Health Guard Gold

Bajaj Allianz General Insurance Company Limited
Bajaj Allianz House, Airport Road, Yerawada, Pune - 411 006. Reg. No.: 113
For more details, log on to : www.bajajallianz.com or
call at : Sales - 1800 209 0144 / Service - 1800 209 5858 (Toll Free No.)
Issuing Office :
HEALTH GUARD GOLD PLAN
Health Guard Gold Plan
POLICY WORDINGS
Preamble
Our agreement to insure You is based on Your Proposal to Us, which is the basis of this agreement, and Your payment of the premium. This Policy records
the entire agreement between Us and sets out what We insure, how We insure it, and what We expect of You and what You can expect of Us.
Types of Policy
• “ Health Guard-Individual”
• “ Health Guard-Family Floater”
Policy period
• “ Health Guard-Individual”: 1 year, 2 years or 3 years
• “ Health Guard-Family Floater”: 1 year, 2 years or 3 years
Scope of cover
The Company hereby agrees to pay in respect of an admissible claim, any or all of the following covers subject to the Sum Insured, limits, terms, conditions
and definitions, exclusions contained or otherwise expressed in this Policy.
A. COVERAGE
1. In-patient Hospitalisation Treatment
If You are hospitalized on the advice of a Doctor as defined under policy because of Illness or Accidental Bodily Injury sustained or contracted during the
Policy Period, then We will pay You, Reasonable and Customary Medical Expenses incurred subject to
i. Room, Boarding and Nursing Expenses as provided by the Hospital/Nursing Home without any sublimit.
ii. If admitted in ICU, we will pay up to actual expenses provided by Hospital.
iii. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees.
iv. Anesthesia, Blood, Oxygen, Operation Theatre Charges, surgical appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, cost of Artificial
Limbs, cost of prosthetic devices implanted during surgical procedure like Pacemaker, orthopedic implants, infra cardiac valve replacements, vascular
stents, relevant laboratory diagnostic tests, X-ray and such similar expenses that are medically necessary.
2. Pre-Hospitalisation
The Medical Expenses incurred during the 60 days immediately before you were Hospitalised, provided that: Such Medical Expenses were incurred for
the same illness/injury for which subsequent Hospitalisation was required, and We have accepted an inpatient Hospitalisation claim under Inpatient
Hospitalisation Treatment. (Section A1)
3. Post-Hospitalisation
The Medical Expenses incurred during the 90 days immediately after You were discharged post Hospitalisation provided that: Such costs are incurred
in respect of the same illness/injury for which the earlier Hospitalisation was required, and We have accepted an inpatient Hospitalisation claim under
Inpatient Hospitalisation Treatment. (Section A1)
4. Road Ambulance
We will pay the reasonable cost to a maximum of Rs 20000/- per policy year incurred on an ambulance offered by a healthcare or ambulance service
provider for transferring You to the nearest Hospital with adequate emergency facilities for the provision of health services following an Emergency.
We will also reimburse the expenses incurred on an ambulance offered by a healthcare or ambulance service provider for transferring You from the
Hospital where you were admitted initially to another hospital with higher medical facilities.
Claim under this section shall be payable by Us only when:
i. Such life threatening emergency condition is certified by the Medical Practitioner, and
ii. We have accepted Your Claim under “In-patient Hospitalisation Treatment” or “Day Care Procedures” section of the Policy.
Subject otherwise to the terms, conditions and exclusions of the Policy.
This benefit will be applicable annually for policies with term more than 1 year.
5. Day Care Procedures

We will pay you the medical expenses as listed above under Section A1 In-patient Hospitalisation Treatment for Day care procedures / Surgeries taken
as an inpatient in a hospital or day care centre but not in the outpatient department. Indicative list of Day Care Procedures is given in the annexure I of
Policy wordings.
CIN: U66010PN2000PLC015329, UIN: IRDAI/HLT/BAGI/P-H/V.II/113/16-17 Health Guard Gold Plan/V002/w.e.f. 1st Jan 2018 1

6. Organ Donor Expenses
We will pay expenses towards organ donor’s treatment for harvesting of the donated organ, provided that,
i. The organ donor is any person whose organ has been made available in accordance and in compliance with THE TRANSPLANTATION OF HUMAN
ORGANS (AMENDMENT) BILL, 2011 and the organ donated is for the use of the Insured Person, and
ii. We have accepted an inpatient Hospitalisation claim for the insured member under In Patient Hospitalisation Treatment (section A1).
7. Convalescence Benefit
In the event of insured hospitalised for a disease/illness/injury for a continuous period exceeding 10 days, We will pay benefit amount of Rs. 5,000 for
Sum Insured up to Rs. 5 lacs and Rs. 7500 for Sum Insured 7.5 lacs and above per policy year.
This benefit will be triggered provided that the hospitalization claim is accepted under Section A1- In Patient Hospitalisation Treatment.
8. Daily Cash Benefit for Accompanying an Insured Child

We will pay Daily Cash Benefit of Rs. 500 per day maximum up to 10 days during each policy year for reasonable accommodation expenses in respect
of one parent/legal guardian, to stay with any minor Insured Person (under the Age of 12), provided the hospitalization claim is paid under Section A1
Inpatient Hospitalisation Treatment.
9. Sum Insured Reinstatement Benefit

If Section A1 Inpatient Hospitalization Treatment Sum Insured and Cumulative Bonus (if any) is exhausted due to claims lodged during the Policy year,
then it is agreed that 100% of the Sum Insured specified under Inpatient Hospitalization Treatment be reinstated for the particular Policy year provided
that:
1. The reinstated Sum Insured will be triggered only after the Inpatient Hospitalization Treatment Sum Insured inclusive of the Cumulative Bonus(If
applicable) has been completely exhausted during the policy year;
2. The reinstated Sum Insured can be used for claims made by the Insured Person in respect of the benefits stated in Inpatient Hospitalization Treatment.
3. If the claimed amount is higher than the Balance Sum Insured inclusive of the Cumulative Bonus(If applicable) under the policy, then this benefit will
not be triggered for such claims
4. The reinstated Sum Insured would be triggered only for subsequent claims made by the Insured Person.In case of relapse within 45 days, this benefit
will not trigger
5. This benefit is applicable only once during each policy year& will not be carried forward to the subsequent policy year/ renewals if the benefit is not
utilized.
6. This benefit is applicable only once in life time of Insured Person covered under this policy for claims regarding CANCER OF SPECIFIED SEVERITY and
KIDNEY FAILURE REQUIRING REGULAR DIALYSIS as defined under the policy.
7. This benefit will be applicable annually for policies with term more than 1 year.
8. Additional premium would not be charged for reinstatement of the Sum Insured.
9. Incase of Family Floater policy, Reinstatement of Sum Insured will be available for all Insured Persons in the Policy.

10. Preventive Health Check Up
At the end of block of every continuous period of 3 years during which You have held Our Health Guard policy, You are eligible for a free Preventive
Health checkup. We will reimburse the amount equal to 1% of the sum insured max up to Rs. 5000/- for each member in Individual policy
during the block of 3 years. This benefit can be availed by proposer & spouse only under Floater Sum Insured Policies.
You may approach us for the arrangement of the Health Check up. For the avoidance of doubt, We shall not be liable for any other ancillary or peripheral
costs or expenses (including but not limited to those for transportation, accommodation or sustenance).
11. Ayurvedic / Homeopathic Hospitalisation Expenses

If You are Hospitalised for not less than 24 hrs, in an Ayurvedic / Homeopathic Hospital which is a government hospital or in any institute recognized
by government and/or accredited by Quality Council of India/National Accreditation Board on Health on the advice of a Doctor because of Illness or
Accidental Bodily Injury sustained or contracted during the Policy Period then We will pay You:
In-patient Treatment- Medical Expenses for Ayurvedic and Homeopathic treatment:

• Room rent, boarding expenses
• Nursing care
• Consultation fees
• Medicines, drugs and consumables,
• Ayurvedic and Homeopathic treatment procedures

Our maximum liability maximum is up to Rs. 20000 per policy year.
The claim will be admissible under the policy provided that,

i. The illness/injury requires inpatient admission and the procedure performed on the insured cannot be carried out on out-patient basis
12. Maternity Expenses

We will pay the Medical Expenses for the delivery of a baby (including caesarean section) and/or expenses related to medically recommended and
lawful termination of pregnancy, limited to maximum 2 deliveries or termination(s) or either, during the lifetime of the insured person, provided that,
i. Our maximum liability per delivery or termination shall be limited to the amount specified in the policy Schedule as per Sum Insured opted.
ii. From Sum insured Rs. 3lacs to Rs. 7.5 lacs is restricted to Rs. 15000 for normal delivery and Rs. 25000 for caesarean section and from Sum insured Rs.
10 lacs to Rs. 50lacs is restricted to Rs. 25000 for normal delivery and Rs. 35000 for caesarean section
iii. We will pay the Medical Expenses of pre-natal and post-natal hospitalization per delivery or termination upto the amount stated in the policy Schedule.
iv. Waiting period of 72 months from the date of issuance of the first policy with us, provided that the policy has been continuously renewed with us
without break for you. Fresh waiting period of 72 months would apply for all the policies which are issued with continuity under portability guidelines
either from our existing Health Product or any other Non-Health or Standalone Health Insurance Company.
v. We will not cover Ectopic pregnancy under this benefit (although it shall be covered under section A1 In patient Hospitalisation Treatment)
vi. Any complications arising out of or as a consequence of maternity/child birth will be covered within the limit of Sum Insured available under this
benefit.
13. New Born Baby Cover

Coverage for new born baby will be considered subject to a valid claim being accepted under Maternity Expenses (section A12). We will pay the
following expenses within the limit of the Sum Insured available under the Maternity Expenses section.
We will pay for,

i. Medical Expenses towards treatment of your new born baby while you are hospitalised as an inpatient for delivery for the hospitalisation,
ii. Hospitalisation charges incurred on the new born baby during post birth including any complications shall be covered up to a period of 90 days from
the date of birth and within limit of the Sum Insured under Maternity Expenses without payment of any additional premium
iii. Mandatory Vaccinations of the new born baby up to 90 days, as recommended by the Indian Pediatric Association will be covered under the Maternity
Expenses Sum Insured.
14. Bariatric Surgery Cover

If You are hospitalized on the advice of a Doctor because of Conditions mentioned below which required you to undergo Bariatric Surgery during the
Policy period, then We will pay You, Reasonable and Customary Expenses related to Bariatric Surgery
Eligibility:
For adults aged 18 years or older, presence of severe obesity documented in contemporaneous clinical records, defined as any of the following:
BMI greater than and equal to 40 in conjunctions with any of the following severe comorbidities:
1. Coronary heart disease; or
2. Medically refractory hypertension (blood pressure greater than 140 mm Hg systolic and/or 90 mm Hg diastolic despite concurrent use of 3 anti-
hypertensive agents of different classes); or
3. Type 2 diabetes mellitus
Special Conditions applicable to Bariatric Surgery Cover

This benefit is subject to a waiting period of 36 months from the date of first commencement of this policy and continuous renewal thereof with the
Company.
Policies which are issued with continuity under portability guidelines either from our existing Health Product or any other Non-Health or Standalone
Health Insurance Company will have to wait for 36 months from issuance of Health Guard policy to avail this benefit.
Our maximum liability will be restricted to 50% of Sum insured maximum up to Rs. 5 lac.
Bariatric surgery performed for Cosmetic reasons is excluded.
The indication for the procedure should be found appropriate by two qualified surgeons and the insured person shall obtain prior approval for cashless
treatment from the Company.
B. Definitions
1. Accident, Accidental
An accident is a sudden, unforeseen and involuntary event caused by external, visible and violent means.

2. Act of Terrorism:-
Whoever
a. With intent to threaten the unity, integrity, security or sovereignty of India or to strike terror in the people or any section of the people does any act or
thing by using bombs, dynamite or other explosive substances or inflammable substances or firearms or other lethal weapons or poisons or noxious
gases or other chemicals or by any other substances (whether biological or otherwise) of a hazardous nature or by any other means whatsoever, in such
a manner as to cause or likely to cause, death of or injuries to any person or persons or loss of or damage to or destruction of property or disruption of
any supplies or services essential to the life of the community or causes damage or destruction of any property or equipment used or intended to be
used for the defense of India or in connection with any other purposes of the Government of India, any state government or any of their agencies or
detains any person and threatens to kill or injure such person in order to compel the Government or any other person to do or abstain from doing any
act
b. Is or continues to be a member of an association declared unlawful under the Unlawful Activities (Prevention) Act 1967, (37 of 1967), or voluntarily does
an act aiding or promoting in any manner the objects of such association and in either case is in possession of any unlicensed firearms, ammunition,
explosives or other instrument or substances capable of causing mass destruction and commits any act resulting in loss of human life or grievous injury
to any person or causes significant damage to any property, commits a terrorist act.
3. Any one illness

Any one illness means continuous period of illness and includes relapse within 45 days from the date of last consultation with the Hospital/Nursing
Home where treatment was taken.
4. Bajaj Allianz Network Hospitals / Network Hospitals

Bajaj Allianz Network Hospitals / Network Hospitals means the Hospitals which have been empanelled by Us as per the latest version of the schedule
of Hospitals maintained by Us, which is available to You on request. For updated list please visit our website.
5. Bajaj Allianz Diagnostic Centre

Bajaj Allianz Diagnostic Centre means the diagnostic centers which have been empanelled by us as per the latest version of the schedule of
diagnostic centers maintained by Us, which is available to You on request.
6. Bariatric surgery:
Means Surgery on the stomach and/or intestines to help a person with extreme obesity to lose weight. Bariatric surgery is an option for people who
have a body mass index (BMI) above 40. Surgery is also an option for people with a body mass index between 35 and 40 who have health problems like
type 2 diabetes or heart disease.
7. Cancer of Specified Severity

I. A malignant tumor characterized by the uncontrolled growth and spread of malignant cells with invasion and destruction of normal tissues. This
diagnosis must be supported by histological evidence of malignancy. The term cancer includes leukemia, lymphoma and sarcoma.
II. The following are excluded –
i. All tumors which are histologically described as carcinoma in situ, benign, pre-malignant, borderline malignant, low malignant potential,
neoplasm of unknown behavior, or non-invasive, including but not limited to: Carcinoma in situ of breasts, Cervical dysplasia CIN-1, CIN - 2 and
CIN-3.
ii. Any non-melanoma skin carcinoma unless there is evidence of metastases to lymph nodes or beyond;
iii. Malignant melanoma that has not caused invasion beyond the epidermis;
iv. All tumors of the prostate unless histologically classified as having a Gleason score greater than 6 or having progressed to at least clinical TNM
classification T2N0M0
v. All Thyroid cancers histologically classified as T1N0M0 (TNM Classification) or below;
vi. Chronic lymphocytic leukaemia less than RAI stage 3
vii. Non-invasive papillary cancer of the bladder histologically described as TaN0M0 or of a lesser classification,
viii. All Gastro-Intestinal Stromal Tumors histologically classified as T1N0M0 (TNM Classification) or below and with mitotic count of less than or
equal to 5/50 HPFs;
ix. All tumors in the presence of HIV infection.
8. Cashless facility
“Cashless facility” means a facility extended by the insurer to the insured where the payments, of the costs of treatment undergone by the insured in
accordance with the policy terms and conditions, are directly made to the network provider by the insurer to the extent pre-authorization approved.
9. Co-Payment
Co-payment means a cost sharing requirement under a health insurance policy that provides that the policyholder/insured will bear a specified
percentage of the admissible claims amount. A co-payment does not reduce the Sum Insured.

10. Condition Precedent
Condition Precedent means a policy term or condition upon which the Insurer’s liability under the policy is conditional upon.
11. Congenital Anomaly

Congenital Anomaly refers to a condition(s) which is present since birth, and which is abnormal with reference to form, structure or position.
a. Internal Congenital Anomaly- Congenital anomaly which is not in the visible and accessible parts of the body
b. External Congenital Anomaly- Congenital anomaly which is in the visible and accessible parts of the body
12. Contribution
Contribution is essentially the right of an insurer to call upon other insurers liable to the same insured to share the cost of an indemnity claim on a
ratable proportion of Sum Insured. This clause shall not apply to any Benefit offered on fixed benefit basis.
13. Cumulative Bonus

Cumulative Bonus means any increase or addition in the Sum Insured granted by the insurer without an associated increase in premium.
14. Day care centre

A day care centre means any institution established for day care treatment of illness and/or injuries or a medical setup with a hospital and which has
been registered with the local authorities, wherever applicable, and is under supervision of a registered and qualified medical practitioner AND must
comply with all minimum criterion as under –
i. has qualified nursing staff under its employment;
ii. has qualified medical practitioner/s in charge;
iii. has fully equipped operation theatre of its own where surgical procedures are carried out;
iv. maintains daily records of patients and will make these accessible to the insurance company’s authorized personnel.
15. Day Care Treatment

Day care treatment means medical treatment, and/or surgical procedure which is:
i. undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 hrs because of technological advancement, and
ii. Which would have otherwise required a hospitalization of more than 24 hours.
Treatment normally taken on an out-patient basis is not included in the scope of this definition.
16. Dental Treatment

Dental treatment means a treatment related to teeth or structures supporting teeth including examinations, fillings (where appropriate), crowns,
extractions and surgery.
17. Dependent child

A child is considered a dependent for insurance purposes until his 35th birthday (even if not enrolled in an educational institution) provided he is
financially dependent, on the proposal.
18. Disclosure to information norm

The Policy shall be void and all premium paid hereon shall be forfeited to the Company, in the event of misrepresentation, mis-description or non-
disclosure of any material fact.
19. Emergency Care

Emergency care means management for an illness or injury which results in symptoms which occur suddenly and unexpectedly, and requires
immediate care by a medical practitioner to prevent death or serious long term impairment of the insured person’s health.
20. Family
For the purpose of Individual Sum Insured policy- includes the insured; his/her lawfully wedded spouse and dependent children, parents, Sister, Brother,
In laws, Aunt, Uncle, Grandchildren.
For the purpose of Family Floater- includes the insured; his/her lawfully wedded spouse and dependent children. For Parents separate floater policy can
be taken.
21. Grace Period

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

22. Hospital
A hospital means any institution established for in-patient care and day care treatment of illness and/or injuries and which has been registered as a
hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act, 2010 or under the enactments specified under
the Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under:
--has qualified nursing staff under its employment round the clock;
--has at least 10 in-patient beds in towns having a population of less than 10,00,000 and at least 15 in-patient beds in all other places;
--has qualified medical practitioner(s) in charge round the clock;
--has a fully equipped operation theatre of its own where surgical procedures are carried out;
--maintains daily records of patients and makes these accessible to the insurance company’s authorized personnel.
23. Hospitalisation
Means admission in a Hospital for a minimum period of 24 In patient Care consecutive hours except for specified procedures/ treatments, where
such admission could be for a period of less than 24 consecutive hours.
24. Illness
Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function and requires medical
treatment.
a. Acute condition - Acute condition is a disease, illness or injury that is likely to respond quickly to treatment which aims to return the person to his or
her state of health immediately before suffering the disease/ illness/ injury which leads to full recovery
b. Chronic condition - A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics:
1. it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /or tests
2. it needs ongoing or long-term control or relief of symptoms
3. it requires rehabilitation for the patient or for the patient to be specially trained to cope with it
4. it continues indefinitely
5. it recurs or is likely to recur
25. Inpatient Care

Inpatient care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.
26. Injury/ Bodily Injury

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

Intensive care unit means an identified section, ward or wing of a hospital which is under the constant supervision of a dedicated medical practitioner(s),
and which is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition, or require life support facilities
and where the level of care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards.
28. Kidney Failure Requiring Regular Dialysis

End stage renal disease presenting as chronic irreversible failure of both kidneys to function, as a result of which either regular renal dialysis (haemodialysis
or peritoneal dialysis) is instituted or renal transplantation is carried out. Diagnosis has to be confirmed by a specialist medical practitioner.
29. Limit of Indemnity

Limit of Indemnity represents Our maximum liability to make payment for each and every claim per person and collectively for all persons mentioned
in the Schedule during the policy period and in the aggregate for the person(s) named in the schedule during the policy period, and means the amount
stated in the Schedule against each Cover.
30. Maternity expense / treatment shall include the following Medical treatment Expenses:
Medical Expenses for a delivery (including complicated deliveries and caesarean sections) incurred during Hospitalization; The lawful medical
termination of pregnancy during the Policy Period limited to 2 deliveries or terminations or either during the lifetime of the Insured Person;
Pre-natal and post-natal Medical Expenses for delivery or termination.
31. New Born Baby

Newborn baby means baby born during the Policy Period and is aged between 1 day and 90 days, both days inclusive.
32. Medical Advise

Medical Advice means any consultation or advice from a Medical Practitioner including the issuance of any prescription or follow-up prescription.

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

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

Medically necessary treatment is defined as any treatment, tests, medication, or stay in hospital or part of a stay in hospital which
- is required for the medical management of the illness or injury suffered by the insured;
- must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity;
- must have been prescribed by a medical practitioner,
- must conform to the professional standards widely accepted in international medical practice or by the medical community in India.
36. Named Insured / Insured:

Insured means the persons, or his Family members, named in the Schedule provided that an Insured or his Family Members has attained the age of 3
months and is not older than 65 years of age at the commencement of the Policy Period.
37. Non- Network

Any hospital, day care centre or other provider that is not part of the network.
38. Notification of Claim

Notification of claim means the process of intimating a claim to the insurer or TPA through any of the recognized modes of communication.
39. OPD treatment

OPD treatment is one in which the Insured visits a clinic / hospital or associated facility like a consultation room for diagnosis and treatment based on
the advice of a Medical Practitioner. The Insured is not admitted as a day care or in-patient.
40. Obesity means abnormal or excessive fat accumulation that may impair health. Obesity is measured in Body Mass Index.
Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults. It is defined as a
person’s weight in kilograms divided by the square of his height in meters (kg/m2).
The WHO definition is:
• BMI greater than or equal to 25 is overweight
• BMI greater than or equal to 30 is obesity
41. Portability
Portability means transfer by an individual health insurance policyholder (including family cover) of the credit gained for pre-existing conditions and
time-bound exclusions if he/she chooses to switch from one insurer to another.
42. Pre-Existing Disease

Pre-Existing Disease means any condition, ailment or injury or related condition(s) for which there were signs or symptoms, and / or were diagnosed,
and / or for which medical advice / treatment was received within 48 months prior to the first policy issued by the insurer and renewed continuously
thereafter.
43. Pre-hospitalization Medical Expenses

Pre-hospitalization Medical Expenses means medical expenses incurred during pre-defined number of days preceding the hospitalization of the
Insured Person, provided that:
i. Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalization was required, and
ii. The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.
44. Post-hospitalization Medical Expenses

Post-hospitalization Medical Expenses means medical expenses incurred during pre-defined number of days immediately after the insured person is
discharged from the hospital provided that:
i. Such Medical Expenses are for the same condition for which the insured person’s hospitalization was required, and
ii. The inpatient hospitalization claim for such hospitalization is admissible by the insurance company.

45. Qualified Nurse
Qualified nurse is a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India.
46. Reasonable and Customary Charges

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

Room Rent means the amount charged by a Hospital towards Room and Boarding expenses and shall include the associated medical expenses.
48. Renewal
Renewal means the terms on which the contract of insurance can be renewed on mutual consent with a provision of grace period for treating the
renewal continuous for the purpose of gaining credit for pre-existing diseases, time-bound exclusions and for all waiting periods.
49. Surgery or Surgical Procedure

Surgery or Surgical Procedure means manual and / or operative procedure (s) required for treatment of an illness or injury, correction of deformities
and defects, diagnosis and cure of diseases, relief from suffering and prolongation of life, performed in a hospital or day care centre by a medical
practitioner.
50. Schedule means the schedule and any annexure to it.
51. Unproven/Experimental treatment

Unproven/Experimental treatment is treatment, including drug Experimental therapy, which is not based on established medical practice in India, is
treatment experimental or unproven.
52. You, Your, Yourself, Your Family named in the schedule means the person or persons that We insure as set out in the Schedule.
53 We, Our, Ours means the Bajaj Allianz General Insurance Company Limited.
C. EXCLUSIONS
We shall not be liable to make any payment for any claim directly or indirectly caused by, based on, arising out of or attributable to any of the
following:
I. Waiting Period
1. Benefits will not be available for Any Pre-existing condition, ailment or injury, until 36 months of continuous coverage have elapsed, after the date of
inception of the first Health Guard policy, provided the preexisting disease / ailment / injury is disclosed on the proposal form.
The above exclusion 1 shall cease to apply if You have maintained a Health Guard policy with Us for a continuous period of a full 36 months without
break from the date of Your first Health Guard policy.
In case of enhancement of Sum Insured, this exclusion shall apply afresh only to the extent of the amount by which the limit of indemnity has been
increased (i.e. enhanced Sum Insured) and if the policy is a renewal of Health Guard policy with Us without break in cover.
2. We will also not pay for claims arising out of or howsoever connected to the following for the first 24 months of Health Guard policy,

1. Any types of gastric or duodenal ulcers, 9. Cataracts,
2. Benign prostatic hypertrophy 10. Hernia of all types
3. All types of sinuses 11. Fistulae, Fissure in ano
4. Haemorrhoids 12. Hydrocele
5. Dysfunctional uterine bleeding 13. Fibromyoma
6. Endometriosis 14. Hysterectomy
7. Stones in the urinary and biliary systems 15. Surgery for any skin ailment
16. Surgery on all internal or external tumours/ cysts/ nodules/polyps
8. Surgery on ears/tonsils/adenoids/paranasal sinuses of any kind including breast lumps with exception of Malignant
tumor or growth.

This exclusion shall apply for a continuous period of 36 months from the date of Your Health Guard policy, if the above referred illness were present
at the time of commencement of the policy and if You had declared such illness at the time of proposing the policy for the first time.
In case of enhancement of Sum Insured, the waiting periods shall apply afresh only to the extent of the amount by which the limit of indemnity has
been increased (i.e. enhanced Sum Insured) and if the policy is a renewal of Health Guard policy with Us without break in cover.
3. Any Medical Expenses incurred during the first 36 months during which You have the benefit of a Health Guard policy with Us in connection with:
• Joint replacement surgery,
• Surgery for prolapsed inter vertebral disc (unless necessitated due to an accident)
• Surgery to correct deviated nasal septum
• Hypertrophied turbinate
• Congenital internal diseases or anomalies
• Treatment for correction of eye sight due to refractive error recommended by Ophthalmologist for medical reasons.
• Bariatric Surgery
4. Any disease contracted and /or medical expenses incurred in respect of any disease /illness by the insured during the first 30 days from the
commencement of the policy, except for accidental injuries.
5. Any treatment arising from or traceable to pregnancy, child birth including cesarean sectionand/or any treatment related to pre and postnatal care
and complications arising out of Pregnancy and Childbirth until 72 months continuous period has elapsed since the inception of the first Health
Guard Policy with US. However this exclusion will not apply to Ectopic Pregnancy proved by diagnostic means and certified to be life threatening by
the attending medical practitioner.
II. GENERAL EXCLUSIONS

1. Any dental treatment that comprises cosmetic surgery, dentures, dental prosthesis, dental implants, orthodontics, orthognathic surgery, jaw
alignment or treatment for the temporomandibular (jaw) joint, or upper and lower jaw bone surgery and surgery related to the temporomandibular
(jaw) unless necessitated by an acute traumatic injury or cancer and also requiring Hospitalisation
2. Medical expenses where Inpatient care is not warranted and does not require supervision of qualified nursing staff and qualified medical practitioner
round the clock
3. War, invasion, acts of foreign enemies, hostilities (whether war be declared or not) [except for compelling the Government or any other person to do
or abstain from doing any act as defined under the definition of Terrorist act], civil war, commotion, unrest, rebellion, revolution, insurrection, military
or usurped power or confiscation or nationalization or requisition of or damage by or under the order of any government or public local authority.
Any Medical expenses incurred due to Acts of Terrorism will be covered under the policy.
4. Circumcision unless required for the treatment of Illness or Accidental bodily injury,
5. Cosmetic or aesthetic treatments of any description, treatment or surgery for change of life/gender.
6. Any form of plastic surgery unless necessary for the treatment of cancer, burns or accidental Bodily Injury
7. The cost of spectacles, contact lenses, hearing aids, crutches, artificial limbs, dentures, artificial teeth and all other external appliances and/or devices
whether for diagnosis or treatment except for intrinsic fixtures used for orthopedic treatments such as plates and K-wires.
8. External medical equipment of any kind used at home as post hospitalisation care including cost of instrument used in the treatment of Sleep Apnoea
Syndrome (C.P.A.P), Continuous Peritoneal Ambulatory Dialysis (C.P.A.D) and Oxygen concentrator for Bronchial Asthmatic condition.
9. Convalescence, general debility, rest cure, congenital external diseases or defects or anomalies, genetic disorders, stem cell implantation or surgery,
or growth hormone therapy.
10. Intentional self-injury (including but not limited to the use or misuse of any intoxicating drugs or alcohol)
11. Ailments requiring treatment due to use or abuse of any substance, drug or alcohol and treatment for de-addiction.
12. Any condition directly or indirectly caused by or associated with Human Immunodeficiency Virus or Variant/mutant viruses and or any syndrome or
condition of a similar kind commonly referred to as AIDS.
13. Medical Expenses relating to any hospitalisation primarily and specifically for diagnostic, X-ray or laboratory examinations and investigations

14. Vaccination or inoculation unless forming a part of post bite treatment or if medically necessary and forming a part of treatment recommended by
the treating doctor.
15. Any fertility, sub fertility, Infertility, sterility, erectile dysfunction, impotence, assisted conception operation or sterilization procedure.
16. Vitamins, tonics, nutritional supplements unless forming part of the treatment for injury or disease as certified by the attending Doctor
17. Experimental, unproven or non-standard treatment
18. Weight management services and treatment related to weight reduction programmes including treatment of obesity
19. Treatment for any mental illness or psychiatric illness, Parkinson’s Disease.
20. All non-medical Items as per Annexure II
21. Any treatment received outside India is not covered under this policy.
D. Conditions
I. Conditions precedent to the contract
1. Conditions Precedent
Where this Policy requires You to do or not to do something, then the complete satisfaction of that requirement by You or someone claiming on
Your behalf is a precondition to any obligation We have under this Policy. If You or someone claiming on Your behalf fails to completely satisfy that
requirement, then We may refuse to consider Your claim.
2. Premium Payment in Instalments (Wherever applicable)

i. If the insured person has opted for Payment of Premium on an instalment basis i.e. Annual (for long term polices only), Half Yearly, Quarterly or
Monthly, as mentioned in the policy Schedule/Certificate of Insurance, the following Conditions shall apply (notwithstanding any terms contrary
elsewhere in the policy)
ii. Grace Period of 15 days would be given to pay the instalment premium due for the policy.
iii. During such grace period, coverage will not be available from the due date of instalment premium till the date of receipt of premium by Company.
iv. The insured person will get the accrued continuity benefit in respect of the “Waiting Periods”, “Specific Waiting Periods” in the event of payment of
premium within the stipulated grace Period.
v. No interest will be charged If the instalment premium is not paid on due date.
vi. In case of instalment premium due not received within the grace period, the policy will get cancelled.
vii. In the event of a claim, all subsequent premium instalments shall immediately become due and payable.
viii. The company has the right to recover and deduct all the pending installments from the claim amount due under the policy.
3. Entry Age and Renewal Age

Cover Member Eligible Entry Age Renewal
Self, Spouse, Parents, Sister, Brother, In laws,
18 years to 65 years lifetime renewals**
“Health Guard” Aunt, Uncle.
Dependent Children,Grandchildren. 3 months to 30 years 35 Years*
* After the completion of maximum renewal age of dependent children, the policy would be renewed for lifetime, subject to Separate proposal form
should be submitted to us at the time of renewal with the insured member as proposer and subsequently the policy should be renewed annually with
us and within the Grace period of 30 days from date of Expiry. Continuity for all the waiting periods shall be extended in the new policy.
** Subject to policy is renewed annually with us within the Grace period of 30 days from date of Expiry
Eligibility:
• Indian nationals residing in India would be considered for this policy.
• This policy can be opted by Non-Resident Indians also; however the policy will be issued during their stay in India & premium paid in Indian currency
& by Indian Account only
• Copy of any one of the below KYC documents will have to be submitted along with the Proposal form: Voters ID Card, Driving License, Passport, PAN
Card
• Sum Insured for Self (i.e. Proposer) cannot be less than any of his/her family members.

II. Conditions when a claim arises
1. Claims Procedure
All Claims will be settled by In house claims settlement team of the company and no TPA is engaged.
If You meet with any Accidental Bodily Injury or suffer an Illness that may result in a claim, then as a condition precedent to Our liability, You must
comply with the following:
A. Cashless Claims Procedure:

Cashless treatment is only available at Network Hospitals. In order to avail of cashless treatment, the following procedure must be followed by You:
i. Prior to taking treatment and/or incurring Medical Expenses at a Network Hospital, You or your representative must call Us and request pre-authorisation
by way of the written form.
ii. After considering Your request and after obtaining any further information or documentation We have sought, We may, if satisfied, send You or
the NetworkHospital, an authorisation letter. The authorisation letter, the ID card issued to You along with this Policy and any other information or
documentation that We have specified must be produced to the NetworkHospital identified in the pre-authorization letter at the time of Your admission
to the same.
iii. If the procedure above is followed, You will not be required to directly pay for the bill amount in the NetworkHospital that We are liable under Section A1In-
Patient Hospitalisation Treatment above and the original bills and evidence of treatment in respect of the same shall be left with the NetworkHospital.
Pre-authorisation does not guarantee that all costs and expenses will be covered. We reserve the right to review each claim for Medical Expenses and
accordingly coverage will be determined according to the terms and conditions of this Policy.
B. Reimbursement Claims Procedure:

If Pre-authorisation as per Cashless Claims Procedure above is denied by Us or if treatment is taken in a Hospital other than a Network Hospital or if You
do not wish to avail cashless facility, then:
i. You or someone claiming on Your behalf must inform Us in writing immediately within 48 hours of hospitalization in case of emergency hospitalization
and 48 hours prior to hospitalization in case of planned hospitalization
ii. You must immediately consult a Doctor and follow the advice and treatment that he recommends.
iii. You must take reasonable steps or measures to minimize the quantum of any claim that may be made under this Policy.
iv. You must have Yourself examined by Our medical advisors if We ask for this, and as often as We consider this to be necessary at our cost.
v. You or someone claiming on Your behalf must promptly and in any event within 30 days of discharge from a Hospital give Us the documentation as
listed out in greater detail below and other information We ask for to investigate the claim or Our obligation to make payment for it.
vi. In the event of the death of the insured person, someone claiming on his behalf must inform Us in writing immediately and send Us a copy of the post
mortem report (if any) within 30 days*
vii. If the original documents are submitted with the co-insurer, the Xerox copies attested by the co-insurer should be submitted
*Note: In case You are claiming for the same event under an indemnity based policy of another insurer and are required to submit the original
documents related to Your treatment with that particular insurer, then You may provide Us with the attested Xerox copies of such documents along
with a declaration from the particular insurer specifying the availability of the original copies of the specified treatment documents with it.
**Note: Waiver of conditions (i) and (vi) may be considered in extreme cases of hardship where it is proved to Our satisfaction that under the
circumstances in which You were placed, it was not possible for You or any other person to give notice or file claim within the prescribed time limit.
List of Claim documents:

• Claim form with NEFT details & cancelled cheque duly signed by Insured
• Original copies of Discharge Summary / Discharge Certificate / Death Summary with Surgical & anesthetics notes
• Attested copies of Indoor case papers
• Original copies Final Hospital Bill with break up of surgical charges, surgeon’s fees, OT charges etc
• Original Paid Receipt against the final Hospital Bill.
• Original bills towards Investigations done / Laboratory Bills.
• Original copies of Investigation Reports against Investigations done.
• Original bills and receipts paid for the transportation from Registered Ambulance Service Provider. Treating Doctor certificate to transfer the Injured
person to a higher medical centre for further treatment (if Applicable).
• Cashless settlement letter or other company settlement letter
• First consultation letter for the current ailment.
• In case of implant surgery, invoice & sticker.
• Aaadhar card & PAN card Copies (Not mandatory if the same is linked with the policy while issuance or in previous claim)
Please send the documents on below address

Bajaj Allianz General Insurance Company
2nd Floor, Bajaj Finserv Building,
Behind Weikfield IT park,
Off Nagar Road, Viman Nagar
Pune 411014| Toll free: 1800-103-2529, 1800-22-5858

2. Paying a Claim
i. You agree that We need only make payment when You or someone claiming on Your behalf has provided Us with necessary documentation and
information.
ii. We will make payment to You or Your Nominee. If there is no Nominee and You are incapacitated or deceased, We will pay Your heir, executor or validly
appointed legal representative and any payment We make in this way will be a complete and final discharge of Our liability to make payment.
iii. On receipt of all the documents and on being satisfied with regard to the admissibility of the claim as per policy terms and conditions, we shall offer
within a period of 30 days a settlement of the claim to the insured. Upon acceptance of an offer of settlement by the insured, the payment of the
amount due shall be made within 7 days from the date of acceptance of the offer by the insured. In the cases of delay in the payment, the insurer shall
be liable to pay interest at a rate which is 2% above the bank rate prevalent at the beginning of the financial year in which the claim is reviewed by it.
iv. However, where the circumstances of a claim warrant an investigation, the Company will initiate and complete such investigation at the earliest, in any
case not later than 30 days from the date of receipt of last necessary document. In such cases, the Company will settle the claim within 45 days from
the date of receipt of last necessary document. In case of delay beyond stipulated 45 days, the Company will be liable to pay interest at a rate which is
2% above the bank rate from the date of receipt of last necessary document to the date of payment of claim.
v. If the insurer, for any reasons decides to reject the claim under the policy the reasons regarding the rejection shall be communicated to the insured in
writing within 30 days of the receipt of documents. The insured may take recourse to the Grievance Redressal procedure stated under policy.
3. Basis of Claims Payment

i. If You suffer a relapse within 45 days of the date when You last obtained medical treatment or consulted a Doctor and for which a claim has been made,
then such relapse shall be deemed to be part of the same claim.
ii. If opted voluntarily by you, You shall bear 10% / 20% of co-payment for each and every claim payable under the Inpatient Hospitalization Treatment
section and Our liability, if any, shall only be in excess of that sum.
iii. The day care procedures listed are subject to the exclusions, terms and conditions of the policy and will not be treated as independent coverage under
the policy.
iv. Our obligation to make payment in respect of surgeries for cataracts (after the expiry of the 24 months period referred to in Exclusion C2) above, shall
be restricted to 20% of the Sum insured for each eye, subject to maximum of Rs 1,00,000/- for each of You.
v. Our obligation to make payment in respect of Bariatric Surgery (after the expiry of the36 months period referred to in Exclusion C3) above, shall be
restricted to 50% of the Sum insured, subject to maximum of Rs 5lac.
vi. We shall make payment in Indian Rupees only.
vii. If claim event falls within two policy periods the claims shall be administered taking into consideration the available sum insured in the two policy
periods, including the deductibles (if any) for each policy period. The claim amount to be payable shall be reduced up to the extent of the premium to
be received for renewal/due date of premium of this policy, if the same is not received earlier.
4. Other Insurance/ Contribution

If two or more policies are taken by You during a period from one or more insurers to indemnify treatment costs, We shall not apply the contribution
clause, but You shall have the right to require a settlement of your claim in terms of any of your policies.
In all such cases the insurer who has issued the chosen policy shall be obliged to settle the claim without insisting on the contribution clause as long as
the claim is within the limits of and according to the terms of the chosen policy.
If the amount to be claimed exceeds the sum insured under a single policy after considering the deductibles or co-pay, you shall have the right to
choose insurers by whom the claim to be settled. In such cases, the insurer may settle the claim with contribution clause.
Except in benefit policies, in cases where Youhave policies from more than one insurer to cover the same risk on indemnity basis, You shall only be
indemnified the hospitalization costs in accordance with the terms and conditions of the policy
5. Arbitration and Reconciliation

i. If any dispute or difference shall arise as to the quantum to be paid under the Policy (liability being otherwise admitted), such difference shall
independently of all other questions be referred to decision of a sole arbitrator in writing by the parties or if they cannot agree upon a single arbitrator
within 30 days of any party invoking arbitration, the same shall be referred to a panel of the arbitrators comprising of two arbitrators, one appointed by
each of the parties to the dispute/difference and the third arbitrator to be appointed by such two arbitrators and arbitration shall be conducted under
and in accordance with the provisions of the Arbitration and Conciliation Act, 1996. The law of the arbitration will be Indian law, and the seat of the
arbitration and venue for all hearings shall be within India.
ii. It is clearly agreed and understood that no difference or dispute shall be referable to arbitration as herein before provided, if Wehave disputed or not
accepted liability under or in respect of this Policy.
iii. It is hereby expressly stipulated and declared that it shall be a condition precedent to any right of action or suit upon this Policy that award by such
arbitrator/arbitrators of the amount of the loss or damage shall be first obtained.
iv. If these arbitration provisions are held to be invalid, then all such disputes or differences shall be referred to the exclusive jurisdiction of the Indian
Courts.
III. Conditions for renewal of the contract.

1. Renewal
i. Under normal circumstances, renewal will not be refused except on the grounds of Yourmoral hazard, misrepresentation, fraud, or your non
cooperation. (Subject to policy is renewed annually with us within the Grace period of 30 days from date of Expiry)
ii. In case of our own renewal, a grace period of 30 days is permissible and the Policy will be considered as continuous for the purpose of all waiting
periods. However, any treatment availed for an Illness or Accident sustained or contracted during the break period will not be admissible under the
Policy.
iii. For renewals received after completion of 30 days grace period, a fresh application of health insurance should be submitted to Us, it would be
processed as per a new business proposal.
iv. For dependent children, Policy is renewable up to 35 years. After the completion of maximum renewal age of dependent children, the policy would
be renewed for lifetime. However a Separate proposal form should be submitted to us at the time of renewal with the insured member as proposer.
Suitable credit of continuity/waiting periods for all the previous policy years would be extended in the new policy, provided the policy has been
maintained without a break
v. Premium payable or any changes in terms & conditions on renewal and on subsequent continuation of cover are subject to change with prior
approval from IRDAI.
vi. The loadings on renewals shall be in terms of increase or decrease in premiums offered for the entire portfolio and shall not be based on any
individual policy claim experience.
2. Cumulative Bonus:
If You renew Your “ Health Guard” with Us without any break and there has been no claim in the preceding year, We will increase the Limit of
Indemnity by 10% of base sum insured per annum, but:
i. The maximum cumulative increase in the Limit of Indemnity will be limited to 10 years and 100% of base sum insured of Your first “Health Guard”
with Us.
ii. This clause does not alter the annual character of this insurance
iii. If a claim is made in any year where a cumulative increase has been applied, then the increased Limit of Indemnity in the policy period of the
subsequent “Health Guard” shall be reduced by 10%, save that the limit of indemnity applicable to Your first “ Health Guard” with Us shall be
preserved.
3. Sum Insured Enhancement:

i. The Insured member can apply for enhancement of Sum Insured at the time of renewal. You can apply for enhancement of Sum Insured by
submitting a fresh proposal form to the company.
ii. The acceptance of enhancement of Sum Insured would be at the discretion of the company, based on the health condition of the insured members
& claim history of the policy.
iii. All waiting periods as defined in the Policy shall apply for this enhanced Sum Insured limit from the effective date of enhancement of such Sum
Insured considering such Policy Period as the first Policy with the Company.
4. Revision/ Modification of the policy:

There is a possibility of revision/ modification of terms, conditions, coverages and/or premiums of this product at any time in future, with appropriate
approval from IRDAI. In such an event of revision/modification of the product, intimation shall be set out to all the existing insured members at least 3
months prior to the date of such revision/modification comes into the effect
5. Migration of policy:
• The insured can opt for migration of policy to our other similar or closely similar products at the time of renewal.
• The premium will be charged as per Our Underwriting Policy for such chosen new product, and all the guidelines, terms and condition of the chosen
product shall be applicable.
• Suitable credit of continuity/waiting periods for all the previous policy years would be extended in the new policy, provided the policy has been
maintained without a break
6. Withdrawal of Policy
There is possibility of withdrawal of this product at any time in future with appropriate approval from IRDA, as We reserve Our right to do so with a
intimation of 3 months to all the existing insured members. In such an event of withdrawal of this product, at the time of Your seeking renewal of this
Policy, You can choose, among Our available similar and closely similar Health insurance products. Upon Your so choosing Our new product, You will
be charged the Premium as per Our Underwriting Policy for such chosen new product, as approved by IRDA.
Provided however, if You do not respond to Our intimation regarding the withdrawal of the product under which this Policy is issued, then this Policy
shall be withdrawn and shall not be available to You for renewal on the renewal date and accordingly upon Your seeking renewal of this Policy, You
shall have to take a Policy under available new products of Us subject to Your paying the Premium as per Our Underwriting Policy for such available
new product chosen by You and also subject to Portability condition.

IV Conditions applicable during the contract
1. Insured
Only those persons named as the insured in the Schedule shall be covered under this Policy. Cover under this Policy shall be withdrawn from any
insured member upon such insured member giving 14 days written notice to be received by Us.
2. Communications
Any communication meant for Us must be in writing and be delivered to Our address shown in the Schedule. Any communication meant for You will
be sent by Us to Your address shown in the Schedule.
3. Fraud
If You make or progress any claim knowing it to be false or fraudulent in any way, then this Policy will be void and all claims or payments due under it
shall be lost and the premium paid shall become forfeited.
4. Cancellation
i. We may cancel this insurance by giving You at least 15 days written notice, and if no claim has been made then We shall refund a pro-rata premium
for the unexpired Policy Period. Under normal circumstances, Policy will not be cancelled except for reasons of mis-representation, fraud, non-
disclosure of material facts or Your non-cooperation.
ii. You may cancel this insurance by giving Us at least 15 days written notice, and if no claim has been made then We shall refund premium on short
term rates for the unexpired Policy Period as per the rates detailed below.
Premium Refund
Period in Risk
Policy Period 1 Year Policy Period 2 Year Policy Period 3 Year
Within 15 Days Pro Rata Refund

Exceeding 15 days but less than 3 months 65.00% 75.00% 80.00%
Exceeding 3 months but less than 6 months 45.00% 65.00% 75.00%
Exceeding 6 months but less than 12 months 0.00% 45.00% 60.00%
Exceeding 12 months but less than 15 months 30.00% 50.00%

Exceeding 24 months but less than 27 months 20.00%

Cancellation grid for premium received on instalment basis and refund is as under
The premium will be refunded as per the below table:
Premium Refund
Period in Risk (from latest instalment date) % of Monthly % of quarterly
% of Half Yearly Premium
Premium Premium
Within 15 days from 1st Installment date As per Free Look Period Condition
Exceeding 15 days but less than or equal to 3 months 30%
No Refund
Exceeding 3 months but less than or equal to 6 months 0%
Note:
• The first slab of Number of days “within 15 days” in above table is applicable only in case of new business.
• In case of renewal policies, period is risk “Exceeding 15 days but less than 3 months” should be read as “within 3 months”.
For the avoidance of doubt, the Company shall remain liable for any claim that was made prior to the date upon which the Policy is cancelled except
in cases such cancellation is on account of Fraud, if any false/fraudulent claim is made by Insured or any one on behalf of Insured, mis-representation
or non-disclosure of material facts or non-co-operation by the Insured
5. Free Look Period

You have a period of 15 days from the date of receipt of the first policy document to review the terms and conditions of this Policy. If You have any
objections to any of the terms and conditions, You have the option of canceling the Policy stating the reasons for cancellation.
If you have not made any claim during the Free look period, you shall be entitled to refund of premium subject to,

• a deduction of the expenses incurred by Us on Your medical examination, stamp duty charges, if the risk has not commenced,
• a deduction of the stamp duty charges, medical examination charges & proportionate risk premium for period on cover, If the risk has commenced
• a deduction of such proportionate risk premium commensurating with the risk covered during such period ,where only a part of risk has commenced
• Free look period is not applicable for renewal policies.
6. Portability Conditions
a. Retail Policies: As per the Portability Guidelines issued by IRDAI, applicable benefits shall be passed on to insured persons who were holding similar
retail health insurance policies of other non-life insurers. The pre-policy medical examination requirements and provisions for such cases shall remain
similar to new proposals cases.
b. Group Policies: As per the Portability Guidelines issued by IRDAI, applicable benefits shall be passed on to insured persons who were insured under
Our Group Health Policy and are availing Our individual Health Policy. However, such benefits shall be applicable only in the event of discontinuation/
non-renewal of the Group Health Policy (applicable for both employer-employee relationships and non-employer-employee relationships) and/
or the particular insured person leaving the group on account of resignation/ retirement (applicable for employer-employee relationships) or
termination of relationship with the Group Administrator (applicable for non-employer-employee relationships). The pre-policy medical examination
requirements and provisions for such cases shall remain similar to non-portable cases.
7. Endorsements
This Policy constitutes the complete contract of insurance. This Policy cannot be changed by anyone (including an insurance agent or broker) except
Us. Any change that We make will be evidenced by a written endorsement signed and stamped by Us.
8. Discounts:
i. Family Discount:10% family discount shall be offered if 2 eligible family members are covered under a single policy and 15% if more than 2 of any
of the eligible family members are covered under a single policy. Moreover, this family discount will be offered for both new policies as well as for
renewal policies. Family discount is not applicable to Health Guard Floater Policies
ii. Employee Discount:20% discount on published premium rates to employees of Bajaj Allianz & its group companies, this discount is applicable only if
the policy is booked in direct office code
iii. Co-pay Discount:
If opted voluntarily and mentioned on the Policy Schedule that a Co-payment is effective by the Insured then Insured will be eligible of additional 10%
or 20% discount on the policy premium.
If a claim has been admitted under Section A 1)In-patient HospitalisationTreatmentthen, the insured person shall bear 10% or 20% respectively of the
eligible claim amount payable under this section and Our liability, if any, shall only be in excess of that sum and would be subject to the Sum Insured.
iv. Long Term Policy Discount:

a) 4 % discount is applicable if policy is opted for 2 years
b) 8 % discount is applicable if policy is opted for 3 years
9. Premium payment Zone:

Zone A
“Following cities has been clubbed in Zone A:-
Delhi / NCR, Mumbai including (Navi Mumbai, Thane and Kalyan), Hyderabad and Secunderabad, Bangalore, Kolkata, Ahmedabad, Vadodara and
Surat.
Zone B
Rest of India apart from Zone A cities are classified as Zone B.
Note:-
• Policyholders paying Zone A premium rates can avail treatment allover India without any co-payment.
• But, those, who pay zone B premium rates and avail treatment in Zone A city will have to pay 20% co-payment on admissible claim amount. This Co –
payment will not be applicable for Accidental Hospitalization cases.”
• Policyholder residing in Zone B can choose to pay premium for Zone A and avail treatment all over India without any co-payment.
10. Inclusion of members under the policy:

Where an Insured Person is added to this Policy, either by way of endorsement or at the time of renewal, the pre-existing disease clause, exclusions
and waiting periods will be applicable considering such Policy Year as the first year of Policy with the Company for the insured member.
11. Territorial Limits & Governing Law

i. We cover insured events arising during the Policy Period, as well as treatment availed, within India only. Our liability to make any payment shall be to
make payment within India and in Indian Rupees only.

ii. The Policy constitutes the complete contract of insurance. No change or alteration shall be valid or effective unless approved in writing by Us, which
approval shall be evidenced by an endorsement on the Schedule.
iii. The construction, interpretation and meaning of the provisions of this Policy shall be determined in accordance with Indian law. The section headings
of this Policy are included for descriptive purposes only and do not form part of this Policy for the purpose of its construction or interpretation.
12. Grievance Redressal Procedure

ajaj Allianz General Insurance has always been known as a forward looking customer centric organization. We take immense pride in the spirit of
B
service and the culture of keeping customer first in our scheme of things. In order to provide you with top-notch service on all fronts, we have provided
you with multiple platforms via which you can always reach one of our representatives.
Level 1
In case you have any service concern, you may please reach out to our Customer Experience team through any of the following options:
• Our website @ https://general.bajajallianz.com/BagicNxt/misc/iTrack/onlineGrievance.jsp
• Call us on our Toll Free No. 1800 209 5858
• Mail us on bagichelp@bajajallianz.co.in,
• Write to: Bajaj Allianz General Insurance Co. Ltd
Bajaj Allianz House, Airport Road, Yerwada
Pune, 411006

Level 2
In case you are not satisfied with the response given to you by our team, you may write to our Grievance Redressal Officer Mr. Rakesh Sharma at
ggro@bajajallianz.co.in.
Level 3
If you are still not satisfied with the resolution provided, you can further escalate to Mr. Hitesh Sindhwani Head, Customer Experience, at email:
head.customerservice@bajajallianz.co.in.

Grievance Redressal cell for Senior Citizens
Senior citizen cell for insured person who are senior citizens
‘Good thing comes with time’ and so for our customers who are above 60 years of age we have created special cell to address any health insurance
related query, Our senior citizen customers can reach us through the below dedicated channels to enable us to service them promptly.
Health toll free number: 1800-103-2529

Email address: seniorcitizen@bajajallianz.co.in
In case your complaint is not fully addressed by the insurer, You may use the Integrated Greivance Management System (IGMS) for escalating the
complaint to IRDAI or call 155255 . Through IGMS you can register your complain online and track its status. For registration please visit IRDAI website
www.irda.gov.in.
If the issue still remains unresolved, You may, subject to vested jurisdiction, approach Insurance Ombudsman for the redressal of the grievance.
The contact details of the ombudsman offices are mentioned below. However, we request you to visit http://www.gbic.co.in for updated details.
Jurisdiction of
Jurisdiction of Office Office
Office Details Office Details
Union Territory, District) Union Territory,
District)
BENGALURU - Shri/Smt........
AHMEDABAD - Shri/Smt........
Office of the Insurance Ombudsman,
Gujarat, Jeevan Soudha Building,PID No. 57-27-N-19
Jeevan Prakash Building, 6th floor,
Dadra & Nagar Haveli, Ground Floor, 19/19, 24th Main Road,
Tilak Marg, Relief Road, Karnataka.
Daman and Diu. JP Nagar, Ist Phase,
Ahmedabad – 380 001.
Bengaluru – 560 078.
Tel.: 079 - 25501201/02/05/06
Tel.: 080 - 26652048 / 26652049
Email: bimalokpal.ahmedabad@ecoi.co.in
Email: bimalokpal.bengaluru@ecoi.co.in

BHOPAL - Shri/Smt........
Office of the Insurance Ombudsman, BHUBANESHWAR - Shri/Smt........
Janak Vihar Complex, 2nd Floor, Office of the Insurance Ombudsman,
6, Malviya Nagar, Opp. Airtel Office, Madhya Pradesh 62, Forest park,
Near New Market, Chattisgarh. Bhubneshwar – 751 009. Orissa.
Bhopal – 462 003. Tel.: 0674 - 2596461 /2596455
Tel.: 0755 - 2769201 / 2769202 Fax: 0674 - 2596429
Fax: 0755 - 2769203 Email: bimalokpal.bhubaneswar@ecoi.co.in
Email: bimalokpal.bhopal@ecoi.co.in
CHANDIGARH - Shri/Smt........ CHENNAI - Shri/Smt........
Office of the Insurance Ombudsman, Punjab, Office of the Insurance Ombudsman, Tamil Nadu,
S.C.O. No. 101, 102 & 103, 2nd Floor, Haryana, Fatima Akhtar Court, 4th Floor, 453, Pondicherry Town
Batra Building, Sector 17 – D, Himachal Pradesh, Anna Salai, Teynampet, and
Chandigarh – 160 017. Jammu & Kashmir, CHENNAI – 600 018. Karaikal (which
Tel.: 0172 - 2706196 / 2706468 Chandigarh. Tel.: 044 - 24333668 / 24335284 are part of
Fax: 0172 - 2708274 Fax: 044 - 24333664 Pondicherry).
Email: bimalokpal.chandigarh@ecoi.co.in Email: bimalokpal.chennai@ecoi.co.in
GUWAHATI - Shri/Smt........
DELHI - Shri/Smt........ Assam,
Office of the Insurance Ombudsman, Meghalaya,
Jeevan Nivesh, 5th Floor,
2/2 A, Universal Insurance Building, Manipur,
Nr. Panbazar over bridge, S.S. Road,
Asaf Ali Road, Delhi. Mizoram,
Guwahati – 781001(ASSAM).
New Delhi – 110 002. Arunachal Pradesh,
Tel.: 0361 - 2132204 / 2132205
Tel.: 011 - 2323481/23213504 Nagaland and
Fax: 0361 - 2732937
Email: bimalokpal.delhi@ecoi.co.in Tripura.
Email: bimalokpal.guwahati@ecoi.co.in
HYDERABAD - Shri/Smt........
Office of the Insurance Ombudsman, JAIPUR - Shri/Smt........
Andhra Pradesh,
6-2-46, 1st floor, “Moin Court”, Office of the Insurance Ombudsman,
Telangana,
Lane Opp. Saleem Function Palace, Jeevan Nidhi – II Bldg., Gr. Floor,
Yanam and
A. C. Guards, Lakdi-Ka-Pool, Bhawani Singh Marg, Rajasthan.
part of Territory of
Hyderabad - 500 004. Jaipur - 302 005.
Pondicherry.
Tel.: 040 - 65504123 / 23312122 Tel.: 0141 - 2740363
Fax: 040 - 23376599 Email: Bimalokpal.jaipur@ecoi.co.in
Email: bimalokpal.hyderabad@ecoi.co.in
ERNAKULAM - Shri/Smt........ KOLKATA - Shri/Smt........
Office of the Insurance Ombudsman, Office of the Insurance Ombudsman,
West Bengal,
2nd Floor, Pulinat Bldg., Kerala, Hindustan Bldg. Annexe, 4th Floor,
Sikkim,
Opp. Cochin Shipyard, M. G. Road, Lakshadweep, 4, C.R. Avenue,
Andaman &
Ernakulam - 682 015. Mahe-a part of Pondicherry. KOLKATA - 700 072.
Nicobar Islands.
Tel.: 0484 - 2358759 / 2359338 Tel.: 033 - 22124339 / 22124340
Fax: 0484 - 2359336 Fax : 033 - 22124341
Email: bimalokpal.ernakulam@ecoi.co.in Email: bimalokpal.kolkata@ecoi.co.in
Districts of Uttar Pradesh :
Laitpur, Jhansi, Mahoba,
Hamirpur, Banda, Chitrakoot,
Allahabad, Mirzapur,
Sonbhabdra, Fatehpur, MUMBAI - Shri/Smt........
LUCKNOW -Shri/Smt........ Pratapgarh, Jaunpur,Varanasi, Office of the Insurance Ombudsman,
Goa,
Office of the Insurance Ombudsman, Gazipur, Jalaun, Kanpur, 3rd Floor, Jeevan Seva Annexe,
Mumbai
6th Floor, Jeevan Bhawan, Phase-II, Lucknow, Unnao, Sitapur, S. V. Road, Santacruz (W),
Metropolitan
Nawal Kishore Road, Hazratganj, Lakhimpur, Bahraich, Mumbai - 400 054.
Region
Lucknow - 226 001. Barabanki, Raebareli, Sravasti, Tel.: 022 - 26106552 / 26106960
excluding Navi
Tel.: 0522 - 2231330 / 2231331 Gonda, Faizabad, Amethi, Fax: 022 - 26106052
Mumbai & Thane.
Fax: 0522 - 2231310 Kaushambi, Balrampur, Basti, Email: bimalokpal.mumbai@ecoi.co.in
Email: bimalokpal.lucknow@ecoi.co.in Ambedkarnagar, Sultanpur,
Maharajgang, Santkabirnagar,
Azamgarh, Kushinagar,
Gorkhpur, Deoria, Mau,
Ghazipur, Chandauli, Ballia,
Sidharathnagar.

State of Uttaranchal and the
following Districts of Uttar
Pradesh:
NOIDA - Shri. Ajesh Kumar Agra, Aligarh, Bagpat, Bareilly, PATNA - Shri/Smt........
Office of the Insurance Ombudsman, Bijnor, Budaun, Bulandshehar, Office of the Insurance Ombudsman,
Bhagwan Sahai Palace Etah, Kanooj, Mainpuri, 1st Floor,Kalpana Arcade Building,,
4th Floor, Main Road, Mathura, Meerut, Moradabad, Bazar Samiti Road, Bihar,
Naya Bans, Sector 15, Muzaffarnagar, Oraiyya, Bahadurpur, Jharkhand.
Distt: Gautam Buddh Nagar, Pilibhit, Etawah, Farrukhabad, Patna 800 006.
U.P-201301. Firozbad, Gautambodhanagar, Tel.: 0612-2680952
Tel.: 0120-2514250 / 2514252 / 2514253 Ghaziabad, Hardoi, Email: bimalokpal.patna@ecoi.co.in
Email: bimalokpal.noida@ecoi.co.in Shahjahanpur, Hapur,
Shamli, Rampur, Kashganj,
Sambhal, Amroha, Hathras,
Kanshiramnagar, Saharanpur.
PUNE - Shri/Smt........
Office of the Insurance Ombudsman, Maharashtra,
Jeevan Darshan Bldg., 3rd Floor, Area of Navi Mumbai and
C.T.S. No.s. 195 to 198, Thane
N.C. Kelkar Road, Narayan Peth, excluding Mumbai
Pune – 411 030. Metropolitan Region
Tel.: 020-41312555
Email: bimalokpal.pune@ecoi.co.in
Annexure I
Indicative list of Day Care Procedures:

1. Suturing - CLW -under LA or GA 66. Incision and excision of tissue in the perianal region
2. Surgical debridement of wound 67. Surgical treatment of anal fistula
3. Therapeutic Ascitic Tapping 68. Surgical treatment of hemorrhoids
4. Therapeutic Pleural Tapping 69. Sphincterotomy/Fissurectomy
5. Therapeutic Joint Aspiration 70. Laparoscopic appendicectomy
6. Aspiration of an internal abscess under ultrasound guid- 71. Laparoscopic cholecystectomy
ance
7. Aspiration of hematoma 72. TURP (Resection prostate)
8. Incision and Drainage 73. Varicose vein stripping or ligation
9. Endoscopic Foreign Body Removal - Trachea /- pharynx- 74. Excision of dupuytren's contracture
larynx/ bronchus
10. Endoscopic Foreign Body Removal -Oesophagus/stomach 75. Carpal tunnel decompression
/rectum.
11. True cut Biopsy - breast/- liver/- kidney-Lymph Node/- 76. Excision of granuloma
Pleura/-lung/-Muscle biopsy/-Nerve biopsy/Synovial biopsy/-
Bone trephine biopsy/-Pericardial biopsy
12. Endoscopic ligation/banding 77. Arthroscopic therapy
13. Sclerotherapy 78. Surgery for ligament tear
14. Dilatation of digestive tract strictures 79. Surgery for meniscus tear
15. Endoscopic ultrasonography and biopsy 80. Surgery for hemoarthrosis/pyoarthrosis
16. Nissen fundoplication for Hiatus Hernia /Gastro esopha- 81. Removal of fracture pins/nails
geal reflux disease
17. Endoscopic placement/removal of stents 82. Removal of metal wire
18. Endoscopic Gastrostomy 83. Incision of bone, septic and aseptic
19. Replacement of Gastrostomy tube 84. Closed reduction on fracture, luxation or epiphyseolysis with osetosynthesis
20. Endoscopic polypectomy 85. Suture and other operations on tendons and tendon sheath
21. Endoscopic decompression of colon 86. Reduction of dislocation under GA
22. Therapeutic ERCP 87. Cataract surgery

23. Brochoscopic treatment of bleeding lesion 88. Excision of lachrymal cyst
24. Brochoscopic treatment of fistula /stenting 89. Excision of pterigium
25. Bronchoalveolar lavage & biopsy 90. Glaucoma Surgery
26. Tonsillectomy without Adenoidectomy 91. Surgery for retinal detachment
27. Tonsillectomy with Adenoidectomy 92. Chalazion removal (Eye)
28. Excision and destruction of lingual tonsil 93. Incision of lachrymal glands
29. Foreign body removal from nose 94. Incision of diseased eye lids
30. Myringotomy 95. Excision of eye lid granuloma
31. Myringotomy with Grommet insertion 96. Operation on canthus & epicanthus
32. Myringoplasty /Tympanoplasty 97. Corrective surgery for entropion&ectropion
33. Antral wash under LA 98. Corrective surgery for blepharoptosis
34. Quinsy drainage 99. Foreign body removal from conjunctiva
35. Direct Laryngoscopy with or w/o biopsy 100. Foreign body removal from cornea
36. Reduction of nasal fracture 101. Incision of cornea
37. Mastoidectomy 102. Foreign body removal from lens of the eye
38. Removal of tympanic drain 103. Foreign body removal from posterior chamber of eye
39. Reconstruction of middle ear 104. Foreign body removal from orbit and eye ball
40. Incision of mastoid process & middle ear 105. Excision of breast lump /Fibro adenoma
41. Excision of nose granuloma 106. Operations on the nipple
42. Blood transfusion for recipient 107. Incision/Drainage of breast abscess
43. Therapeutic Phlebotomy 108. Incision of pilonidal sinus
44. Haemodialysis/Peritoneal Dialysis 109. Local excision of diseased tissue of skin and subcutaneous tissue
45. Chemotherapy 110. Simple restoration of surface continuity of the skin and subcutaneous tissue
46. Radiotherapy 111. Free skin transportation, donor site
47. Coronary Angioplasty (PTCA) 112. Free skin transportation recipient site
48. Pericardiocentesis 113. Revision of skin plasty
49. Insertion of filter in inferior vena cava 114. Destruction of the diseases tissue of the skin and subcutaneous tissue
50. Insertion of gel foam in artery or vein 115. Incision, excision, destruction of the diseased tissue of the tongue
51. Carotid angioplasty 116. Glossectomy
52. Renal angioplasty 117. Reconstruction of the tongue
53. Tumor embolisation 118. Incision and lancing of the salivary gland and a salivary duct
54. TIPS procedure for portal hypertension 119. Resection of a salivary duct
55. Endoscopic Drainage of Pseudopancreatic cyst 120. Reconstruction of a salivary gland and a salivary duct
56. Lithotripsy 121. External incision and drainage in the region of the mouth, jaw and face
57. PCNS (Percutaneous nephrostomy) 122. Incision of hard and soft palate
58. PCNL (percutaneous nephrolithotomy) 123. Excision and destruction of the diseased hard and soft palate
59. Suprapubiccytostomy 124. Incision, excision and destruction in the mouth
60. Tran urethral resection of bladder tumor 125. Surgery to the floor of mouth
61. Hydrocele surgery 126. Palatoplasty
62. Epididymectomy 127. Transoral incision and drainage of pharyngeal abscess
63. Orchidectomy 128. Dilatation and curettage
64. Herniorrhaphy 129. Myomectomies
65. Hernioplasty 130. Simple Oophorectomies
Note:
i. Above mentioned list is a indicative list of procedures, any other surgeries/procedures requiring less than 24 hours hospitalisation due to technological
advances will also be covered under this policy provided such procedures comply with the standard definition of Day Care Centre and Day Care
treatment mentioned in the definitions.
ii. The standard exclusions and waiting periods are applicable to all of the above procedures depending on the medical condition/disease under
treatment. Only 24 hours hospitalization is not mandatory.

Annexure II:- List of Non-Medical Items
List of Expenses Generally List of Expenses Generally
S. S.
Excluded (“Non-Medical”) in SUGGESTIONS Excluded (“Non-Medical”) in SUGGESTIONS
NO NO
Hospital Indemnity Policy - Hospital Indemnity Policy -
TOILETRIES/COSMETICS/ PERSONAL COMFORT OR CONVENIENCE
ADMINISTRATIVE OR NON-MEDICAL CHARGES
ITEMS
1 HAIR REMOVAL CREAM Not Payable 107 ADMISSION KIT Not Payable
BABY CHARGES (UNLESS
2 Not Payable 108 BIRTH CERTIFICATE Not Payable
SPECIFIED/INDICATED)
BLOOD RESERVATION
3 BABY FOOD Not Payable 109 CHARGES AND ANTE NATAL Not Payable
BOOKING CHARGES
4 BABY UTILITES CHARGES Not Payable 110 CERTIFICATE CHARGES Not Payable
5 BABY SET Not Payable 111 COURIER CHARGES Not Payable
6 BABY BOTTLES Not Payable 112 CONVENYANCE CHARGES Not Payable
7 BRUSH Not Payable 113 DIABETIC CHART CHARGES Not Payable
DOCUMENTATION CHARGES
8 COSY TOWEL Not Payable 114 Not Payable
/ ADMINISTRATIVE EXPENSES
DISCHARGE PROCEDURE
9 HAND WASH Not Payable 115 Not Payable
CHARGES
10 M01STUR1SER PASTE BRUSH Not Payable 116 DAILY CHART CHARGES Not Payable
ENTRANCEPASS / VISITORS
11 POWDER Not Payable 117 Not Payable
PASS CHARGES
EXPENSES RELATED
To be claimed by patient under Post
12 RAZOR Payable 118 TO PRESCRIPTION ON
Hosp where admissible
DISCHARGE
13 SHOE COVER Not Payable 119 FILE OPENING CHARGES Not Payable
INCIDENTAL EXPENSES
14 BEAUTY SERVICES Not Payable 120 / MISC. CHARGES (NOT Not Payable
EXPLAINED)
Essential and may be paid
specifically for cases who
15 BELTS/ BRACES 121 MEDICAL CERTIFICATE Not Payable
have undergone surgery o
f thoracic o r lumbar spine.
16 BUDS Not Payable 122 MAINTENANCE CHARGES Not Payable
17 BARBER CHARGES Not Payable 123 MEDICAL RECORDS Not Payable
18 CAPS Not Payable 124 PREPARATION CHARGES Not Payable
19 COLD PACK/HOT PACK Not Payable 125 PHOTOCOPIES CHARGES Not Payable
PATIENT IDENTIFICATION
20 CARRY BAGS Not Payable 126 Not Payable
BAND / NAME TAG
21 CRADLE CHARGES Not Payable 127 WASHING CHARGES Not Payable
22 COMB Not Payable 128 MEDICINE BOX Not Payable
DISPOSABLES RAZORS CHARGES ( Payable upto 24 hrs, shifting
23 Payable 129 MORTUARY CHARGES
for site preparations) charges not payable
EAU-DE-COLOGNE / ROOM MEDICO LEGAL CASE
24 Not Payable 130
FRESHNERS CHARGES (MLC CHARGES)
25 EYE PAD Not Payable
26 EYE SHEILD Not Payable EXTERNAL DURABLE DEVICES
27 EMAIL / INTERNET CHARGES Not Payable 131 WALKING AIDS CHARGES Not Payable
FOOD CHARGES (OTHER THAN
28 PATIENT’S DIET PROVIDED BY Not Payable 132 BIPAP MACHINE Not Payable
HOSPITAL)
29 FOOT COVER Not Payable 133 COMMODE Not Payable
30 GOWN Not Payable 134 CPAP/ CAPD EQUIPMENTS Device not payable
Essential in bariatric and
varicose vein surgery and
31 LEGGINGS should be considered for 135 INFUSION PUMP - COST Device not payable
these conditions where
surgery itself is payable.

OXYGEN CYLINDER (FOR
32 LAUNDRY CHARGES Not Payable 136 USAGE OUTSIDE THE Not Payable
HOSPITAL)
33 MINERAL WATER Not Payable 137 PULSEOXYMETER CHARGES Device not payable
34 OIL CHARGES Not Payable 138 SPACER Not Payable
35 SANITARY PAD Not Payable 139 SPIROMETRE Device not payable
36 SLIPPERS Not Payable 140 S P0 2PRO B E Not Payable
37 TELEPHONE CHARGES Not Payable 141 NEBULIZER KIT Not Payable
38 TISSUE PAPER Not Payable 142 STEAM INHALER Not Payable
39 TOOTH PASTE Not Payable 143 ARMSLING Not Payable
40 TOOTH BRUSH Not Payable 144 THERMOMETER Not Payable (paid by patient)
41 GUEST SERVICES Not Payable 145 CERVICAL COLLAR Not Payable
42 BED PAN Not Payable 146 SPLINT Not Payable
43 BED UNDER PAD CHARGES Not Payable 147 DIABETIC FOOT WEAR Not Payable
KNEE BRACES ( LONG/
44 CAMERA COVER Not Payable 148 Not Payable
SHORT/ HINGED)
KNEE IMMOBILIZER/
45 CLINIPLAST Not Payable 149 Not Payable
SHOULDER IMMOBILIZER
Essential and should be paid
Not Payable/ Payable by specifically for cases who have
46 CREPE BANDAGE 150 LUMBOSACRAL BELT
the patient undergone surgery of lumbar
spine.
Payable for any ICU patient
requiring more than 3 days in
NIMBUS BED OR WATER OR ICU, all patients with paraplegia /
47 CURAPORE Not Payable 151
AIR BED CHARGES quadriplegia for any reason and at
reasonable cost of approximately
Rs 200/day
48 DIAPER OF ANY TYPE Not Payable 152 AMBULANCE COLLAR Not Payable
Not Payable (However if
CD is specifically sought
49 DVD, CD CHARGES 153 AMBULANCE EQUIPMENT Not Payable
by Insure r /T PA then
payable)
50 EYELET COLLAR Not Payable 154 MICROSHEILD Not Payable
Essential and should be paid in
post surgerypatients of major
abdominal surgery including
51 FACE MASK Not Payable 155 ABDOMINAL BINDER TAH, LSCS, incisional hernia
repair, exploratory laparotomy
for intestinal obstruct ion, liver
transplant etc.
52 FLEXI MASK Not Payable
53 GAUSE SOFT Not Payable ITEMS PA YABLE IF SUPPORTED BY A PRESCRIPTION
May be payable when prescribed
BETADINE \ HYDROGEN
for patient , not payable for hospital
54 GAUZE Not Payable 156 PEROXIDE\SPIRIT\
use in OT o r ward o r for dressings
DISINFECTANTS ETC
in hospital
PRIVATE NURSES CHARGES- Post hospitalization nursing
55 HAND HOLDER Not Payable 157
SPECIAL NURSING CHARGES charges not Payable
NUTRITION PLANNING
HANSAPLAST/ADHESIVE Patient Diet provided by hospital is
56 Not Payable 158 CHARGES - DIETICIAN
BANDAGES payable
CHARGES- DIET CHARGES
Payable -S u g a r free variants
57 INFANT FOOD Not Payable 159 SUGAR FREE Tablets of admissible medicines are not
excluded
Reasonable costs for one CREAMS POWDERS LOTIONS
sling in case o f upper (Toileteries are not payable
58 SLINGS 160 Payable when prescribed
arm fractures should be only prescribed medical
considered pharmaceuticals payable)
161 Digestion gels Payable when prescribed

Upto 5 electrodes are required for
every case visiting OT or ICU. For
ITEMS SPECIFICALLY EXCLUDED IN THE POLICIES 162 ECG ELECTRODES longer stay in ICU, may require a
change and at least one set every
second day must be payable.
WEIGHT CONTROL PROGRAMS/ Exclusion in policy unless Sterilized Gloves payable /
59 163 GLOVES
SUPPLIES/ SERVICES otherwise specified unsterilized gloves not payable
COST OF SPECTACLES/ CONTACT Exclusion in policy unless Payable - payable Pre op e ra t iv e
60 164 HIV KIT
LENSES/ HEARING AIDS ETC., otherwise specified screening
DENTAL TREATMENT EXPENSES
Exclusion in policy unless LISTERINE/ ANTISEPTIC
61 THAT DO NOT REQUIRE 165 Payable when prescribed
otherwise specified MOUTHWASH
HOSPITALISATION
HORMONE REPLACEMENT Exclusion in policy unless
62 166 LOZENGES Payable when prescribed
THERAPY otherwise specified
Exclusion in policy unless
63 HOME VISIT CHARGES 167 MOUTH PAINT Payable when prescribed
otherwise specified
INFERTILITY/ SUBFERTILITY/
Exclusion in policy unless If used during hospitalization is
64 ASSISTED CONCEPTION 168 NEBULISATION KIT
otherwise specified payable reasonably
PROCEDURE
OBESITY (INCLUDING MORBID
65 OBESITY) TREATMENT IF 169 NOVARAPID Payable when prescribed
otherwise specified
EXCLUDED IN POLICY
PSYCHIATRIC & PSYCHOSOMATIC Exclusion in policy unless
66 170 VOLINI GEL/ ANALGESIC GEL Payable when prescribed
DISORDERS otherwise specified
CORRECTIVE SURGERY FOR Exclusion in policy unless
67 171 ZYTEE GEL Payable when prescribed
REFRACTIVE ERROR otherwise specified
TREATMENT OF SEXUALLY Exclusion in policy unless Routine Vaccination not Payable /
68 172 VACCINATION CHARGES
TRANSMITTED DISEASES otherwise specified Post Bite Vaccination Payable
69 DONOR SCREENING CHARGES
otherwise specified
ADMISSION/REGISTRATION Exclusion in policy unless
70 PART OF HOSPITAL'S OWN COSTS AND NOT PA YA BLE
CHARGES otherwise specified
HOSPITALISATION FOR
Exclusion in policy unless Not Payable - P a r t of Hospital's
71 EVALUATION/ DIAGNOSTIC 173 AHD
otherwise specified internal Cost
PURPOSE
EXPENSES FOR INVESTIGATION/
Not Payable - Exclusion in
TREATMENT IRRELEVANT TO THE Not Payable - P a r t of Hospital's
72 policy unless otherwise 174 ALCOHOL SWABES
DISEASE FOR WHICH ADMITTED internal Cost
specified
OR DIAGNOSED
ANY EXPENSES WHEN THE
PATIENT IS DIAGNOSED
WITH RETRO VIRUS + OR Not payable as per HIV/ SCRUB SOLUTION/ Not Payable - P a r t of Hospital's
73 175
SUFFERING FROM /HIV/ AIDS AIDS exclusion STERILLIUM internal Cost
ETC IS DETECTED/ DIRECTLY OR
INDIRECTLY
Not Payable except Bone
STEM CELL IMPLANTATION/
74 Marrow Transplantation
SURGERY and storage
where covered by policy
OTHERS
ITEMS WHICH FORM PART OF HOSPITAL SERVICES WHERE SEPARA TE VACCINE CHARGES FOR
176 Not Payable
CONSUMABLES ARE NOT PA YABLE BUT THE SER VICE IS BABY
WARD AND THEATRE BOOKING Payable under OT Charges AESTHETIC TREATMENT /
75 177 Not Payable
CHARGES ,not payable separately SURGERY
Rental charged by the
ARTHROSCOPY & ENDOSCOPY hospital payable. Purchase
76 178 TPA CHARGES Not Payable
INSTRUMENTS of Instruments not
payable.
Payable under OT Charges
77 MICROSCOPE COVER 179 VISCO BELT CHARGES Not Payable
, not separately

ANY KIT WITH NO DETAILS
SURGICAL BLADES,HARMONIC Payable under OT Charges MENTIONED [DELIVERY KIT,
78 180 Not Payable
SCALPEL,SHAVER , not separately ORTHOKIT, RECOVERY KIT,
ETC]
79 SURGICAL DRILL 181 EXAMINATION GLOVES Not Payable
, not separately
80 EYE KIT 182 KIDNEY TRAY Not Payable
,not separately
81 EYE DRAPE 183 MASK Not Payable
,not separately
Payable under Radiology
82 X-RAY FILM Charges, not as 184 OUNCE GLASS Not Payable
consumable
Payable under OUTSTATION Not payable, except for
83 SPUTUM CUP Investigation Charges, not 185 CONSULTANT'S/ SURGEON'S telemedicine consultations w here
as consumable FEES covered by policy
Part o f OT Charges , not
84 BOYLES APPARATUS CHARGES 186 OXYGEN MASK Not Payable
separately
BLOOD GROUPING AND CROSS Part o f Cost of Blood, not
85 187 PAPER GLOVES Not Payable
MATCHING OF DONORS SAMPLES payable
Should be payable in case o f PI
Not Payable -Part of
86 Antiseptic or disinfetant lotions 188 PELVIC TRACTION BELT VI) requiring traction as this is
Dressing Charges
generally not reused
BAND AIDS, BANDAGES, STERLILE Not Payable - Part of
87 189 REFERAL DOCTOR'S FEES Not Payable
INJECTIONS, NEEDLES, SYRINGES Dressing charges
Not payable pre hospitalisation
Not Payable -Part of ACCU CHECK ( Glucometery/ or post hospitalisation / Reports
88 COTTON 190
Dressing Charges Strips) and Charts required / Device not
payable
Not Payable- Part of
89 COTTON BANDAGE 191 PAN CAN Not Payable
Dressing Charges
Not Payable-Payable
by the patient when
90 MICROPORE/ SURGICAL TAPE prescribed , otherwise 192 SOFNET Not Payable
included as Dressing
Charges
91 BLADE Not Payable 193 TROLLY COVER Not Payable
Not Payable -Part of
Hospital Services/
92 APRON 194 UROMETER, URINE JUG Not Payable
Disposable linen to be part
of OT/ICU charges
Not Payable (service is Payable-Ambulance from home
charged by hospitals, to hospital or inter hospital
93 TORNIQUET 195 AMBULANCE
consumables can not be shifts is payable/ RTA as specific
separately charged) requirement is payable
TEGADERM / VASOFIX Payable - maximum o f 3 in 48 hrs
94 ORTHOBUNDLE, GYNAEC BUNDLE Part o f Dressing Charges 196
SAFETY an d then 1 in 24 hrs
Payable w here medically necessary
95 URINE CONTAINER Not Payable 197 URINE BAG till a reasonable cost - maximum 1
per 24hrs
198 SOFTOVAC Not Payable
Essential for case like CABG etc.
ELEMENTS OF ROOM CHARGE 199 STOCKINGS
where it should be paid.
Actual tax levied by
government is payable. P a
96 LUXURY TAX
r t of room charge for sub
limits
Part o f room charge not
97 HVAC
payable separately
Part of room charge not
98 HOUSE KEEPING CHARGES
payable separately

SERVICE CHARGES WHERE
Part of room charge
99 NURSING CHARGE ALSO
notpayable separately
CHARGED
Payable under room
TELEVISION & AIR CONDITIONER
100 charges not if separately
CHARGES
levied
Part of Room Charge , Not
101 SURCHARGES
payable separately
Not Payable - P a r t of
102 ATTENDANT CHARGES
Room Charges
Part of nursing charges,
103 M IV INJECTION CHARGES
not payable
Part of Laundry/
104 CLEAN SHEET Housekeeping not payable
separately
EXTRA DIET OF PATIENT(OTHER
Patient Diet provided by
105 THAN THAT WHICH FORMS PART
hospital is payable
OF BED CHARGE)
Not Payable- part of room
106 BLANKET/WARMER BLANKET
charges

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Bajaj Allianz General Insurance Company Limited

5. Day Care Procedures

HEALTH GUARD GOLD PLAN

8. Daily Cash Benefit for Accompanying an Insured Child

9. Sum Insured Reinstatement Benefit

11. Ayurvedic / Homeopathic Hospitalisation Expenses

In-patient Treatment- Medical Expenses for Ayurvedic and Homeopathic treatment:

HEALTH GUARD GOLD PLAN

The claim will be admissible under the policy provided that,

12. Maternity Expenses

13. New Born Baby Cover

We will pay for,

14. Bariatric Surgery Cover

Special Conditions applicable to Bariatric Surgery Cover

HEALTH GUARD GOLD PLAN

3. Any one illness

4. Bajaj Allianz Network Hospitals / Network Hospitals

5. Bajaj Allianz Diagnostic Centre

7. Cancer of Specified Severity

HEALTH GUARD GOLD PLAN

11. Congenital Anomaly

13. Cumulative Bonus

14. Day care centre

15. Day Care Treatment

16. Dental Treatment

17. Dependent child

18. Disclosure to information norm

19. Emergency Care

21. Grace Period

HEALTH GUARD GOLD PLAN

25. Inpatient Care

26. Injury/ Bodily Injury

27. Intensive Care Unit

28. Kidney Failure Requiring Regular Dialysis

29. Limit of Indemnity

31. New Born Baby

32. Medical Advise

HEALTH GUARD GOLD PLAN

34. Medical Practitioner/ Physician/ Doctor:

35. Medically Necessary

36. Named Insured / Insured:

37. Non- Network

38. Notification of Claim

39. OPD treatment

42. Pre-Existing Disease

43. Pre-hospitalization Medical Expenses

44. Post-hospitalization Medical Expenses

HEALTH GUARD GOLD PLAN

46. Reasonable and Customary Charges

47. Room rent

49. Surgery or Surgical Procedure

50. Schedule means the schedule and any annexure to it.

51. Unproven/Experimental treatment

HEALTH GUARD GOLD PLAN

II. GENERAL EXCLUSIONS

HEALTH GUARD GOLD PLAN

17. Experimental, unproven or non-standard treatment

20. All non-medical Items as per Annexure II

2. Premium Payment in Instalments (Wherever applicable)