepted a claim under this benefit, We will also making them accessible to the insurance company’s
indemnify the Insured Person’s Pre-hospitalization Medical authorized representative.
Expenses and Post-hospitalization Medical Expenses in
accordance with Sections 3.2 and 3.3 above. AYUSH Hospitals referred above shall also obtain either pre-entry
level certificate (or higher level of certificate) issued by National
What is not covered: Accreditation Board for Hospitals and Healthcare Providers
OPD Treatment and Diagnostic Services costs are not covered (NABH) or State Level Certificate (or higher level of certificate)
under this benefit. under National Quality Assurance Standards (NQAS), issued by
National Health Systems Resources Centre (NHSRC).
V. Domiciliary Hospitalization a. Pre-hospitalization Medical Expenses incurred for up to 60
days immediately preceding the Insured Person’s admission
What is covered. and Post-hospitalization Medical Expenses incurred for up to
We will indemnify on Reimbursement basis only, the Medical 90 days immediately following the Insured Person’s discharge
Expenses incurred for the Insured Person’s Domiciliary will also be indemnified under this benefit in accordance
Hospitalization during the Policy Period following an Illness or with Sections 3.2 and 3.3 above, provided that these Medical
Injury. Expenses relate only to Alternative Treatments and not
Allopathy.
Conditions: b. Any non-allopathic treatment taken by the Insured Person shall
a. a. The Domiciliary Hospitalization continues for at only be covered under Section 3.6 (Alternative Treatments) as
least 3 consecutive days in which case We will make payment per the applicable terms and conditions, except for treatment
under this benefit in respect of Medical Expenses incurred under Section 3.12 (Mental Disorders Treatment) and Section
from the first day of Domiciliary Hospitalization; 3.13 (HIV / AIDS).
b. b. The treating Medical Practitioner confirms in writing
that the Insured Person’s condition was such that the Insured What is not covered:
Person could not be transferred to a Hospital OR the Insured a. Medical Expenses incurred on treatment taken under Yoga
Person satisfies Us that a Hospital bed was unavailable. shall not be covered.
c. c. If We have accepted a claim under this benefit, We
will also indemnify the Insured Person’s Pre-hospitalization VII. Living Organ Donor Transplant
Medical Expenses and Post-hospitalization Medical Expenses
in accordance with Sections 3.2 and 3.3 above. What is covered:
We will indemnify the Medical Expenses incurred for a living organ
VI. Alternative Treatments donor’s treatment as an Inpatient for the harvesting of the organ
What is covered: donated.
We will indemnify the Medical Expenses incurred on the Insured
Person’s Hospitalization for Inpatient Care during the Policy Conditions:
Period on treatment taken under Ayurveda, Unani, Siddha and a. The donation conforms to the Transplantation of Human
Homeopathy. Organs Act 1994 and any amendments thereafter and the
organ is for the use of the Insured Person.
Conditions: b. The organ transplant is certified in writing by a Medical
a. The treatment should be taken in AYUSH Hospital. An AYUSH Practitioner as Medically Necessary Treatment for the Insured
Hospital is a healthcare facility wherein medical / surgical / Person.

c. We have accepted the recipient Insured Person’s claim under c. e-Consultation must not be considered a substitute to medical
Section 3.1 (Inpatient Care). opinion or advice nor shall be same pursued over a medical
advice or opinion given by treating physician or doctor.
What is not covered: d. By seeking e-Consultation under this benefit, the Insured
a. Stem cell donation whether or not it is Medically Necessary Person is not prohibited or advised against visiting or
Treatment except for Bone Marrow Transplant. consulting with any other independent Medical Practitioner
b. Pre-hospitalization Medical Expenses or Post-hospitalization or commencing or continuing any treatment advised by such
Medical Expenses of the organ donor. Medical Practitioner.
c. Screening or any other Medical Expenses related to the organ e. The Insured Person is free to choose whether or not to obtain
donor, which are not incurred during the duration of Insured the e-Consultation, and if obtained then whether or not to act
Person’s Hospitalization for organ transplant. on it in whole or in part.
d. Transplant of any organ/tissue where the transplant is f. e-Consultation under this benefit shall not be valid for any
Unproven / experimental treatment or investigational in medico-legal purposes.
nature. g. We do not represent correctness of e-Consultation and shall
e. Expenses related to organ transportation or preservation. not assume or deem to assume any liability towards any
f. Any other medical treatment or complication in respect of loss or damage arising out of or in relation to any opinion,
the donor, which is directly or indirectly consequence to advice, prescription, actual or alleged errors, omissions and
harvesting. representations made by the Medical Practitioner.
VIII. Emergency Ambulance X. Pharmacy and Diagnostic Services

What is covered: What is covered:
We will indemnify the costs incurred, on transportation of the You may purchase medicines or avail diagnostic services from Our
Insured Person by road Ambulance to a Hospital for treatment in Service Provider through Our website or mobile application.
an Emergency following an Illness or Injury.
Conditions - The above coverage is subject to fulfilment of
Conditions: following conditions:
a. The medical condition of the Insured Person requires a. The cost for the purchase of the medicines or for availing
immediate ambulance services from the place where diagnostic services shall be borne by You.
the Insured Person is injured or is ill to a Hospital where b. Further it is made clear that purchase of medicines from Our
appropriate medical treatment can be obtained or; Service Provider is Your absolute discretion and choice.
b. The medical condition of the Insured Person requires
immediate ambulance services from the existing Hospital to XI. Loyalty Additions (applicable only for Base Sum Insured up to
another Hospital with advanced facilities as advised by the Rs. 25 Lac)
treating Medical Practitioner for management of the current What is covered:
Hospitalization. a. If the Policy is Renewed with Us without a break or if the
c. This benefit is available for only one transfer per Policy continues to be in force for the 2nd Policy Year in the 2
Hospitalization. year / 3 year Policy Period respectively (if applicable), We will
d. The ambulance service shall be offered by a healthcare or provide Loyalty Additions in the form of Cumulative Bonus by
ambulance Service Provider. increasing the Sum Insured applicable under the Policy by 5%
e. We have accepted a claim under Section 3.1 (Inpatient Care) of the Base Sum Insured of the immediately preceding Policy
above. Year subject to a maximum of 50% of the Base Sum Insured.
f. We will cover expenses up to the amount specified in Your There will be no change in the sub-limits applicable to various
Policy Schedule. benefits due to increase in Sum Insured under this benefit.
What is not covered: Conditions:

The Insured Person’s transfer to any Hospital or diagnostic centre a. If the Insured Person in the expiring Policy is covered under an
for evaluation purposes only. Individual Policy and has an accumulated Cumulative Bonus
in the expiring Policy under this benefit, and such expiring
IX. e-Consultation Policy is Renewed with Us on a Family Floater Policy, then We
What is covered: will provide the credit for the accumulated Cumulative Bonus
If the Insured Person is diagnosed with an Illness or is planning to to the Family Floater Policy.
undergo a planned Surgery or a Surgical Procedure, the Insured b. If the Insured Persons in the expiring Policy are covered on a
Person can, at the Insured Person’s sole direction, obtain an Family Floater Policy and such Insured Persons Renew their
e-Consultation from Our Service Provider during the Policy Period. expiring Policy with Us by splitting the Floater Sum Insured
stated in the Policy Schedule in to two or more floater /
Conditions: individual, then We will provide the credit of the accumulated
a. e-Consultation shall be requested through Our call centre or Cumulative Bonus to each of the split Policy.
website. c. If the Insured Persons covered on a Family Floater Policy are
b. e-Consultation will be arranged by Us (without any liabilities) reduced at the time of Renewal, the applicable accumulated
and will be based solely only on the information provided by Cumulative Bonus shall remain same under the Policy.
the Insured Person. d. In case the Base Sum Insured under the Policy is reduced at

the time of Renewal, the applicable accumulated Cumulative attempted suicide by any means.
Bonus shall also be reduced in proportion to the Base Sum c. Any neuro-developmental delays and disorders.
Insured.. d. Mental retardation which is a condition of arrested or
e. In case the Base Sum Insured under the Policy is increased at incomplete development of mind of a person, specially
the time of Renewal, the applicable accumulated Cumulative characterized by subnormality of intelligence
Bonus shall also be increased in proportion to the Base Sum
Insured.. Sub-limit:
f. This benefit is not applicable for e-Consultation and Optional a. The following disorders / conditions shall be covered only
benefits (if opted for) such as Personal Accident Cover up to 10% of Base Sum Insured or Rs. 50,000, whichever is
and Critical Illness Cover. Enhancement of Sum Insured lower. This sub-limit shall apply for all the following disorders
due to Loyalty Additions benefit cannot be utilized for the / conditions on cumulative basis.
aforementioned benefits.
g. This benefit is not applicable for Policy with Base Sum Insured Disorder /
greater than Rs. 25 Lac. Description
Condition
Severe Severe depression is characterized by a persistent
XII. Mental Disorders Treatment
Depression feeling of sadness or a lack of interest in outside
What is covered:
stimuli. It affects the way one feels, thinks and
We will indemnify the expenses incurred by the Insured Person for
behaves.
Inpatient treatment for Mental Illness up to the limit as specified
in Your Policy Schedule. Schizophrenia Schizophrenia is mental disorder, that distorts the
way a person thinks, acts, expresses emotions,
Conditions: perceives reality, and relates to others. Schizophrenia
a. Mental Disorders Treatment is only covered where patient result in combination of hallucinations, delusions,
is diagnosed by a qualified psychiatrist or a professional and extremely disordered thinking and behavior that
registered with the concerned State Authority or a professional impairs daily functioning,
having a post-graduate degree (Ayurveda) in Mano Vigyan Bipolar Bipolar disorder is a mental illness that brings severe
Avum Manas Roga or a post-graduate degree (Homoeopathy) Disorder high and low moods and changes in sleep, energy,
in Psychiatry or a post-graduate degree (Unani) in Moalijat thinking, and behavior. It includes periods of extreme
(Nafasiyatt) or a post-graduate degree (Siddha) in Sirappu mood swings with emotional highs and lows.
Maruthuvam.
Post traumatic Post-traumatic stress disorder is an anxiety disorder
b. The Hospitalization is for Medically Necessary Treatment.
stress caused by very stressful, frightening or distressing
c. The treatment should be taken in Mental Health
disorder events. It includes flashbacks, nightmares, severe
Establishment, including Ayurveda, Yoga and Naturopathy,
anxiety and uncontrollable thoughts about the event.
Unani, Siddha and Homoeopathy establishment, by whatever
name called, either wholly or partly, meant for the care of Generalized Generalized Anxiety Disorder is a mental health
persons with mental illness, established, owned, controlled anxiety disorder characterized by a perpetual state of worry,
or maintained by the appropriate Government, local disorder fear, apprehension, inability to relax.
authority, trust, whether private or public, corporation, ICD codes for the above disorders / conditions are provided in Annexure II.
co-operative society, organization or any other entity or
person, where persons with mental illness are admitted and
reside at, or kept in, for care, treatment, convalescence and b. Pre-hospitalization and Post-hospitalization Medical Expenses
rehabilitation, either temporarily or otherwise; and includes are also covered within the overall benefit sub-limit as
any general hospital or general nursing home established or specified above in point (a).
maintained by the appropriate Government, local authority,
trust, whether private or public, corporation, co-operative XIII. HIV / AIDS
society, organization or any other entity or person; but does What is covered:
not include a family residential place where a person with We will indemnify the expenses incurred by the Insured Person for
mental illness resides with his relatives or friend. Hospitalization (including Day Care Treatment) due to condition
d. Pre-hospitalization Medical Expenses incurred for up to 60 caused by or associated with HIV / AIDS.
days, if falling within the Policy Period, immediately preceding
the Insured Person’s admission and Post-hospitalization Conditions:
Medical Expenses incurred for up to 90 days, if falling within a. The Hospitalization or Day Care Treatment is Medically
the Policy Period, immediately following the Insured Person’s Necessary and the Illness is the outcome of HIV / AIDS. This
discharge will also be indemnified under this benefit as per needs to be prescribed in writing by a registered Medical
Section 3.2 & Section 3.3 respectively. Practitioner.
b. The coverage under this benefit is provided for opportunistic
What is not covered: infections which are caused due to low immunity status in HIV
a. The condition which is not clinically significant or is related / AIDS resulting in acute infections which may be bacterial,
to anxiety, bereavement, relationship or academic problems, viral, fungal or parasitic.
acculturation difficulties or work pressure. c. The patient should be a declared HIV positive.
b. Treatment related to intentional self inflicted Injury or d. Pre-hospitalization Medical Expenses incurred for up to 60

days, if falling within the Policy Period, immediately preceding up to the sub-limit as specified for each procedure / treatment
the Insured Person’s admission and Post-hospitalization in the below table:
Medical Expenses incurred for up to 90 days, if falling within
the Policy Period, immediately following the Insured Person’s Procedure / Treatment Sub-limit* (Rs.)
discharge will also be indemnified will also be indemnified Deep Brain Stimulation 5 Lac
under this benefit as per Section 3.2 & Section 3.3 respectively.
Immunotherapy- Monoclonal Antibody to be 5 Lac
What is not covered: given as injection
a. Chronic health conditions including ischemic heart disease, Intra vitreal injections 5 Lac
chronic liver disease, chronic kidney disease, cerebro-vascular Robotic surgeries 2.5 Lac
disease/ stroke, bronchial asthma and neoplasms which are
Stereotactic radio surgeries 3.5 Lac
not directly related to the patient’s immunity status would
not be covered under this benefit. BronchicalThermoplasty 2 Lac
b. Lifestyle diseases like diabetes, hypertension, heart diseases Vaporisation of the prostrate (Green laser 2 Lac
and dyslipidemia which are not related to HIV / AIDS would treatment or holmium laser treatment)
not be covered under this benefit.
*Maximum payout will be the sub-limit specified or Base Sum
XIV. Artificial Life Maintenance: Insured, whichever is lower.
What is covered:
We will indemnify the expenses incurred by the Insured Person for b. Pre-hospitalization and Post-hospitalization Medical Expenses
Artificial life maintenance, including life support machine used to are also covered within the overall benefit sub-limit as
sustain the Insured Person who is not brain dead, up to the limit as specified above in point (a).
specified in Your Policy Schedule
XVI. The expenses that are not covered or subsumed into room
Conditions: charges / procedure charges / costs of treatment are placed as
a. Artificial life maintenance is Medically Necessary and Annexure III
prescribed by the treating Medical Practitioner.
4. Optional Benefits
What is not covered: The following optional benefits shall apply under the Policy only
Artificial life maintenance for the Insured Person who has been if it is specified in the Policy Schedule. Optional benefits can be
declared brain dead or in vegetative state as demonstrated by: selected by You only at the time of issuance of the First Policy or
a. Deep coma and unresponsiveness to all forms of stimulation; at Renewal on payment of the corresponding additional premium.
or
b. Absent pupillary light reaction; or The optional benefits ‘Personal Accident Cover’ and ‘Critical
c. Absent oculovestibular and corneal reflexes; or Illness Cover’ will be payable (only on Reimbursement basis) if
d. Complete apnea. the conditions mentioned in the below sections are contracted
or sustained by the Insured Person covered under these optional
XV. Modern Treatments benefits during the Policy Period.
What is covered:
The following procedures / treatments will be covered either as The applicable optional benefits will be payable subject to the
Inpatient Care or as part of Day Care Treatment in a hospital up to terms, conditions and exclusions of this Policy and subject always
the limit as specified in Your Policy Schedule. to any sub-limits for the optional benefit as specified in Your Policy
a. Uterine Artery Embolization and HIFU (High intensity focused Schedule.
ultrasound)
b. Balloon Sinuplasty All claims for any applicable optional benefits under the Policy
c. Deep Brain stimulation must be made in accordance with the process defined under
d. Oral chemotherapy Section 7.2 (XII) (Claim Process & Requirements).
e. Immunotherapy- Monoclonal Antibody to be given as
injection I. Personal Accident Cover
f. Intra vitreal injections What is covered:
g. Robotic surgeries This optional benefit is available either to the Primary Insured
h. Stereotactic radio surgeries Person or Primary Insured Person along with his/her spouse,
i. BronchicalThermoplasty which is specified in the Policy Schedule.
j. Vaporisation of the prostrate (Green laser treatment or
holmium laser treatment) If the Insured Person covered under this optional benefit dies or
k. IONM - (Intra Operative Neuro Monitoring) sustains any Injury resulting solely and directly from an Accident
l. Stem cell therapy: Hematopoietic stem cells for bone marrow occurring during the Policy Period at any location worldwide, and
transplant for haematological conditions to be covered. while the Policy is in force, We will provide the benefits described
below.
Sub-limit:
a. The following procedures / treatments shall be covered only

1. Accident Death (AD) it is irreversible, such as in case of amputation/loss of
What is covered: limbs etc; and
If the Injury due to Accident solely and directly results in the 3. If the Insured Person dies before a claim has been admitted
Insured Person’s death within 365 days from the occurrence under this optional benefit, no amount will be payable under
of the Accident, We will make payment of Personal Accident this optional benefit, however We will consider the claim
Cover Sum Insured specified in the Policy Schedule. If a under Section 4.1(1) (Accident Death) subject to terms and
claim is made under this optional benefit, the coverage for conditions mentioned therein; and
that Insured Person under the Policy shall immediately and 4. We will not make payment under Accident Permanent Total
automatically cease. Any claim incurred before death of Disability more than once in the Insured Person’s lifetime for
such Insured person shall be admissible subject to terms and any and all Policy Periods.
conditions under this Policy. 5. 5. If a claim under this optional benefit is admitted,
then coverage for the Insured Person will immediately and
2. Accident Permanent Total Disability (APTD) automatically cease under Section 4.1(Personal Accident
What is covered: Cover) and this optional benefit shall not be applied in respect
If the Injury due to Accident solely and directly results of that Insured Person on any Renewal thereafter. However,
in the Permanent Total Disability of the Insured Person other applicable benefits can be Renewed in respect of the
which means that the Injury results in one or more of the Insured Person.
following conditions within 365 days from the occurrence of
an Accident, We will make payment of 125% of the Personal 3. Accident Permanent Partial Disability (APPD)
Accident Cover Sum Insured as specified in the Policy What is covered:
Schedule. If the Injury due to Accident solely and directly results in the
Permanent Partial Disability of the Insured Person which is
1. Loss of use of limbs or sight of the nature specified in the table below within 365 days
The Insured Person suffers from total and irrecoverable from the occurrence of such Accident, We will make payment
loss of: under this optional benefit in accordance with the table
1. The use of two limbs (including paraplegia and below:
hemiplegia) OR
2. The sight in both eyes OR Conditions:
3. The use of one limb and the sight in one eye 1. The Permanent Partial Disability is proved through a
disability certificate issued by a Medical Board duly
2. Loss of independent living constituted by the Central and/or the State Government;
The Insured Person is permanently unable to perform and
independently three or more of the following six 2. We will admit a claim under this optional benefit only if
activities of daily living. the Permanent Partial Disability continues for a period
1. Washing: the ability to maintain an adequate level of at least 6 continuous calendar months from the
of cleanliness and personal hygiene. commencement of the Permanent Partial Disability,
2. Dressing: the ability to put on and take off all unless it is irreversible; and
necessary garments, artificial limbs or other surgical 3. If the Insured Person dies before a claim has been
appliances that are medically necessary. admitted under this optional benefit, no amount will be
3. Feeding: the ability to transfer food from a plate or payable under this optional benefit, however We will
bowl to the mouth once food has been prepared consider the claim under Section 4.1(1) (Accident Death)
and made available. subject to the terms and conditions mentioned therein.
4. Toileting: the ability to manage bowel and bladder 4. If a claim under this optional benefit has been admitted,
function, maintaining an adequate and socially then no further claim in respect of the same condition
acceptable level of hygiene. will be admitted under this optional benefit.
5. Mobility: the ability to move indoors from room 5. If a claim under this optional benefit is paid and the
to room on level surfaces at the normal place of entire Personal Accident Sum Insured specified in the
residence. Policy Schedule does not get utilized, then the balance
6. Transferring: the ability to move from a lying position Personal Accident Cover Sum Insured shall be available
in a bed to a sitting position in an upright chair or for further claims under Section 4.1 (Personal Accident
wheel chair and vice versa. Cover) until the entire Personal Accident Cover Sum
Insured is consumed. The Personal Accident Cover
Conditions: Sum Insured specified in the first Policy Schedule shall
1. The Permanent Total Disability is proved through a be a lifetime limit for the Insured Person and once this
disability certificate issued by a Medical Board duly limit is exhausted, coverage for the Insured Person will
constituted by the Central and/or the State Government; immediately and automatically cease under Section 4.1
and (Personal Accident Cover) and this optional benefit shall
2. We will admit a claim under this optional benefit only not be applied in respect of that Insured Person on any
if the Permanent Total Disability continues for a period Renewal thereafter. However, other applicable benefits
of at least 6 continuous calendar months from the can be Renewed in respect of the Insured Person
commencement of the Permanent Total Disability unless

Permanent Partial Disability Grid
S. % of Personal Accident
Nature of Disability
No. Cover Sum Insured payable
1 Loss or total and permanent loss of use of both the hands from the wrist joint 100%
2 Loss or total and permanent loss of use of both feet from the ankle joint 100%
3 Loss or total and permanent loss of use of one hand from the wrist joint and of one foot from the ankle 100%
joint
4 Loss or total and permanent loss of use of one hand from the wrist joint and total and permanent loss of 100%
sight in one eye
5 Loss or total and permanent loss of use of one foot from the ankle joint and total and permanent loss of 100%
sight in one eye
6 Total and permanent loss of speech and hearing in both ears 100%
7 Total and permanent loss of hearing in both ears 50%
8 Loss or total and permanent loss of use of one hand from wrist joint 50%
9 Loss or total and permanent loss of use of one foot from ankle joint 50%
10 Total and permanent loss of sight in one eye 50%
11 Total and permanent loss of speech 50%
12 Permanent total loss of use of four fingers and thumb of either hand 40%
13 Permanent total loss of use of four fingers of either hand 35%
14 Uniplegia 25%
15 Permanent total loss of use of one thumb of either hand
a. Both joints 25%
b. One joint 10%
16 Permanent total loss of use of fingers of either hand
a. Three joints 10%
b. Two joints 8%
c. One joint 5%
17 Permanent total loss of use of toes of either foot
a. All toes- one foot 20%
b. Great toe- both joints 5%
c. Great toe- one joint 2%
d. Other than great toe, one toe 1%
II. Critical Illness Cover growth and spread of malignant cells with invasion and
What is covered: destruction of normal tissues. This diagnosis must be
This optional benefit is available either to the Primary Insured supported by histological evidence of malignancy. The
Person or Primary Insured Person along with his/her spouse, term cancer includes leukemia, lymphoma and sarcoma.
which is specified in the Policy Schedule. II. The following are excluded –
i. All tumors which are histologically described as
If the Insured Person covered under this optional benefit is carcinoma in situ, benign, pre-malignant, borderline
diagnosed for the first time with any of the following listed Critical malignant, low malignant potential, neoplasm of
Illnesses or if any of the following Critical Illnesses occurs or unknown behaviour, or non-invasive, including but
manifests itself in the Insured Person during the Policy Period for not limited to: Carcinoma in situ of breasts, Cervical
the first time, We will pay the Critical Illness Sum Insured specified dysplasia CIN-1, CIN -2 and CIN-3.
in the Policy Schedule provided that the Insured Person survives ii. Any non-melanoma skin carcinoma unless there is
the Survival Period of 30 days from the diagnosis of the Critical evidence of metastases to lymph nodes or beyond;
Illness during the Policy Period. iii. Malignant melanoma that has not caused invasion
beyond the epidermis;
1. Cancer of Specified Severity iv. All tumors of the prostate unless histologically
I. A malignant tumor characterized by the uncontrolled classified as having a Gleason score greater than

6 or having progressed to at least clinical TNM i. no response to external stimuli continuously for at
classification T2N0M0 least 96 hours;
v. All Thyroid cancers histologically classified as ii. life support measures are necessary to sustain life;
T1N0M0 (TNM Classification) or below; and
vi. Chronic lymphocytic leukaemia less than RAI stage 3 iii. Permanent neurological deficit which must be
vii. Non-invasive papillary cancer of the bladder assessed at least 30 days after the onset of the coma.
histologically described as TaN0M0 or of a lesser II. The condition has to be confirmed by a specialist medical
classification, practitioner. Coma resulting directly from alcohol or drug
viii. All Gastro-Intestinal Stromal Tumors histologically abuse is excluded
classified as T1N0M0 (TNM Classification) or be low
and with mitotic count of less than or equal to 5/50 6. Kidney Failure requiring Regular Dialysis
HPFs; I. End stage renal disease presenting as chronic irreversible
ix. All tumors in the presence of HIV infection. failure of both kidneys to function, as a result of which
either regular renal dialysis (haemodialysis or peritoneal
2. Myocardial Infarction dialysis) is instituted or renal transplantation is carried
(First Heart Attack of specific severity) out. Diagnosis has to be confirmed by a specialist medical
I. The first occurrence of heart attack or myocardial practitioner
infarction, which means the death of a portion of the
heart muscle as a result of inadequate blood supply to 7. Stroke resulting in Permanent Symptoms
the relevant area. The diagnosis for Myocardial Infarction I. Any cerebrovascular incident producing permanent
should be evidenced by all of the following criteria: neurological sequelae. This includes infarction of brain
i. A history of typical clinical symptoms consistent with tissue, thrombosis in an intracranial vessel, haemorrhage
the diagnosis of acute myocardial infarction (For e.g. and embolisation from an extracranial source. Diagnosis
typical chest pain) has to be confirmed by a specialist medical practitioner
ii. New characteristic electrocardiogram changes and evidenced by typical clinical symptoms as well as
iii. Elevation of infarction specific enzymes, Troponins typical findings in CT Scan or MRI of the brain. Evidence
or other specific biochemical markers. of permanent neurological deficit lasting for at least 3
II. The following are excluded: months has to be produced.
i. Other acute Coronary Syndromes II. The following are excluded:
ii. Any type of angina pectoris i. Transient ischemic attacks (TIA)
iii. A rise in cardiac biomarkers or Troponin T or I in ii. Traumatic injury of the brain
absence of overt ischemic heart disease OR following iii. Vascular disease affecting only the eye or optic nerve
an intra-arterial cardiac procedure. or vestibular functions.
3. Open Chest CABG 8. Major Organ /Bone Marrow Transplant

I. actual undergoing of heart surgery to correct blockage or I. The actual undergoing of a transplant of:
narrowing in one or more coronary artery(s), by coronary i. One of the following human organs: heart, lung, liver,
artery bypass grafting done via a sternotomy (cutting kidney, pancreas, that resulted from irreversible
through the breast bone) or minimally invasive keyhole end-stage failure of the relevant organ, or
coronary artery bypass procedures. The diagnosis must be ii. Human bone marrow using haematopoietic stem
supported by a coronary angiography and the realization cells. The undergoing of a transplant has to be
of surgery has to be confirmed by a cardiologist. confirmed by a specialist medical practitioner.
II. The following are excluded:
i. Angioplasty and/or any other intra-arterial II. The following are excluded:
procedures i. Other stem-cell transplants
ii. Where only islets of langerhans are transplanted
4. Open Heart Replacement or Repair of Heart Valves
I. The actual undergoing of open-heart valve surgery 9. Permanent Paralysis of Limbs
is to replace or repair one or more heart valves, as a I. Total and irreversible loss of use of two or more limbs as
consequence of defects in, abnormalities of, or disease a result of injury or disease of the brain or spinal cord.
affected cardiac valve(s). The diagnosis of the valve A specialist medical practitioner must be of the opinion
abnormality must be supported by an echocardiography that the paralysis will be permanent with no hope of
and the realization of surgery has to be confirmed recovery and must be present for more than 3 months.
by a specialist medical practitioner. Catheter based
techniques including but not limited to, balloon 10. Motor Neuron Disease with Permanent Symptoms
valvotomy/valvuloplasty are excluded. I. Motor neuron disease diagnosed by a specialist medical
practitioner as spinal muscular atrophy, progressive
5. Coma of Specified Severity bulbar palsy, amyotrophic lateral sclerosis or primary
I. A state of unconsciousness with no reaction or response lateral sclerosis. There must be progressive degeneration
to external stimuli or internal needs. This diagnosis must of corticospinal tracts and anterior horn cells or bulbar
be supported by evidence of all of the following: efferent neurons. There must be current significant

and permanent functional neurological impairment 17. Fulminant Viral Hepatitis
with objective evidence of motor dysfunction that has I. A sub-massive to massive necrosis of the liver by any
persisted for a continuous period of at least 3 months. virus, leading precipitously to liver failure.
This diagnosis must be supported by all of the following:
11. Multiple Sclerosis with Persisting Symptoms i. rapid decreasing of liver size; and
I. The unequivocal diagnosis of Definite Multiple Sclerosis ii. necrosis involving entire lobules, leaving only a
confirmed and evidenced by all of the following: collapsed reticular framework; and
i. investigations including typical MRI findings which iii. rapid deterioration of liver function tests; and
unequivocally confirm the diagnosis to be multiple iv. deepening jaundice; and
sclerosis and v. hepatic encephalopathy.
ii. there must be current clinical impairment of motor Acute Hepatitis infection or carrier status alone does not
or sensory function, which must have persisted for a meet the diagnostic criteria
continuous period of at least 6 months.
II. Other causes of neurological damage such as SLE and HIV 18. Aplastic Anemia
are excluded. I. Aplastic Anemia is chronic persistent bone marrow
failure. A certified hematologist must make the diagnosis
12. Deafness of severe irreversible aplastic anemia. There must
I. Total and irreversible loss of hearing in both ears as be permanent bone marrow failure resulting in bone
a result of illness or accident. This diagnosis must be marrow cellularity of less than 25% and there must be
supported by pure tone audiogram test and certified two of the following:
by an Ear, Nose and Throat (ENT) specialist. Total means i. Absolute neutrophil count of less than 500/mm³
“the loss of hearing to the extent that the loss is greater ii. Platelets count less than 20,000/mm³
than 90decibels across all frequencies of hearing” in both iii. Reticulocyte count of less than 20,000/mm³
ears. The Insured Person must be receiving treatment for
more than 3 consecutive months with frequent blood
13. End Stage Lung Failure product transfusions, bone marrow stimulating agents,
I. End stage lung disease, causing chronic respiratory failure, or immunosuppressive agents or the Insured Person
as confirmed and evidenced by all of the following: has received a bone marrow or cord blood stem cell
i. FEV1 test results consistently less than 1 litre transplant. Temporary or reversible Aplastic Anemia is
measured on 3 occasions 3 months apart; and excluded and not covered under this Policy
ii. Requiring continuous permanent supplementary
oxygen therapy for hypoxemia; and 19. Muscular Dystrophy
iii. Arterial blood gas analysis with partial oxygen I. Muscular Dystrophy is a disease of the muscle causing
pressure of 55mmHg or less (PaO2 < 55mmHg); and progressive and permanent weakening of certain muscle
iv. Dyspnea at rest. groups. The diagnosis of Muscular Dystrophy must be
made by a consultant neurologist, and confirmed with
14. End Stage Liver Failure the appropriate laboratory, biochemical, histological, and
I. Permanent and irreversible failure of liver function that electromyography evidence. The disease must result in
has resulted in all three of the following: the permanent inability of the Insured Person to perform
i. Permanent jaundice; and (whether aided or unaided) at least three (3) of the six
ii. Ascites; and (6)“Activities of Daily Living”.
iii. Hepatic encephalopathy. Activities of Daily Living are defined as:
II. Liver failure secondary to drug or alcohol abuse is a. Washing : the ability to maintain an adequate level
excluded. of cleanliness and personal hygiene
b. Dressing : the ability to put on and take off all
15. Loss of Speech necessary garments, artificial limbs or other
I. Total and irrecoverable loss of the ability to speak as a surgical appliances that are Medically Necessary
result of injury or disease to the vocal cords. The inability c. Feeding : the ability to transfer food from a plate or
to speak must be established for a continuous period bowl to the mouth once food has been prepared and
of 12 months. This diagnosis must be supported by made available
medical evidence furnished by an Ear, Nose, Throat (ENT) d. Toileting : the ability to manage bowel and bladder
specialist. function, maintaining an adequate and socially
II. All psychiatric related causes are excluded acceptable level of hygiene
e. Mobility : the ability to move indoors from room
16. Third Degree Burns to room on level surfaces at the normal place of
I. There must be third-degree burns with scarring that cover residence
at least 20% of the body’s surface area. The diagnosis f. Transferring: the ability to move from a lying position
must confirm the total area involved using standardized, in a bed to a sitting position in an upright chair or
clinically accepted, body surface area charts covering wheel chair and vice versa
20% of the body surface area.

20. Bacterial Meningitis b. This exclusion shall not, however, apply if the
I. Bacterial meningitis is a bacterial infection of the Insured Person has continuous coverage for more
meninges of the brain causing brain dysfunction. There than twelve months
must be an unequivocal diagnosis by a consultant c. The within referred waiting period is made applicable
physician of bacterial meningitis that must be proven to the enhanced Sum Insured in the event of granting
on analysis and culture of the cerebrospinal fluid. There higher Sum Insured subsequently.
must also be permanent objective neurological deficit
that is present on physical examination at least 3 months iv. If the Insured Person is diagnosed / undergoes a
after the diagnosis of the meningitis infection. Surgical Procedure or any medical condition occurs
falling under the definition of Critical Illness as
Conditions applicable to ‘Critical Illness cover’: specified above that may result in a claim, then
i. We will not make payment under Section 4.2 (Critical We shall be given written notice immediately and
Illness Cover) more than once in the Insured Person’s in any event within 7 days of the aforesaid Illness/
lifetime for any and all Policy Periods condition/ Surgical Procedure.
ii. The diagnosis of a Critical Illness must be verified in v. We shall not be liable to make any payment under
writing by a Medical Practitioner. this optional benefit if the Insured Person does not
iii. The Waiting Periods specified below shall be survive the Survival Period.
applicable to the Insured Person and claims shall vi. If diagnosis of the Critical Illness takes place on or
be assessed accordingly. On Renewal, if the Critical before the Policy expiry date specified in the Policy
Illness Cover Sum Insured specified in the Policy Schedule, but the Survival Period expires after the
Schedule is enhanced, the Waiting Periods would Policy expiry date, such claims would be admissible
apply afresh to the extent of the increase in benefit if the Insured Person survives the Survival Period.
amount limit, subject to Underwriting Guidelines vii. In the event of death of the Insured Person post
and in accordance with the existing guidelines of the the Survival Period, the immediate family member/
IRDAI. relative of the Insured Person claiming on Insured
Person’s behalf must inform Us in writing immediately
We shall not be liable to make any payment under this Policy and send a copy of all the required documents
for covered listed Critical Illnesses directly or indirectly caused to prove the cause of death within 30 days of the
by, based on, arising out of or howsoever attributable to any death. We upon acceptance of the admission of
of the following: claim under the Policy shall make payment to the
Nominee/legal heirs of the Insured Person.
i. Pre-existing Diseases: viii. If We have admitted a claim under this optional
a. All the listed Critical Illnesses under the optional benefit for an Insured Person in any Policy Year, this
benefit, which occurs or manifests itself as a result optional benefit shall not be renewed in respect
of any Pre-existing Disease (PED) and its direct of that Insured Person for any subsequent Policy
complications shall be excluded until the expiry of Year, but the cover for this optional benefit will be
48 months of continuous coverage after the date of renewable for other Insured Persons.
inception of the first Policy with Us.
b. In case of enhancement of Sum Insured the exclusion III. Modification in Room Rent
shall apply afresh to the extent of Sum Insured If this optional benefit is in force under the Policy, then the
increase. maximum eligibility for a room category in case of Hospitalization
c. If the Insured Person is continuously covered without of the Insured Person payable by Us will be limited to stay in a
any break as defined under the portability norms of Single Private Room.
the extant IRDAI (Health Insurance) regulations, then
waiting period for the same would be reduced to the 5. Claim Cost Sharing
extent of prior coverage.
d. Coverage under this optional benefit after the expiry The following claim cost sharing options shall apply under the
of 48 months for any Pre-existing Disease is subject Policy if specified in the Policy Schedule and shall apply to all
to the same being declared at the time of application Insured Persons. These claim cost sharing options can be selected
and accepted by Us. only at the time of issuance of the First Policy and cannot be
altered at Renewal by You unless as specified below under Section
Pre-existing Disease waiting period shall be applicable only if 5.1.
the pre-existing medical condition is the direct cause of any
Critical Illness and confirmed by the Medical Practitioner. I. Annual Aggregate Deductible
The Insured Person shall bear on his/her own account an amount
ii. 90-day waiting period: equal to the Deductible specified in the Policy Schedule for
a. All the listed Critical Illnesses under the optional all admissible claim amounts We assess to be payable by Us in
benefit, which occurs or manifests itself within 90 respect of all claims made by that Insured Person in a Policy Year.
days from the first Policy commencement date shall It is agreed that Our liability to make payment under the Policy in
be excluded except claims arising due to an Accident, respect of any claim made in that Policy Year will only commence
provided the same are covered. once the Deductible has been exhausted.

It is further agreed that: disorders of retina
a. Deductible will not apply to any claim under Section 3.9 c. Hyperplasia of prostate, hydrocele and spermatocele
(e-Consultation), Section 4.1 (Personal Accident Cover) and d. Abnormal utero-vaginal bleeding, female genital
Section 4.2 (Critical Illness Cover). prolapse, endometriosis/adenomyosis, fibroids,
b. Deductible option can be altered without any medical PCOD, or any condition requiring dilation and
underwriting or pre policy medical check-up, subject to the curettage or hysterectomy
following conditions: e. Hemorrhoids, fissure or fistula or abscess of anal and
i. This option can be availed only once in a lifetime and at rectal region
the time of Renewal, post completion of 5 Policy Years; f. Hernia of all sites,
and g. Osteoarthritis, systemic connective tissue disorders,
ii. The eldest member’s Age in the Policy has not crossed dorsopathies, spondylopathies, inflammatory
50 years. polyarthropathies, arthrosis such as RA, gout,
iii. In case of waiver of Deductible, We will offer an option, intervertebral disc disorders, arthroscopic surgeries
at the time of renewal, to opt for an equivalent indemnity for ligament repair
health insurance Policy (without any Deductible) offered h. Chronic kidney disease and failure
by Us for same Sum Insured. Your current Policy will lapse i. Varicose veins of lower extremities
in case You exercise the option of waiver of Deductible. j. All internal or external benign or in situ neoplasms/
tumours, cyst, sinus, polyp, nodules, swelling, mass
6. Exclusions or lump
6.1. Standard Exclusions k. Ulcer, erosion and varices of gastro intestinal tract
l. Surgical treatment for diseases of middle ear and
I. Pre-existing Diseases (Code–Excl01): mastoid (including otitis media, cholesteatoma,
a. Expenses related to the treatment of a Pre-existing perforation of tympanic membrane), Tonsils and
Disease (PED) and its direct complications shall be adenoids, nasal septum and nasal sinuses
excluded until the expiry of 36 months of continuous m. Internal Congenital Anomaly
coverage after the date of inception of the first Policy n. Surgery of Genito-urinary system unless necessitated
with Us. by malignancy
b. In case of enhancement of Sum Insured the exclusion o. Spinal disorders
shall apply afresh to the extent of Sum Insured increase.
c. If the Insured Person is continuously covered without III. 30-day waiting period (Code- Excl03):
any break as defined under the portability norms of the a. Expenses related to the treatment of any Illness within
extant IRDAI (Health Insurance) regulations, then waiting 30 days from the first Policy commencement date shall
period for the same would be reduced to the extent of be excluded except claims arising due to an Accident,
prior coverage. provided the same are covered.
d. Coverage under the Policy after the expiry of 36 months b. This exclusion shall not, however, apply if the Insured
for any Pre-existing Disease is subject to the same being Person has continuous coverage for more than twelve
declared at the time of application and accepted by Us. months
c. The within referred waiting period is made applicable
II. Specified disease/procedure waiting period- Code- Excl02 to the enhanced Sum Insured in the event of granting
a. Expenses related to the treatment of the listed conditions, higher Sum Insured subsequently.
surgeries/treatments shall be excluded until the expiry
of 24 months of continuous coverage after the date of Note: Exc01, Excl02, Excl03 shall not apply to Section 3.9
inception of the first Policy with us. This exclusion shall (e-Consultation), Section 4.1 (Personal Accident Cover) and
not be applicable for claims arising due to an Accident Section 4.2 (Critical Illness Cover).
(covered from day 1 or Cancer (covered after 30-day
waiting period). IV. Investigation & Evaluation (Code-Excl04)
b. In case of enhancement of Sum Insured the exclusion a. Expenses related to any admission primarily for
shall apply afresh to the extent of Sum Insured increase. diagnostics and evaluation purposes only are excluded.
c. If any of the specified disease/procedure falls under the b. Any diagnostic expenses which are not related or not
waiting period specified for pre-Existing diseases, then incidental to the current diagnosis and treatment are
the longer of the two waiting periods shall apply. excluded.
d. The waiting period for listed conditions shall apply even
if contracted after the Policy or declared and accepted V. Rest Cure, rehabilitation and respite care (Code-Excl05)
without a specific exclusion. Expenses related to any admission primarily for enforced bed
e. If the Insured Person is continuously covered without rest and not for receiving treatment. This also includes:
any break as defined under the applicable norms on a. Custodial care either at home or in a nursing facility for
portability stipulated by IRDAI then waiting period for the personal care such as help with activities of daily living
same would be reduced to the extent of prior coverage. such as bathing, dressing, moving around either by
f. List of specific diseases/procedures: skilled nurses or assistant or non-skilled persons.
a. Pancreatitis and stones in biliary and urinary system b. Any services for people who are terminally ill to address
b. Cataract, glaucoma and other disorders of lens, physical, social, emotional and spiritual needs.

VI. Obesity/ Weight Control (Code-Excl06) minerals and organic substances unless prescribed by a
Expenses related to the surgical treatment of obesity that does Medical Practitioner as part of Hospitalization claim or Day
not fulfil all the below conditions: Care procedure (Code-Excl14)
a. Surgery to be conducted is upon the advice of the Doctor.
b. The surgery/Procedure conducted should be supported by XV. Refractive Error (Code-Excl15)
clinical protocols. Expenses related to the treatment for correction of eye sight due
c. The member has to be 18 years of age or older and; to refractive error less than 7.5 dioptres.
d. Body Mass Index (BMI);
i. greater than or equal to 40 or XVI. Unproven Treatments (Code-Excl16)
ii. greater than or equal to 35 in conjunction with any of the Expenses related to any unproven treatment, services and supplies
following severe co-morbidities following failure of less for or in connection with any treatment. Unproven treatments are
invasive methods of weight loss: treatments, procedures or supplies that lack significant medical
1. Obesity-related cardiomyopathy documentation to support their effectiveness.
2. Coronary heart disease
3. Severe Sleep Apnea XVII. Birth control, Sterility and Infertility (Code-Excl17)
4. Uncontrolled Type2 Diabetes Expenses related to Birth Control, sterility and infertility. This
includes:
VII. Change-of-Gender treatments (Code-Excl07) a. Any type of contraception, sterilization
Expenses related to any treatment, including surgical management, b. Assisted Reproduction services including artificial
to change characteristics of the body to those of the opposite sex. insemination and advanced reproductive technologies such
as IVF, ZIFT, GIFT, ICSI
VIII. Cosmetic or plastic Surgery (Code-Excl08) c. Gestational Surrogacy
Expenses for cosmetic or plastic surgery or any treatment to d. Reversal of sterilization
change appearance unless for reconstruction following an
Accident, Burn(s) or Cancer or as part of medically necessary XVIII. Maternity Expenses (Code-Excl18)
treatment to remove a direct and immediate health risk to the a. Medical treatment expenses traceable to childbirth (including
insured. For this to be considered a medical necessity, it must be complicated deliveries and caesarean sections incurred
certified by the attending Medical Practitioner. during Hospitalization) except ectopic pregnancy;
b. Expenses towards miscarriage (unless due to an Accident)
IX. Hazardous or Adventure sports (Code-Excl09) and lawful medical termination of pregnancy during the
Expenses related to any treatment necessitated due to participation Policy Period.
as a professional in hazardous or adventure sports, including but
not limited to, para-jumping, rock climbing, mountaineering, 6.2. Specific Exclusions
rafting, motor racing, horse racing or scuba diving, hand gliding, I. Personal Waiting Periods:
sky diving, deep-sea diving. Conditions specified for an Insured Person under Personal
Waiting Period in the Policy Schedule will be subject to a
X. Breach of law (Code-Excl10) Waiting Period of 24 months from the inception of the First
Expenses for treatment directly arising from or consequent upon Policy with Us for that Insured Person and will be covered
any Insured Person committing or attempting to commit a breach from the commencement of the third Policy Year for that
of law with criminal intent. Insured Person as long as the Insured Person has been insured
continuously under the Policy without any break.
XI. Excluded Providers (Code-Excl11)
Expenses incurred towards treatment in any Hospital or by II. Charges related to a Hospital stay not expressly mentioned
any Medical Practitioner or any other provider specifically as being covered. This will include charges for RMO charges ,
excluded by Us and disclosed in Our website / notified to surcharges and service charges levied by the Hospital.
the Policyholders are not admissible. However, in case of life
threatening situations following an Accident, expenses up to III. Circumcision:
the stage of stabilization are payable but not the complete Circumcision unless necessary for the treatment of a disease
claim. or necessitated by an Accident.
XII. Treatment for, alcoholism, drug or substance abuse or any IV. Conflict & Disaster:
addictive condition and consequences thereof. (Code-Excl12) Treatment for any Injury or Illness resulting directly or
indirectly from nuclear, radiological emissions, war or war like
XIII. Treatments received in heath hydros, nature cure clinics, situations (whether war is declared or not), rebellion (act of
spas or similar establishments or private beds registered as armed resistance to an established government or leader),
a nursing home attached to such establishments or where acts of terrorism.
admission is arranged wholly or partly for domestic reasons.
(Code-Excl13) V. External Congenital Anomaly:
Screening, counseling or treatment related to external
XIV. Dietary supplements and substances that can be purchased Congenital Anomaly.
without prescription, including but not limited to vitamins,

VI. Dental/oral treatment: 3. Service in the armed forces, or any police organization, of
Treatment, procedures and preventive, diagnostic, restorative, any country at war or at peace or service in any force of
cosmetic services related to disease, disorder and conditions an international body or participation in any of the naval,
related to natural teeth and gingiva except if required by an military or air force operation during peace time.
Insured Person while Hospitalized due to an Accident. 4. Any change of profession after inception of the Policy or any
Renewal which results in the enhancement of Our risk, if not
VII. Hormone Replacement Therapy: accepted and endorsed by Us on the Policy Schedule.
Treatment for any condition / illness which requires hormone 5. Committing an assault, a criminal offence or any breach of
replacement therapy. law with criminal intent.
6. Taking or absorbing, accidentally or otherwise, any
VIII. Multifocal Lens and ambulatory devices such as walkers, intoxicating liquor, drug, narcotic, medicine, sedative or
crutches, splints, stockings of any kind and also any medical poison, except as prescribed by a Medical Practitioner other
equipment which is subsequently used at home. than the Policyholder or an Insured Person.
7. Participation in aviation/marine activities (including crew)
IX. Sexually transmitted Infections & diseases (other than HIV / other than as a passenger in an aircraft/water craft that
AIDS): is authorized by the relevant regulations to carry such
Screening, prevention and treatment for sexually related passengers between established airports or ports.
infection or disease (other than HIV / AIDS). 8. Engaging in or taking part in professional/adventure sports
or any hazardous pursuits, speed contest or racing of any
X. Sleep disorders: kind (other than on foot), bungee jumping, parasailing,
Treatment for any conditions related to disturbance of normal ballooning, parachuting, skydiving, paragliding, hang gliding,
sleep patterns or behaviors. mountain or rock climbing necessitating the use of guides or
ropes, potholing, abseiling, deep sea diving, polo, snow and
XI. Any treatment or medical services received outside the ice sports, hunting.
geographical limits of India. 9. Body or mental infirmity or any Illness except where such
condition arises directly as a result of an Accident during
XII. Any expenses incurred on OPD treatment the Policy Period. However this exclusion is not applicable
to claims made under Section 4.1(3) (Permanent Partial
XIII. Unrecognized Physician or Hospital: Disability).
a. Treatment or Medical Advice provided by a Medical
Practitioner not recognized by the Medical Council of India 7. General Terms and Clauses
or by Central Council of Indian Medicine or by Central council 7.1. Standard General Terms and Clauses
of Homeopathy.
b. Treatment provided by anyone with the same residence as an I. Free Look Period
Insured Person or who is a member of the Insured Person’s The Free Look Period shall be applicable on new individual health
immediate family or relatives. insurance policies and not on renewals or at the time of porting/
c. Treatment provided by Hospital or health facility that is not migrating the policy.
recognized by the relevant authorities in India.
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
XIV. Permanent Exclusions for Personal Accident Cover distance marketing) from date of receipt of the policy document
We shall not be liable to make any payment under any benefits to review the terms and conditions of the policy, and to return the
under Section 4.1 (Personal Accident Cover) if the claim is same if not acceptable.
attributable to, or based on, or arises out of, or is directly or
indirectly connected to any of the following: lf the insured has not made any claim during the Free Look Period,
1. Suicide or self inflicted Injury, whether the Insured Person is the insured shall be entitled to
medically sane or insane. a. a refund of the premium paid less any expenses incurred by
2. Treatment for any Injury or Illness resulting directly or the Company on medical examination of the insured person
indirectly from nuclear, radiological emissions, war or war and the stamp duty charges
like situations (whether war is declared or not), rebellion (act
of armed resistance to an established government or leader), II. Cancellation
acts of terrorism. I. 7 otherwise, no refunds of premium shall be made
in respect of Cancellation where, any claim has been
admitted or has been lodged or any benefit has been
availed by the insured person under the policy.

1 year 2 years 3 years
Policy in-force up to Refund Premium (%) Policy in-force up to Refund Premium (%) Policy in-force up to Refund Premium (%)
Up to 30 days 75% Up to 30 days 87.5% Up to 30 days 90%
31 to 90 days 50% 31 to 90 days 75% 31 to 90 days 87.5%
91 to 180 days 25% 91 to 180 days 62.5% 91 to 180 days 75%
exceeding 180 days 0% 181 to 365 days 50% 181 to 365 days 60%
366 to 455 days 25% 366 to 455 days 50%
456 to 545 days 12% 456 to 545 days 25%
Exceeding 545 days 0% 545 to 720 days 12%
Exceeding 720 days 0%
II. The Company may cancel the policy at any time on behalf to obtain any benefit under this policy, all benefits
grounds of misrepresentation non-disclosure of material under this policy and the premium paid shall be forfeited.
facts, fraud by the insured person by giving 15 days’
written notice. There would be no refund of premium Any amount already paid against claims made under this
on cancellation on grounds of misrepresentation, non- policy but which are found fraudulent later shall be repaid by
disclosure of material facts or fraud. all recipient(s)/policyholder(s), who has made that particular
claim, who shall be jointly and severally liable for such
III. Renewal of Policy repayment to the insurer.
The policy shall ordinarily be renewable except on grounds of
fraud, misrepresentation by the insured person. For the purpose of this clause, the expression “fraud” means
I. The Company shall endeavor to give notice for any of the following acts committed by the insured person
renewal. However, the Company is not under or by his agent or the hospital/doctor/any other party acting
obligation to give any notice for renewal. on behalf of the insured person, with intent to deceive the
II. Renewal shall not be denied on the ground that the insurer or to induce the insurer to issue an insurance policy:
insured person had made a claim or claims in the a) the suggestion, as a fact of that which is not true and which
preceding policy years. the insured person does not believe to be true; b) the active
III. Request for renewal along with requisite premium concealment of a fact by the insured person having knowledge
shall be received by the Company before the end of or belief of the fact; c) any other act fitted to deceive; and d)
the policy period. any such act or omission as the law specially declares to be
IV. At the end of the policy period, the policy shall fraudulent
terminate and can be renewed within the Grace
Period of 30 days to maintain continuity of benefits The Company shall not repudiate the claim and / or forfeit the
without break in policy. Coverage is not available policy benefits on the ground of Fraud, if the insured person
during the grace period. / beneficiary can prove that the misstatement was true to the
V. No loading shall apply on renewals based on best of his knowledge and there was no deliberate intention to
individual claims experience suppress the fact or that such misstatement of or suppression
of material fact are within the knowledge of the insurer.
IV. Nomination
The policyholder is required at the inception of the policy VI. Possibility of Revision of Terms of the Policy Including
to make a nomination for the purpose of payment of claims the Premium Rates
under the policy in the event of death of the policyholder. Any The Company, with prior approval of lRDAl, may revise or
change of nomination shall be communicated to the company modify the terms of the policy including the premium rates.
in writing and such change shall be effective only when an The insured person shall be notified three months before the
endorsement on the policy is made. ln the event of death changes are effected.
of the policyholder, the Company will pay the nominee {as
named in the Policy Schedule/Policy Certificate/Endorsement VII. Withdrawal of Policy
(if any)} and in case there is no subsisting nominee, to the ln the likelihood of this product being withdrawn in future,
legal heirs or legal representatives of the policyholder whose the Company will intimate the insured person about the same
discharge shall be treated as full and final discharge of its 90 days prior to expiry of the policy.
liability under the policy.
lnsured Person will have the option to migrate to similar
V. Fraud health insurance product available with the Company at the
lf any claim made by the insured person, is in any respect time of renewal with all the accrued continuity benefits such
fraudulent, or if any false statement, or declaration is made or as cumulative bonus, waiver of waiting period as per IRDAI
used in support thereof, or if any fraudulent means or devices guidelines, provided the policy has been maintained without
are used by the insured person or anyone acting on his/her a break.

VIII. Redressal of Grievances: to indemnify treatment costs, the insured person
a. ln case of any grievance the insured person may contact shall have the right to require a settlement of his/her
the company through claim in terms of any of his/her policies. ln all such
Website: www.nivabupa.com cases the insurer chosen by the insured person shall
Toll free: 1860-500-8888 be obliged to settle the claim as long as the claim is
E-mail: customercare@nivabupa.com (Senior citizens within the limits of and according to the terms of the
may write to us at: seniorcitizensupport@nivabupa.com) chosen policy.
Fax : 011-3090-2010 II. lnsured person having multiple policies shall also
Courier: Customer Services Department have the right to prefer claims under this policy for
Niva Bupa Health Insurance Company Limited the amounts disallowed under any other policy /
D-5, 2nd Floor, Logix Infotech Park policies even if the sum insured is not exhausted.
opp. Metro Station, Sector 59, Then the insurer shall independently settle the claim
Noida, Uttar Pradesh, 201301 subject to the terms and conditions of this policy.
III. lf the amount to be claimed exceeds the sum insured
lnsured person may also approach the grievance cell under a single policy, the insured person shall have
at any of the company’s branches with the details of the right to choose insurer from whom he/she wants
grievance lf lnsured person is not satisfied with the to claim the balance amount.
redressal of grievance through one of the above methods, IV. Where an insured person has policies from more
insured person may contact the grievance officer at than one insurer to cover the same risk on indemnity
Head – Customer Services basis, the insured person shall only be indemnified
Niva Bupa Health Insurance Company Limited the treatment costs in accordance with the terms
D-5, 2nd Floor, Logix Infotech Park and conditions of the chosen policy
opp. Metro Station, Sector 59,
Noida, Uttar Pradesh, 201301 XI. Condition Precedent to Admission of Liability
Contact No: 1860-500-8888 The terms and conditions of the policy must be fulfilled by
Fax No.: 011-3090-2010 the insured person for the Company to make any payment for
Email ID: customercare@nivabupa.com claim(s) arising under the policy.
For updated details of grievance officer, kindly refer the XII. Complete Discharge
link https://www.nivabupa.com/customer-care/health- Any payment to the policyholder, insured person or his/ her
services/grievance-redressal.aspx nominees or his/ her legal representative or assignee or to
the Hospital, as the case may be, for any benefit under the
If the Insured person is not satisfied with the above, they policy shall be a valid discharge towards payment of claim by
can escalate to GRO@nivabupa.com. the Company to the extent of that amount for the particular
claim.
b. l f lnsured person is not satisfied with the redressal of
grievance through above methods, the insured person XIII. Portability
may also approach the office of lnsurance Ombudsman Portability:
of the respective area/region for redressal of grievance as The insured person will have the option to port the policy to
per lnsurance Ombudsman Rules 2017 ( at the addresses other insurers by applying to such insurer to port the entire
given in Annexure 1). policy along with all the members of the family, if any, at least
c. Grievance may also be lodged at IRDAI lntegrated 45 days before, but not earlier than 60 days from the policy
Grievance Management System - https://igms. irda.gov. renewal date as per IRDAI guidelines related to portability. lf
in/ such person is presently covered and has been continuously
covered without any lapses under any health insurance policy
IX. Moratorium Period with an lndian General/Health insurer, the proposed insured
After completion of eight continuous years under the Policy person will get the accrued continuity benefits in waiting
no look back to be applied. This period of eight years is called periods as per IRDAI guidelines on portability
as moratorium period. The moratorium would be applicable
for the sums insured of the first Policy and subsequently For Detailed Guidelines on portability, kindly refer the link
completion of 8 continuous years would be applicable from https://www.irdai.gov.in/ADMINCMS/cms/whatsNew_
date of enhancement of sums insured only on the enhanced Layout.aspx?page=PageNo3987&flag=1
limits. After the expiry of Moratorium Period no health
insurance claim shall be contestable except for proven fraud XIV. Migration:
and permanent exclusions specified in the Policy contract. The insured person will have the option to migrate the policy
The policies would however be subject to all limits, sub limits, to other health insurance products/plans offered by the
co-payments, deductibles as per the Policy contract. company by applying for migration of the policy atleast 30
days before the policy renewal date as per IRDAI guidelines on
X. Multiple Policies Migration. lf such person is presently covered and has been
I. ln case of multiple policies taken by an insured continuously covered without any lapses under any health
person during a period from one or more insurers insurance product/plan offered by the company, the insured

person will get the accrued continuity benefits in waiting c. Disclosures on Renewal:
periods as per IRDAI guidelines on migration. You shall make a full disclosure to Us in writing of any material
change in the health condition or geographical location of any
For Detailed Guidelines on migration, kindly refer the link Insured Person at the time of seeking Renewal of this Policy,
https://www.irdai.gov.in/ADMINCMS/cms/whatsNew_ irrespective of any claim arising or made. The terms and
Layout.aspx?page=PageNo3987&flag=1 condition of the existing Policy will not be altered.
7.2. Specific Terms and Clauses d. Renewal for Insured Persons who have achieved Age 26:
I. Automatic Cancellation: If any Insured Person who is a child and has completed Age
i. Individual Policy: 26 years at the time of Renewal, then such Insured Person
The Policy shall automatically terminate in the event of will have to take a separate policy based on Our underwriting
death of the Insured Person. guidelines, as per Our Board approved underwriting policy as
ii. For Family Floater Policies: he/she will no longer be eligible to be covered under a Family
The Policy shall automatically terminate in the event of Floater Policy. In such cases, the credit of the Waiting Periods
the death of all the Insured Persons. . served under the Policy will be passed on to the separate
iii. Refund: policy taken by such Insured Person.
A refund in accordance with the table in Section 7.1 (II)
shall be payable if there is an automatic cancellation of e. Addition of Insured Persons on Renewal:
the Policy provided that no claim has been made and Where an individual is added to this Policy, either by way
e-Consultation has not been availed under the Policy of endorsement or at the time of Renewal, the Pre-existing
by or on behalf of any Insured Person. We will pay the Disease clause, exclusions, loading (if any) and Waiting Periods
refund of premium to the Nominee named in the Policy will be applicable considering such Policy Year as the first year
Schedule or Your legal heirs or legal representatives of the Policy with Us for that Insured Person.
holding a valid succession certificate.
f. Changes to Sum Insured on Renewal:
II. Loading on Premium You may opt for enhancement of Sum Insured at the time of
There is no premium loading applicable basis the health status Renewal, subject to underwriting. All Waiting Periods shall
of the Insured under the Policy. apply afresh for this enhanced limit from the effective date of
such enhancement.
III. Other Renewal Conditions
a. Continuity of benefits on Timely Renewal: IV. Change of Policyholder
i. The Renewal premium is payable on or before the due a. The Policyholder may be changed only at the time of
date and in any circumstances before the expiry of Grace Renewal. The new Policyholder must be a member of
Period the Insured Person’s immediate family. Such change
ii. Renewal premium rates for this Policy may be further would be solely subject to Our discretion and payment
altered by Us including in the following circumstances: of premium by You. The Renewed Policy shall be treated
A. You proposed to add an Insured Person to the Policy as having been Renewed without break. The Policyholder
B. You change any coverage provision may be changed upon request in case of Your death, Your
iii. Renewal premium will alter based on individual Age. The emigration from India or in case of Your divorce during
reference of Age for calculating the premium for Family the Policy Period.
Floater Policies shall be the Age of the eldest Insured b. Any alteration in the Policy due to unavoidable
Person. circumstances as in case of the Policyholder’s death,
emigration or divorce during the Policy Period should be
b. Reinstatement: reported to Us immediately.
i. The Policy shall lapse after the expiration of the c. Renewal of such Policies will be according to terms and
Grace Period. If the Policy is not Renewed within conditions of existing Policy.
the Grace Period then We may agree to issue a
fresh Policy subject to Our underwriting criteria, as V. Obligations in case of a minor
per Our Board approved underwriting policy and If an Insured Person is less than 18 years of Age, You or
no continuing benefits shall be available from the another adult Insured Person or legal guardian (in case of
expired Policy. Your and all other adult Insured Person’s demise) shall be
ii. We will not pay for any Medical Expenses which are completely responsible for ensuring compliance with all the
incurred between the date the Policy expires and the terms and conditions of this Policy on behalf of that minor
date immediately before the reinstatement date of Insured Person.
Your Policy.
iii. If there is any change in the Insured Person’s medical VI. Authorization to obtain all pertinent records or information:
or physical condition, We may add exclusions or As a Condition Precedent to the payment of benefits, We
charge an extra premium from the reinstatement and/or Our Service Provider shall have the authority to
date. obtain all pertinent records or information from any Medical

Practitioner, Hospital, clinic, insurer, individual or institution the Insured Person’s treatment and to investigate the
to assess the validity of a claim submitted by or on behalf of circumstances pertaining to the claim.
any Insured Person. c. We and Our Service Provider must be given all reasonable
co-operation in investigating the claim in order to assess
VII. Policy Disputes Our liability and quantum in respect of the claim.
Any dispute concerning the interpretation of the terms, d. It is hereby agreed and understood that no change in
conditions, limitations and/or exclusions contained herein the Medical Record provided under the Medical Advice
shall be governed by Indian law and shall be subject to the information, by the Hospital or the Insured Person to Us or
jurisdiction of the Indian Courts. Our Service Provider during the period of Hospitalization
or after discharge by any means of request will be
VIII. Territorial Jurisdiction accepted by Us. Any decision on request for acceptance
All benefits are available in India only and all claims shall be of such change will be considered on merits where the
payable in India in Indian Rupees only. change has been proven to be for reasons beyond the
claimant’s control.
IX. Notices
Any notice, direction or instruction given under this Policy B. Claims Procedure: On the occurrence or the discovery
shall be in writing and delivered by hand, post, or facsimile to: of any Illness or Injury that may give rise to a claim
a. You/the Insured Person at the address specified in the under this Policy, then as a Condition Precedent to Our
Policy Schedule or at the changed address of which We liability under the Policy the following procedure shall be
must receive written notice. complied with:
b. Us at the following address: a. For Availing Cashless Facility: Cashless Facility
Niva Bupa Health Insurance Company Limited can be availed only at Our Network Providers or
D-5, 2nd Floor, Logix Infotech Park Service Providers (as applicable). The complete list
opp. Metro Station, Sector 59, of Network Providers are available on Our website
Noida, Uttar Pradesh, 201301 and at Our branches and can also be obtained by
Fax No.: 011-3090-2010 contacting Us over the telephone. In order to avail
c. No insurance agents, brokers or other person/entity is Cashless Facility, the following process must be
authorized to receive any notice on Our behalf. followed:
d. In addition, We may send You/the Insured Person other i. Process for Obtaining Pre-Authorization
information through electronic and telecommunications A. For Planned Treatment:
means with respect to Your Policy from time to time. We must be contacted to pre-authorize Cashless
Facility for planned treatment at least 72 hours prior
X. Alteration to the Policy to the proposed treatment. Once the request for pre-
This Policy constitutes the complete contract of insurance. authorisation has been granted, the treatment must
Any change in the Policy will only be evidenced by a written take place within 15 days of the pre-authorization
endorsement signed and stamped by Us. No one except Us date at a Network Provider.
can within the permission of the IRDAI change or vary this B. In Emergencies:
Policy. If the Insured Person has been Hospitalized in an
Emergency, We must be contacted to pre-authorize
XI. Assignment Cashless Facility within 48 hours of the Insured
The Policy can be assigned subject to applicable laws. Person’s Hospitalization or before discharge from the
Hospital, whichever is earlier.
XII. Claims Process & Requirements
The fulfillment of the terms and conditions of this Policy All final authorization requests, if required, shall be sent at
(including payment of full premium in advance by the due least six hours prior to the Insured Person’s discharge from
dates mentioned in the Policy Schedule) in so far as they the Hospital.
relate to anything to be done or complied with by You or any
Insured Person, including complying with the following in Each request for pre-authorization must be accompanied
relation to claims, shall be Condition Precedent to admission with completely filled and duly signed pre-authorization form
of Our liability under this Policy. including all of the following details:
I. The health card We have issued to the Insured Person at
A. Claims Administration: the time of inception of the Policy (if available) supported
On the occurrence or discovery of any Illness or Injury that with KYC document;
may give rise to a claim under this Policy, the Claims Procedure II. The Policy Number;
set out below shall be followed: III. Name of the Policyholder;
IV. Name and address of Insured Person in respect of whom
a. We advise You to submit all claims related documents, the request is being made;
including documents for claims within the Deductible V. Nature of the Illness/Injury and the treatment/Surgery
amount, once the Deductible limit has been exhausted. required;
b. We/Our Service Provider must be permitted to inspect VI. Name and address of the attending Medical Practitioner;
the medical and Hospitalization records pertaining to VII. Hospital where treatment/Surgery is proposed to be

taken; v. Name and address of the attending Medical Practitioner;
VIII. Date of admission; vi. Hospital where treatment/Surgery was taken;
IX. First and any subsequent consultation paper / Medical vii. Date of admission and date of discharge;
Record since beginning of diagnosis of that treatment/ viii. Any other information that may be relevant to the Illness/
Surgery; Injury/ Hospitalization.
X. Admission note;
XI. Treating Medical Practitioner certificate for Illness / C. Claims Documentation:
Insured Event history with justification of Hospitalization.
For medical claims – Reimbursement Facility:
If these details are not provided in full or are insufficient
for Us to consider the request, We will request additional We shall be provided with the following necessary information
information or documentation in respect of that request. and documentation in respect of all claims at Your/Insured
Person’s expense within 30 days of the Insured Event giving
When We have obtained sufficient details to assess the rise to a claim or within 30 days from the date of occurrence
request, We will issue the authorization letter specifying of an Insured Event or completion of Survival Period (in case
the sanctioned amount, any specific limitation on the claim, of Critical Illness Cover).
applicable Deductibles and non-payable items, if applicable,
or reject the request for pre-authorisation specifying reasons For medical claims – Cashless Facility:
for the rejection.
We will be provided these documents by the Network Provider
In case of preauthorization request where chronicity of immediately following the Insured Person’s discharge from
condition is not established as per clinical evidence based Hospital.
information, We may reject the request for preauthorization
and ask the claimant to claim as Reimbursement. Claim Necessary information and documentation for medical claims
document submission for Reimbursement shall not be
deemed as an admission of Our liability. a. Claim form duly completed and signed by the claimant.
b. Details of past medical history record, first and
Once the request for pre-authorisation has been granted, subsequent consultation.
the treatment must take place within 15 days of the pre- c. Age / Identity proof document of Insured Person in case
authorization date and pre-authorization shall be valid of claim approved under Cashless Facility (not required if
only if all the details of the authorized treatment, including submitted at the time of pre-authorization request) and
dates, Hospital, locations, indications and disease details, Policyholder in case of Reimbursement claim.
match with the details of the actual treatment received. For i. Self attested copy of valid age proof (passport /
Hospitalization on a Cashless Facility basis, We will make the driving license / PAN card / class X certificate / birth
payment of the amount assessed to be due, directly to the certificate);
Network Provider / Service Provider. ii. Self attested copy of identity proof (passport /
driving license / PAN card / voter identity card);
We reserve the right to modify, add or restrict any Network iii. Recent passport size photograph
Provider or Service Provider for Cashless Facility at Our sole d. Cancelled cheque/ bank statement / copy of passbook
discretion. mentioning account holder’s name, IFSC code and
account number printed on it of Policyholder / nominee (
ii. Reauthorization in case of death of Policyholder).
Cashless Facility will be provided subject to re-authorization if e. Original discharge summary.
requested for either change in the line of treatment or in the f. Bar code sticker and invoice for implants and prosthesis
diagnosis or for any procedure carried out on the incidental (if used and only in case of Surgery/Surgical Procedure).
diagnosis/finding prior to the discharge from the Hospital. g. Original final bill from Hospital with detailed break-up
and paid receipt.
b. For Reimbursement Claims: h. Room tariff of the entitled room category (in case of a
For all claims for which Cashless Facility has not been pre- Non-Network provider and if room tariff is not a part of
authorized or for which treatment has not been taken at a Hospital bill): duly signed and stamped by the Hospital in
Network Provider/Service Provider or for which Cashless which treatment is taken.
Facility is not available, We shall be given written notice of (In case You are unable to submit such document, then We
the claim along with the following details within 48 hours shall consider the Reasonable and Customary Charges of
of admission to the Hospital or before discharge from the the Insured Person’s eligible room category of Our Network
Hospital, whichever is earlier: Provider within the same geographical area for identical or
i. The Policy Number; similar services.)
ii. Name of the Policyholder; i. Original bills of pharmacy/medicines purchased, or
iii. Name and address of the Insured Person in respect of of any other investigation done outside Hospital with
whom the request is being made; reports and requisite prescriptions.
iv. Nature of Illness or Injury and the treatment/Surgery j. For Medico-legal cases (MLC) or in case of Accident
taken; i. MLC/ Panchnama / First Information Report (FIR)

copy attested by the concerned Hospital / police of delay in payment, We shall be liable to pay interest
station (if applicable); at a rate which is 2% above the bank rate prevalent at
ii. Original self-narration of incident in absence of MLC the beginning of the financial year in which the claim has
/ FIR. fallen due.
k. Original laboratory investigation, diagnostic, radiological c. Payment for Reimbursement claims will be made to You.
& pathological reports with supporting prescriptions. In the unfortunate event of Your death, We will pay the
Nominee named in the Policy Schedule or Your legal
In the event of the Insured Person’s death during heirs or legal representatives holding a valid succession
Hospitalization, written notice accompanied by a copy of the certificate.
post mortem report (if any) shall be given to Us regardless of d. If a claim is made which extends in to two Policy Periods,
whether any other notice has been given to Us. then such claim shall be paid taking into consideration
the available Sum Insured in these Policy Periods. Such
For Personal Accident claims eligible claim amount will be paid to the Policyholder/
Insured Person after deducting the extent of premium to
Additional claim documentation for Personal Accident Cover be received for the Renewal/due date of premium of the
under Section 4.1: Policy, if not received earlier.
e. All admissible claims under this Policy shall be assessed
1. Accident Death by Us in the following progressive order:-
i. Copy of death certificate (issued by the office i. If a room has been opted in a Hospital for which
of Registrar of Births and Deaths or any other the room category is higher than the eligible limit
authorized legal institution) as applicable for that Insured Person as specified in
ii. Copy of post mortem report wherever applicable the Policy Schedule, then the Associated Medical
Expenses payable shall be pro-rated as per the
2. Accident Permanent Total Disability or Accident applicable limits in accordance with Section 3.1.
Permanent Partial Disability ii. The Deductible (if applicable) shall be applied to
i. Certificate of disability issued by a Medical Board the aggregate of all claims that are either paid or
duly constituted by the Central and/or the State payable under this Policy. Our liability to make
Government. payment shall commence only once the aggregate
amount of all eligible claims as per policy terms and
For Critical Illness claims conditions exceeds the Deductible limit within the
same Policy Year.
Additional claim documentation for Critical Illness Cover f. The claim amount assessed above would be deducted
under Section 4.2: from the amount / sub-limit mentioned against each
benefit or treatment as per terms and conditions and
1. Treating Medical Practitioner’s certification for insured Sum Insured as specified in the Policy Schedule.
person’s survival post survival period.
E. Delay in Claim Intimation or Claim Documentation:
D. Claims Assessment & Repudiation: If the claim is not notified to Us or claim documents are not
a. At Our discretion, We may investigate claims to determine submitted within the stipulated time as mentioned in the
the validity of a claim. All costs of investigation will be above sections, then We shall be provided the reasons for
borne by Us and all investigations will be carried out by the delay, in writing. We will condone such delay on merits
those individuals/entities that are authorized by Us in where the delay has been proved to be for reasons beyond
writing. the claimant’s control.
b. We shall settle or repudiate a claim within 30 days
of the receipt of the last necessary information and F. Claims process for Section 3.9 (e-Consultation):
documentation set out above. However, where the After validation of Insured Person and Policy details, We
circumstances of a claim warrant an investigation in Our will evaluate the information of the Insured Person from
opinion, We shall initiate and complete such investigation the perspective to check eligibility of cover only and if the
at the earliest, in any case not later than 30 days from request is approved, We will facilitate arrangement as per the
the date of receipt of last necessary document. In such conditions specified under respective benefits admissible to
cases, Insurer shall settle the claim within 45 days from the Insured Person.
the date of receipt of last necessary document. In case
Niva Bupa Health Insurance Company Limited

Registered office:- C-98, First Floor, Lajpat Nagar, Part 1, New Delhi-110024
Disclaimer: Insurance is a subject matter of solicitation. Niva Bupa Health Insurance Company Limited (formerly known as Max Bupa Health Insurance Company
Limited) (IRDAI Registration No. 145). ‘Bupa’ and ‘HEARTBEAT’ logo are registered trademarks of their respective owners and are being used by Niva Bupa Health
Insurance Company Limited under license. Customer Helpline: 1860-500-8888. Website: www.nivabupa.com. CIN: U66000DL2008PLC182918. For more details on
terms and conditions, exclusions, risk factors, waiting period & benefits, please read sales brochure carefully before concluding a sale.
Annexure I
Product Benefit Table (all limits in INR unless defined as percentage)
Base Sum Insured (SI) per Policy Year (in Lacs) 2L 3L/4L 5 L / 7.5 L / 10L / 15L / 25L / 40L / 45L / 65L /
70L / 90L / 95L
Annual aggregate Deductible E-saver: 10k, 25k, 50k
Super Top-up: 1L to 10L in multiples of 1L
Baseline cover benefits
In-patient treatment
Nursing charges for Hospitalization as an inpatient
excluding Private Nursing charges
Medical Practitioners’ fees, excluding any charges
or fees for Standby Services
Physiotherapy, investigation and diagnostics
procedures directly related to the current
admission
Medicines, drugs and consumables as prescribed Covered up to Sum Insured
by the treating Medical Practitioner
Intravenous fluids, blood transfusion, injection
administration charges and /or consumables
Operation theatre charges
The cost of prosthetics and other devices or
equipment if implanted internally during Surgery
Intensive Care Unit charges
Room Rent (per day) Up to 1% of Base Sum Insured per day Single private room; up to Sum Insured
Pre-Hospitalization Medical Expenses (60 days) Covered up to Sum Insured
Post-Hospitalization Medical Expenses (90 days) Covered up to Sum Insured
Day Care Treatment Covered up to Sum Insured
Domiciliary treatment Covered up to Sum Insured
Alternative treatment Covered up to Sum Insured
Living Organ Donor Transplant Covered up to Sum Insured
Emergency Ambulance Up to Rs.1,500 per hospitalization
e-Consultation Unlimited tele / online consultations
Pharmacy and diagnostic services Available through our empanelled service provider
Increase of 5% of expiring Base Sum Insured in a Policy Year; maximum up to 50% of
Loyalty Additions Base Sum Insured; no increase in sub-limits (This benefit is applicable only for Base Sum
Insured up to Rs. 25 Lac)
Mental Disorders Treatment Covered up to Sum Insured (sub-limit applicable on few conditions)
HIV / AIDS Covered up to Sum Insured
Artificial Life Maintenance Covered up to Sum Insured
Modern Treatments Covered up to Sum Insured (sub-limit applicable on few conditions)
OPTIONAL BENEFITS (which may be added at customer level at an additional premium)

Personal Accident cover
- Accident Death
Options available: 1Lac, 2Lacs, 5Lacs to 50Lacs (in multiple of 5Lacs)
- Accident Permanent Total Disability
- Accident Permanent Partial Disability
Critical illness cover Options available: 1Lac to 10Lacs (in multiple of 1 Lac)
Single private room; covered up to Sum
Modification in room rent Insured (optional available only for Not applicable
deductible more than 50,000)

Annexure II
ICD codes for the specified disorders / conditions
Disorder / Condition ICD Codes

Severe Depression F33- F33.9 O90.6, F34.1, F32.0 - F32.9, F30.0 - F30.9, F43.21
Schizophrenia F20.0 - F20.8, F21 - F24, F25 - F25.9
Bipolar Disorder F31.0 - F31.9
Post traumatic stress disorder F43.0, F43.1, F43.2, F43.8, F43.9
Generalized anxiety disorder F40.1, F41- F41.8, F40.8- F40.9, F60.7, F93.0- F94.0

Annexure III
The expenses that are not covered or subsumed into room charges / procedure charges / costs of treatment
List I – Expenses not covered
S.No Item S.No Item

1 BABY FOOD 35 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE
2 BABY UTILITIES CHARGES HOSPITAL)
3 BEAUTY SERVICES 36 SPACER
4 BELTS/ BRACES 37 SPIROMETRE
5 BUDS 38 NEBULIZER KIT
6 COLD PACK/HOT PACK 39 STEAM INHALER
7 CARRY BAGS 40 ARMSLING
8 EMAIL / INTERNET CHARGES 41 THERMOMETER
9 FOOD CHARGES (OTHER THAN PATIENT's DIET 42 CERVICAL COLLAR

PROVIDED BY HOSPITAL) 43 SPLINT
10 LEGGINGS 44 DIABETIC FOOT WEAR
11 LAUNDRY CHARGES 45 KNEE BRACES (LONG/ SHORT/ HINGED)
12 MINERAL WATER 46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER
13 SANITARY PAD 47 LUMBO SACRAL BELT
14 TELEPHONE CHARGES 48 NIMBUS BED OR WATER OR AIR BED CHARGES
15 GUEST SERVICES 49 AMBULANCE COLLAR
16 CREPE BANDAGE 50 AMBULANCE EQUIPMENT
17 DIAPER OF ANY TYPE 51 ABDOMINAL BINDER
18 EYELET COLLAR 52 PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES
19 SLINGS 53 SUGAR FREE Tablets
20 BLOOD GROUPING AND CROSS MATCHING OF DONORS 54 CREAMS POWDERS LOTIONS (Toiletries are not payable,
SAMPLES only prescribed medical pharmaceuticals payable)
21 SERVICE CHARGES WHERE NURSING CHARGE ALSO 55 ECG ELECTRODES
CHARGED
56 GLOVES
22 TELEVISION CHARGES
57 NEBULISATION KIT
23 SURCHARGES
58 ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT,
24 ATTENDANT CHARGES ORTHOKIT, RECOVERY KIT, ETC]
25 EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH 59 KIDNEY TRAY
FORMS PART OF BED CHARGE)
60 MASK
26 BIRTH CERTIFICATE
61 OUNCE GLASS
27 CERTIFICATE CHARGES
62 OXYGEN MASK
28 COURIER CHARGES
63 PELVIC TRACTION BELT
29 CONVEYANCE CHARGES
64 PAN CAN
30 MEDICAL CERTIFICATE
65 TROLLY COVER
31 MEDICAL RECORDS
66 UROMETER, URINE JUG
32 PHOTOCOPIES CHARGES
67 AMBULANCE
33 MORTUARY CHARGES
68 VASOFIX SAFETY
34 WALKING AIDS CHARGES

List II – Items that are to be subsumed into Room Charges
S.No Item S.No Item

1 BABY CHARGES (UNLESS SPECIFIED/INDICATED) 21 HVAC
2 HAND WASH 22 HOUSE KEEPING CHARGES
3 SHOE COVER 23 AIR CONDITIONER CHARGES
4 CAPS 24 IM IV INJECTION CHARGES
5 CRADLE CHARGES 25 CLEAN SHEET
6 COMB 26 BLANKET/WARMER BLANKET
7 EAU-DE-COLOGNE / ROOM FRESHNERS 27 ADMISSION KIT
8 FOOT COVER 28 DIABETIC CHART CHARGES
9 GOWN 29 DOCUMENTATION CHARGES / ADMINISTRATIVE
10 SLIPPERS EXPENSES
11 TISSUE PAPER 30 DISCHARGE PROCEDURE CHARGES
12 TOOTH PASTE 31 DAILY CHART CHARGES
13 TOOTH BRUSH 32 ENTRANCE PASS / VISITORS PASS CHARGES
14 BED PAN 33 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE
15 FACE MASK 34 FILE OPENING CHARGES
16 FLEXI MASK 35 INCIDENTAL EXPENSES / MISC. CHARGES (NOT

EXPLAINED)
17 HAND HOLDER
36 PATIENT IDENTIFICATION BAND / NAME TAG
18 SPUTUM CUP
37 PULSEOXYMETER CHARGES
19 DISINFECTANT LOTIONS
20 LUXURY TAX
List III – Items that are to be subsumed into Procedure Charges
S.No Item S.No Item

1 HAIR REMOVAL CREAM 13 SURGICAL DRILL
2 DISPOSABLES RAZORS CHARGES (for site preparations) 14 EYE KIT
3 EYE PAD 15 EYE DRAPE
4 EYE SHEILD 16 X-RAY FILM
5 CAMERA COVER 17 BOYLES APPARATUS CHARGES
6 DVD, CD CHARGES 18 COTTON
7 GAUSE SOFT 19 COTTON BANDAGE
8 GAUZE 20 SURGICAL TAPE
9 WARD AND THEATRE BOOKING CHARGES 21 APRON
10 ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS 22 TORNIQUET
11 MICROSCOPE COVER 23 ORTHOBUNDLE, GYNAEC BUNDLE
12 SURGICAL BLADES, HARMONICSCALPEL,SHAVER

List IV – Items that are to be subsumed into costs of treatment
S.No Item S.No Item

1 ADMISSION/REGISTRATION CHARGES 10 HIV KIT
2 HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC 11 ANTISEPTIC MOUTHWASH
PURPOSE
12 LOZENGES
3 URINE CONTAINER
13 MOUTH PAINT
4 BLOOD RESERVATION CHARGES AND ANTE NATAL
BOOKING CHARGES 14 VACCINATION CHARGES
5 BIPAP MACHINE 15 ALCOHOL SWABES
6 CPAP/ CAPD EQUIPMENTS 16 SCRUB SOLUTION/STERILLIUM
7 INFUSION PUMP– COST 17 GLUCOMETER & STRIPS
8 HYDROGEN PEROXIDE\SPIRIT\ DISINFECTANTS ETC 18 URINE BAG
9 NUTRITION PLANNING CHARGES - DIETICIAN CHARGES-

DIET CHARGES

Annexure IV
List of Insurance Ombudsmen
Office Details Jurisdiction of Office Union Territory, District)

AHMEDABAD - Shri Kuldip Singh Gujarat,
Office of the Insurance Ombudsman, UT of Dadra & Nagar Haveli,
Jeevan Prakash Building, Daman and Diu.
6th floor, Tilak Marg, Relief Road, Ahmedabad – 380 001.
Tel.: 079 - 25501201/02/05/06
Email: bimalokpal.ahmedabad@cioins.co.in
BENGALURU - Smt. Neerja Shah Karnataka.
Office of the Insurance Ombudsman,
Jeevan Soudha Building,PID No. 57-27-N-19
Ground Floor, 19/19, 24th Main Road, JP Nagar, Ist Phase,
Bengaluru – 560 078.
Tel.: 080 - 26652048 / 26652049
Email: bimalokpal.bengaluru@cioins.co.in
BHOPAL - Shri Guru Saran Shrivastava Madhya Pradesh Chhattisgarh.
Janak Vihar Complex, 2nd Floor, 6, Malviya Nagar, Opp. Airtel Office,
Near New Market, Bhopal – 462 003.
Tel.: 0755 - 2769201 / 2769202
Fax: 0755 - 2769203
Email: bimalokpal.bhopal@cioins.co.in
BHUBANESHWAR - Shri Suresh Chandra Panda Orissa.
62, Forest park, Bhubneshwar – 751 009.
Tel.: 0674 - 2596461 /2596455
Fax: 0674 - 2596429
Email: bimalokpal.bhubaneswar@cioins.co.in
CHANDIGARH - Dr. Dinesh Kumar Verma Punjab, Haryana (excluding Gurugram, Faridabad, Sonepat and
Office of the Insurance Ombudsman, Bahadurgarh), Himachal Pradesh,
S.C.O. No. 101, 102 & 103, 2nd Floor, UT of Jammu & Kashmir, Ladakh and Chandigarh.
Batra Building, Sector 17 – D, Chandigarh – 160 017.
Tel.: 0172 - 2706196 / 2706468
Fax: 0172 - 2708274
Email: bimalokpal.chandigarh@cioins.co.in
CHENNAI - Shri M. Vasantha Krishna Tamil Nadu, UT-Pondicherry Town and
Office of the Insurance Ombudsman, Karaikal (which are part of UT of Pondicherry).
Fatima Akhtar Court, 4th Floor, 453,
Anna Salai, Teynampet, CHENNAI – 600 018.
Tel.: 044 - 24333668 / 24335284
Fax: 044 - 24333664
Email: bimalokpal.chennai@cioins.co.in
DELHI - Shri Sudhir Krishna Delhi & Following Districts of Haryana - Gurugram, Faridabad,
Office of the Insurance Ombudsman, Sonepat & Bahadurgarh.
2/2 A, Universal Insurance Building,
Asaf Ali Road, New Delhi – 110 002.
Tel.: 011 - 23232481/23213504
Email: bimalokpal.delhi@cioins.co.in

GUWAHATI - Shri Kiriti .B. Saha Assam, Meghalaya, Manipur, Mizoram,
Office of the Insurance Ombudsman, Arunachal Pradesh, Nagaland and Tripura.
Jeevan Nivesh, 5th Floor, Nr. Panbazar over bridge, S.S. Road,
Guwahati – 781001(ASSAM).
Tel.: 0361 - 2632204 / 2602205
Email: bimalokpal.guwahati@cioins.co.in
HYDERABAD - Shri I. Suresh Babu Andhra Pradesh, Telangana, UT of Yanam and
Office of the Insurance Ombudsman, part of UT of Pondicherry
6-2-46, 1st floor, “Moin Court”, Lane Opp. Saleem Function Palace,
A. C. Guards, Lakdi-Ka-Pool, Hyderabad - 500 004.
Tel.: 040 - 23312122
Fax: 040 - 23376599
Email: bimalokpal.hyderabad@cioins.co.in
JAIPUR - Smt. Sandhya Baliga Rajasthan.
Jeevan Nidhi – II Bldg., Gr. Floor,
Bhawani Singh Marg, Jaipur - 302 005.
Tel.: 0141 - 2740363
Email: bimalokpal.jaipur@cioins.co.in
ERNAKULAM - Ms. Poonam Bodra Kerala, UT of Lakshadweep, Mahe-a part of UT of Pondicherry.
2nd Floor, Pulinat Bldg., Opp. Cochin Shipyard, M. G. Road,
Ernakulam - 682 015.
Tel.: 0484 - 2358759 / 2359338
Fax: 0484 - 2359336
Email: bimalokpal.ernakulam@cioins.co.in
KOLKATA - Shri P. K. Rath West Bengal, Sikkim, UT of Andaman & Nicobar Islands.
Hindustan Bldg. Annexe, 4th Floor, 4, C.R. Avenue,
KOLKATA - 700 072.
Tel.: 033 - 22124339 / 22124340
Fax : 033 - 22124341
Email: bimalokpal.kolkata@cioins.co.in
LUCKNOW -Shri Justice Anil Kumar Srivastava Districts of Uttar Pradesh :
Office of the Insurance Ombudsman, Lalitpur, Jhansi, Mahoba, Hamirpur, Banda, Chitrakoot, Allahabad,
6th Floor, Jeevan Bhawan, Phase-II, Mirzapur, Sonbhabdra, Fatehpur, Pratapgarh, Jaunpur,Varanasi,
Nawal Kishore Road, Hazratganj, Lucknow - 226 001. Gazipur, Jalaun, Kanpur, Lucknow, Unnao, Sitapur, Lakhimpur,
Tel.: 0522 - 2231330 / 2231331 Bahraich, Barabanki, Raebareli, Sravasti, Gonda, Faizabad,
Fax: 0522 - 2231310 Amethi, Kaushambi, Balrampur, Basti, Ambedkarnagar, Sultanpur,
Email: bimalokpal.lucknow@cioins.co.in Maharajgang, Santkabirnagar, Azamgarh, Kushinagar, Gorkhpur,
Deoria, Mau, Ghazipur, Chandauli, Ballia, Sidharathnagar.
MUMBAI - Shri Milind A. Kharat Goa,
Office of the Insurance Ombudsman, Mumbai Metropolitan Region
3rd Floor, Jeevan Seva Annexe, excluding Navi Mumbai & Thane
S. V. Road, Santacruz (W), Mumbai - 400 054.
Tel.: 022 - 26106552 / 26106960
Fax: 022 - 26106052
Email: bimalokpal.mumbai@cioins.co.in

NOIDA - Shri Chandra Shekhar Prasad State of Uttaranchal and the following Districts of Uttar Pradesh:
Office of the Insurance Ombudsman, Agra, Aligarh, Bagpat, Bareilly, Bijnor, Budaun, Bulandshehar,
Bhagwan Sahai Palace 4th Floor, Main Road, Etah, Kanooj, Mainpuri, Mathura, Meerut, Moradabad,
Naya Bans, Sector 15, Distt: Gautam Buddh Nagar, U.P-201301. Muzaffarnagar, Oraiyya, Pilibhit, Etawah, Farrukhabad, Firozbad,
Tel.: 0120-2514252 / 2514253 Gautambodhanagar, Ghaziabad, Hardoi, Shahjahanpur,
Email: bimalokpal.noida@cioins.co.in Hapur, Shamli, Rampur, Kashganj, Sambhal, Amroha, Hathras,
Kanshiramnagar, Saharanpur.
PATNA - Shri N. K. Singh Bihar,
Office of the Insurance Ombudsman, Jharkhand.
1st Floor, Kalpana Arcade Building,,
Bazar Samiti Road, Bahadurpur, Patna 800 006.
Tel.: 0612-2680952
Email: bimalokpal.patna@cioins.co.in
PUNE - Shri Vinay Sah Maharashtra,
Office of the Insurance Ombudsman, Area of Navi Mumbai and Thane
Jeevan Darshan Bldg., 3rd Floor, C.T.S. No.s. 195 to 198, excluding Mumbai Metropolitan Region.
N.C. Kelkar Road, Narayan Peth, Pune – 411 030.
Tel.: 020-41312555
Email: bimalokpal.pune@cioins.co.in
EXECUTIVE COUNCIL OF INSURERS,

3rd Floor, Jeevan Seva Annexe,
S. V. Road, Santacruz (W),
Mumbai - 400 054.
Tel.: 022 - 69038801/03/04/05/06/07/08/09

Email: inscoun@cioins.co.in
Shri B. C. Patnaik, Secretary General
Smt Poornima Gaitonde, Secretary

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Max Bupa Health Recharge –

Policy Terms & Conditions

1. Preamble ii. Any non-melanoma skin carcinoma unless there is

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

VIII. Emergency Ambulance X. Pharmacy and Diagnostic Services

What is not covered: Conditions:

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

3. Open Chest CABG 8. Major Organ /Bone Marrow Transplant

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Niva Bupa Health Insurance Company Limited

OPTIONAL BENEFITS (which may be added at customer level at an additional premium)

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

Disorder / Condition ICD Codes

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

S.No Item S.No Item

3 BEAUTY SERVICES 36 SPACER

4 BELTS/ BRACES 37 SPIROMETRE

5 BUDS 38 NEBULIZER KIT

6 COLD PACK/HOT PACK 39 STEAM INHALER

7 CARRY BAGS 40 ARMSLING

8 EMAIL / INTERNET CHARGES 41 THERMOMETER

9 FOOD CHARGES (OTHER THAN PATIENT's DIET 42 CERVICAL COLLAR

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

S.No Item S.No Item

11 TISSUE PAPER 30 DISCHARGE PROCEDURE CHARGES

12 TOOTH PASTE 31 DAILY CHART CHARGES

13 TOOTH BRUSH 32 ENTRANCE PASS / VISITORS PASS CHARGES

14 BED PAN 33 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE

15 FACE MASK 34 FILE OPENING CHARGES

16 FLEXI MASK 35 INCIDENTAL EXPENSES / MISC. CHARGES (NOT

List III – Items that are to be subsumed into Procedure Charges

S.No Item S.No Item

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920

S.No Item S.No Item

5 BIPAP MACHINE 15 ALCOHOL SWABES

6 CPAP/ CAPD EQUIPMENTS 16 SCRUB SOLUTION/STERILLIUM

7 INFUSION PUMP– COST 17 GLUCOMETER & STRIPS

8 HYDROGEN PEROXIDE\SPIRIT\ DISINFECTANTS ETC 18 URINE BAG

9 NUTRITION PLANNING CHARGES - DIETICIAN CHARGES-