HBPolicy Wording

Heart Beat –
Policy Document
1. Preamble
This ‘Heartbeat’ policy is a contract of insurance between You and Us which is subject to payment of full premium in advance and the terms, conditions and
exclusions of this Policy. This Policy has been issued on the basis of the Disclosure to Information Norm, including the information provided by You in the Proposal
Form and / or the Information Summary Sheet.
Please inform Us immediately of any change in the address or any other changes affecting You or any Insured Person which would impact the benefits,
terms and conditions under this Policy.
In addition, please note the list of exclusions is set out in Section 5 of this Policy.
2. Definitions & Interpretation
For the purposes of interpretation and understanding of this Policy, We have defined, in this Section, some of the important words used in the Policy which will
have the special meaning accorded to these terms for the purposes of this Policy. For the remaining language and words used, the usual meaning as described in
standard English language dictionaries shall apply. The words and expressions defined in the Insurance Act 1938, IRDA Act 1999, regulations notified by the IRDAI
and circulars and guidelines issued by the IRDAI, together with their amendment shall carry the meanings given therein.
Note: Where the context permits, the singular will be deemed to include the plural, one gender shall be deemed to include the other genders and references
to any statute shall be deemed to refer to any replacement or amendment of that statute.
Defined Terms
The terms listed below in this Section and used elsewhere in the Policy in Initial Capitals shall have the meaning set out against them in this Section.
Standard definitions
2.1. Accident or Accidental means a sudden, unforeseen and involuntary event caused by external, visible and violent means.
2.2. 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 is approved.
2.3. Congenital Anomaly means a condition 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.
2.4. 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 claim amount. A Co-payment does not reduce the Sum Insured.
2.5. Cumulative Bonus means any increase or addition in the Sum Insured granted by the insurer without an associated increase in premium.
2.6. Day Care Center means any institution established for Day Care Treatment of Illness and/or Injuries or a medical set-up with a Hospital and which has
been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified Medical Practitioner AND must
comply with all minimum criterion as under:
a. has Qualified Nursing staff under its employment;
b. has qualified Medical Practitioner(s) in charge;
c. has a fully equipped operation theatre of its own where Surgical Procedures are carried out;
d. maintains daily records of patients and will make these accessible to the insurance company’s authorized personnel.
2.7. Day Care Treatment refers to medical treatment, and/or Surgical Procedure which is:
a. undertaken under General or Local Anaesthesia in a Hospital/Day Care Center in less than 24 hrs because of technological advancement, and
b. which would have otherwise required a Hospitalization of more than 24 hours.
Treatment normally taken on an OPD basis is not included in the scope of this definition.
Product Name: Heart Beat | Product UIN: NBHHLIP23113V072223

2.8. Deductible means a cost-sharing requirement under a health insurance policy that provides that the Insurer will not be liable for a specified rupee
amount in case of indemnity policies and for a specified number of days/hours in case of hospital cash policies which will apply before any benefits are
payable by the insurer. A deductible does not reduce the Sum Insured.
2.9. Dental Treatment means a treatment related to teeth or structures supporting teeth including examinations, fillings (where appropriate), crowns,
extractions and Surgery.
2.10. Domiciliary Hospitalization means medical treatment for an Illness/disease/Injury which in the normal course would require care and treatment at a
Hospital but is actually taken while confined at home under any of the following circumstances:
a. the condition of the patient is such that he/she is not in a condition to be removed to a Hospital, or
b. the patient takes treatment at home on account of non availability of room in a Hospital.
2.11. Hospital (within India) means any institution established for Inpatient 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:
a. has Qualified Nursing staff under its employment round the clock;
b. has at least 10 Inpatient beds in towns having a population of less than 10,00,000 and at least 15 Inpatient beds in all other places;
c. has qualified Medical Practitioner(s) in charge round the clock;
d. has a fully equipped operation theatre of its own where Surgical Procedures are carried out;
e. maintains daily records of patients and makes these accessible to the Insurance company’s authorized personnel.
2.12. Hospitalization or Hospitalized means the admission in a Hospital for a minimum period of 24 consecutive Inpatient Care hours except for specified
procedures/treatments, where such admission could be for a period of less than 24 consecutive hours.
2.13. ICU (Intensive Care Unit) Charges means the amount charged by a Hospital towards ICU expenses which shall include the expenses for ICU bed, general
medical support services provided to any ICU patient including monitoring devices, critical care nursing and intensivist charges.
2.14. 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:
i. it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /or tests
ii. it needs ongoing or long-term control or relief of symptoms
iii. it requires rehabilitation for the patient or for the patient to be specially trained to cope with it
iv. it continues indefinitely
v. it recurs or is likely to recur
2.15. 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.
2.16. Inpatient Care means treatment for which the Insured Person has to stay in a Hospital for more than 24 hours for a covered event.
2.17. 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.
2.18. Maternity Expense shall include:
a. Medical Treatment Expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during Hospitalization);
b. Expenses towards lawful medical termination of pregnancy during the Policy Period.
2.19. Medical Advice means any consultation or advice from a Medical Practitioner including the issuance of any prescription or follow-up prescription.

2.20. Medical Expenses means those expenses that an Insured Person has necessarily and actually incurred for medical treatment on account of Illness or
Accident on the advice of a Medical Practitioner, as long as these are no more than would have been payable if the Insured Person had not been insured
and no more than other Hospitals or doctors in the same locality would have charged for the same medical treatment.
2.21. 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 the scope and jurisdiction of his licence.
Only for the purposes of any claim or treatment permitted to be made or taken outside India, Medical Practitioner shall mean a general practitioner,
surgeon, anaesthetist or physician who:
a. holds a degree of a recognized institute; and
b. is registered with a Medical Council or equivalent body of the country where the treatment has taken place; and
c. is legally qualified to practice medicine or Surgery in the jurisdiction where he practices.
2.22. Medically Necessary Treatment means any treatment, tests, medication, or stay in Hospital or part of a stay in Hospital which:
a. is required for the medical management of the Illness or Injury suffered by the insured;
b. must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity;
c. must have been prescribed by a Medical Practitioner;
d. must conform to the professional standards widely accepted in international medical practice or by the medical community in India.
2.23. Network Provider means Hospital enlisted by an insurer, TPA or jointly by an insurer and TPA to provide medical services to an insured by a Cashless
Facility.
Only for the purposes of any claim or treatment permitted to be made or taken outside India, Network Provider shall mean the Hospitals that are a part
of the Service Provider’s network, a list of which is available with the Service Provider.
2.24. New Born Baby means baby born during the Policy Period and is aged between 1 day and 90 days, both days inclusive.
2.25. Non-Network means any Hospital, Day Care Center or other provider that is not part of the network.
2.26. Notification of Claim means the process of intimating a claim to the insurer or TPA through any of the recognized modes of communication.
2.27. OPD Treatment means the 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.
2.28. Pre-existing Disease means any condition, ailment, injury or disease

a. That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement or
b. For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy
issued by the insurer or its reinstatement.
2.29. Pre-hospitalization Medical Expenses means medical expenses incurred during pre-defined number of days preceding the hospitalization of the
Insured Person, provided that:
a. Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalization was required, and
b. The Inpatient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.
2.30. 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:
a. Such Medical Expenses are for the same condition for which the Insured Person’s Hospitalization was required, and
b. The Inpatient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.
2.31. Qualified Nurse means a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India.
2.32. 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.
2.33. 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.

2.34. Room Rent means the amount charged by a Hospital towards Room and Boarding expenses and shall include the Associated Medical Expenses.
2.35. 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 or prolongation of life, performed in a Hospital or Day Care Center by a Medical
Practitioner.
Specific Definitions
2.36. Age means age as on last birthday.
2.37. AYUSH Treatment refers to the medical and / or hospitalization treatments given under Ayurveda, Yoga and Naturopathy, Unani, Sidha and Homeopathy
systems.
2.38. AYUSH Hospital:
An AYUSH Hospital is a healthcare facility wherein medical/surgical/para surgical treatment procedures and interventions are carried out by AYUSH
Medical Practitioner(s) comprising of any of the following:
a. Central or State Government AYUSH Hospital; or
b. Teaching Hospital attached to AYUSH College recognized by the Central Government/Central Council of Indian Medicine/Central Council of
Homeopathy; or
c. AYUSH Hospital, standalone or co-located with In-patient healthcare facility of any recognized system of medicine, registered with the local
authorities, wherever applicable, and is under the supervision of a qualified registered AYUSH Medical Practitioner and must comply with all the
following criterion:
I. Having at least 5 in-patient beds
II. Having qualified AYUSH Medical Practitioner in charge round the clock;
III. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures are to be carried out;
IV. Maintaining daily records of the patients and making them accessible to the insurance company’s authorized representative
2.39. Associated Medical Expenses shall include Room Rent, nursing charges, Medical Practitioners’ fees and operation theatre charges
2.40. Base Sum Insured means the amount stated in the Policy Schedule.
2.41. Bone Marrow Transplant is the actual undergoing of a transplant of human bone marrow using haematopoietic stem cells. The undergoing of a
transplant has to be confirmed by a specialist medical practitioner. The following will be excluded:
a. Other stem-cell transplants
b. Where only islets of langerhans are transplanted
2.42. Break in Policy means the period of gap that occurs at the end of the existing policy term, when the premium due for renewal on a given policy is not
paid on or before the premium renewal date or within 30 days thereof.
2.43. Critical Illness, an Illness, medical event or Surgical Procedure specifically defined in Section 4.2.
2.44. Diagnostic Services means those diagnostic tests and exploratory or therapeutic procedures required for the detection, identification and treatment of a
medical condition.
2.45. Emergency means a medical condition or symptom resulting from Illness or Injury which arises suddenly and unexpectedly and requires immediate care
and treatment by a Medical Practitioner to prevent death or serious long term impairment of the Insured Person’s health.
2.46. Emergency Assistance Service Provider means the licensed entity which will provide identified emergency medical assistance and personal services to
people travelling more than 150(one hundred and fifty) kilometers from their declared place of residence in India.
2.47. Evidence Based Clinical Practice means process of making clinical decisions for Inpatient Care using current best evidence in conjugation with clinical
expertise.
2.48. e-Consultation means opinion from a Medical Practitioner 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 the scope and jurisdiction of his license.

2.49. Family Floater Policy means a Policy described as such in the Policy Schedule where the family members (two or more) named in the Policy Schedule
are Insured Persons under this Policy. Only the following family members can be covered under a Family Floater Policy:
a. Insured Person; and/or
b. Insured Person’s legally married spouse (for as long as she/he continues to be married to the Insured Person); and/or
c. Insured Person’s children who are less than 21 years of Age on the commencement of the Policy Period (a maximum 4 children can be covered under
the Policy as Insured Persons).
2.50. Family First Policy means a Policy described as such in the Policy Schedule where You and Your family members named in the Policy Schedule are
insured under this Policy. Only the following family members can be covered under a Family First Policy:
a. Your legally married spouse for as long as Your spouse continues to be married to You;
b. Son;
c. Daughter-in-law as long as Your son continues to be married to Your Daughter-in-law;
d. Daughter;
e. Son-in-law as long as Your daughter continues to be married to Your Son-in-law;
f. Father;
g. Mother;
h. Father-in-law as long as Your spouse continues to be married to You;
i. Mother-in-law as long as Your spouse continues to be married to You;
j. Grandfather;
k. Grandmother;
l. Grandson;
m. Granddaughter;
n. Brother;
o. Sister;
p. Sister-in-law;
q. Brother-in-law;
r. Nephew;
s. Niece.
2.51. First Policy means for the purposes of this Policy the Policy Schedule issued to the Policyholder at the time of inception of the first Policy mentioned in
the Policy Schedule with Us.
2.52. 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.
2.53. Hospital (outside India) means an institution (including nursing homes) established outside India for Inpatient medical care and treatment of sickness
and injuries which has been registered and licensed as such with the appropriate local or other authorities in the relevant area, wherever applicable, and
is under the constant supervision of a Medical Practitioner. The term Hospital shall not include a clinic, rest home, or convalescent home for the addicted,
detoxification centre, sanatorium, old age home.
2.54. Individual Policy means a Policy described as such in the Policy Schedule where the individual named in the Policy Schedule is the Insured Person under
this Policy.
2.55. Information Summary Sheet means the information and details provided to Us or Our representatives over the telephone for the purposes of applying
for this Policy which has been recorded by Us and confirmed by You.
2.56. Inpatient means admission for treatment in a Hospital for more than 24 hours for an Insured Event.
2.57. IRDAI means the Insurance Regulatory and Development Authority of India.
2.58. Insured Event means any event specifically mentioned as covered under this Policy.
2.59. Insured Person means person(s) named as insured persons in the Policy Schedule.

2.60. Medical Record means the collection of information as submitted in claim documentation concerning a Insured Person’s Illness or Injury that is created
and maintained in the regular course of management, made by Medical Practitioners who have knowledge of the acts, events, opinions or diagnoses
relating to the Insured Person’s Illness or Injury, and made at or around the time indicated in the documentation.
2.61. Mental Illness means a substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behaviour, capacity
to recognise reality or ability to meet the ordinary demands of life, mental conditions associated with the abuse of alcohol and drugs, but does not
include mental retardation which is a condition of arrested or incomplete development of mind of a person, specially characterised by subnormality of
intelligence.
2.62. Migration: “Migration” means, the right accorded to health insurance policyholders (including all members under family cover and members of group
health insurance policy), to transfer the credit gained for pre-existing conditions and time bound exclusions, with the same insurer.
2.63. Policy means these terms and conditions, the Policy Schedule (as amended from time to time), Your statements in the Proposal and the Information
Summary Sheet and any endorsements attached by Us to the Policy from time to time.
2.64. Policy Period is the period between the inception date and the expiry date of the Policy as specified in the Policy Schedule or the date of cancellation of
this Policy, whichever is earlier.
2.65. Policy Year means the period of one year commencing on the date of commencement specified in the Policy Schedule or any anniversary thereof.
2.66. Policy Schedule means a certificate issued by Us, and, if more than one, then the latest in time. The Policy Schedule contains details of the Policyholder,
Insured Persons, the Sum Insured and other relevant details related to the coverage.
2.67. Portability Portability means the right accorded to individual health insurance policyholders (including all members under family cover), to transfer the
credit gained for pre-existing conditions and time bound exclusions, from one insurer to another insurer.
2.68. Reimbursement means settlement of claims paid directly by Us to the Policyholder/Insured Person.
2.69. Second Medical Opinion means an alternate evaluation of diagnosis or treatment modalities arranged by Us from a Medical Practitioner related to
Specified Illnesses or planned Surgery or Surgical Procedure which the Insured Person has been diagnosed or advised to undergo during the Policy Year.
The Second Medical Opinion will be arranged by Us solely on the Insured Person’s request.
2.70. Service Provider means any person, organization, institution that has been empanelled with Us to provide services specified under the benefits to the
Insured Person.
2.71. Shared accommodation means a Hospital room with two or more patient beds.
2.72. Single Private Room means an air conditioned room in a Hospital where a single patient is accommodated and which has an attached toilet (lavatory
and bath). Such room type shall be the most basic and the most economical of all accommodations available as a single occupancy room in that
Hospital.
2.73. Specified Illness means the following Illnesses or procedures:

a. Cancer:
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.
b. Myocardial Infarction (First Heart Attack of specific severity):
i. The first occurrence of heart attack or myocardial infarction, which means the death of a portion of the heart muscle as a result of inadequate
blood supply to the relevant area. The diagnosis for Myocardial Infarction should be evidenced by all of the following criteria:
i. A history of typical clinical symptoms consistent with the diagnosis of acute myocardial infarction (For e.g. typical chest pain)
ii. New characteristic electrocardiogram changes
iii. Elevation of infarction specific enzymes, Troponins or other specific biochemical markers.
ii. The following are excluded:
i. Other acute Coronary Syndromes
ii. Any type of angina pectoris
iii. A rise in cardiac biomarkers or Troponin T or I in absence of overt ischemic heart disease OR following an intra-arterial cardiac procedure.
c. Open Chest CABG:

I. The actual undergoing of heart surgery to correct blockage or narrowing in one or more coronary artery(s), by coronary artery bypass grafting
done via a sternotomy (cutting through the breast bone) or minimally invasive keyhole coronary artery bypass procedures. The diagnosis must
be supported by a coronary angiography and the realization of surgery has to be confirmed by a cardiologist.
II. The following are excluded:
i. Angioplasty and/or any other intra-arterial procedures
d. Major Organ/Bone Marrow Transplant:
I. The actual undergoing of a transplant of:
i. One of the following human organs: heart, lung, liver, kidney, pancreas, that resulted from irreversible end-stage failure of the relevant
organ, or
ii. Human bone marrow using haematopoietic stem cells. The undergoing of a transplant has to be confirmed by a specialist medical
practitioner.
i. Other stem-cell transplants
ii. Where only islets of langerhans are transplanted
e. Stroke Resulting in Permanent Symptoms:
Any cerebrovascular incident producing permanent neurological sequelae. This includes infarction of brain tissue, thrombosis in an intracranial vessel,
haemorrhage and embolisation from an extracranial source.
Diagnosis has to be confirmed by a specialist medical practitioner and evidenced by typical clinical symptoms as well as typical findings in CT Scan
or MRI of the brain.
Evidence of permanent neurological deficit lasting for atleast 3 months has to be produced.
The following are excluded:
i. Transient ischemic attacks (TIA)
ii. Traumatic Injury of the brain
iii. Vascular disease affecting only the eye or optic nerve or vestibular functions
f. Surgery of Aorta:
Surgery of aorta including graft, insertion of stents or endovascular repair.
Specific Exclusion: Surgery for correction of an underlying Congenital Anomaly.
g. Angioplasty:
I. Coronary Angioplasty is defined as percutaneous coronary intervention by way of balloon angioplasty with or without stenting for treatment
of the narrowing or blockage of minimum 50 % of one or more major coronary arteries. The intervention must be determined to be medically
necessary by a cardiologist and supported by a coronary angiogram (CAG).
II. Coronary arteries herein refer to left main stem, left anterior descending, circumflex and right coronary artery.
III. Diagnostic angiography or investigation procedures without angioplasty/stent insertion are excluded.
h. Primary (Idiopathic) Pulmonary Hypertension:
I. An unequivocal diagnosis of Primary (Idiopathic) Pulmonary Hypertension by a Cardiologist or specialist in respiratory medicine with evidence
of right ventricular enlargement and the pulmonary artery pressure above 30 mm of Hg on Cardiac Cauterization. There must be permanent
irreversible physical impairment to the degree of at least Class IV of the New York Heart Association Classification of cardiac impairment.
II. The NYHA Classification of Cardiac Impairment are as follows:
i. Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms.
ii. Class IV: Unable to engage in any physical activity without discomfort. Symptoms may be present even at rest.
III. Pulmonary hypertension associated with lung disease, chronic hypoventilation, pulmonary thromboembolic disease, drugs and toxins, diseases
of the left side of the heart, congenital heart disease and any secondary cause are specifically excluded.
i. Brain Surgery:

Any brain (intracranial) Surgery required to treat traumatic or non-traumatic conditions.
Specific Exclusion: Surgery for treating Neurocysticercosis.
2.74. Standby Services are services of another Medical Practitioner requested by treating Medical Practitioner and involving prolonged attendance without
direct (face-to-face) patient contact or involvement.
2.75. Suite Room means
a. a space available for boarding in a Hospital which contains two or more rooms; Or
b. a space available for boarding in a Hospital which contains an extended living/dining/kitchen area
2.76. Sum Insured
In case of Individual Policy, Sum Insured means the total of the Base Sum Insured, Loyalty Additions and re-fill amount, which is Our maximum, total and
cumulative liability for any and all claims during the Policy Year in respect of the Insured Person.
In case of Family Floater Policy, Sum Insured means the total of the Base Sum Insured, Loyalty Additions and re-fill amount, which is Our maximum, total
and cumulative liability for any and all claims during the Policy Year in respect of all Insured Persons.
In case of Family First Policy, Sum Insured means the total of the Base Sum Insured for each Insured Person, the Loyalty Additions for each Insured Person
and the Floater Sum Insured specified in the Policy Schedule which is Our maximum, total and cumulative liability for any and all claims during the Policy
Year in respect of each Insured Person. For aforesaid purposes:
a. The Base Sum Insured stated in the Policy Schedule for each Insured Person is available for claims in respect of that Insured Person only, during the
Policy Year.
b. If the Base Sum Insured for an Insured Person is exhausted due to payment of claims, then that Insured Person may utilise the Floater Sum Insured
stated in the Policy Schedule for any claims arising in that Policy Year. In the event of a claim being admitted from the Floater Sum Insured, the Floater
Sum Insured shall stand correspondingly reduced by the amount of claim paid (including ‘taxes’) or admitted and only the remaining amount of the
Floater Sum Insured shall be available for claims arising in that Policy Year in respect of the Insured Persons who have exhausted their Base Sum
Insured during that Policy Year.
c. The total of the Base Sum Insured for all Insured Persons, the Loyalty Additions for all Insured Persons and the Floater Sum Insured specified in the
Policy Schedule is Our maximum, total and cumulative liability for all claims during a Policy Year in respect of all Insured Persons.
If the Policy Period is 2 years, then the Sum Insured shall be applied separately for each Policy Year in the Policy Period.
2.77. Survival Period means the period, if any, specified under the Policy after the occurrence of an Insured Event that the Insured Person has to survive
before a claim becomes admissible under the Policy.
2.78. Waiting Period means a time-bound exclusion period related to condition(s) specified in the Policy Schedule or the Policy which shall be served before a
claim related to such condition(s) becomes admissible.
2.79. We/Our/Us means Niva Bupa Health Insurance Company Limited.
2.80. You/Your/Policyholder means the person named in the Policy Schedule who has concluded this Policy with Us.

3. Benefits available under the Policy
The benefits available under this Policy are described below.
a. The Policy covers Reasonable and Customary Charges incurred towards medical treatment taken by the Insured Person during the Policy Period for an
Illness, Injury or condition as described in the sections below and contracted or sustained during the Policy Period. The benefits listed in the sections below
will be payable subject to the terms, conditions and exclusions of this Policy and the availability of the Sum Insured and any sub-limits for the benefit as
maybe specified in the Policy Schedule.
b. All the benefits (including optional benefits) which are available under the Policy along with the respective limits / amounts applicable based on the Sum
Insured have been summarized in the Product Benefit Table in Annexure II
c. The expenses that are not covered or subsumed into room charges/ procedure charges/ costs of treatment are mentioned in Annexure VI
d. All claims under the Policy must be made in accordance with the process defined under Section 6.2.16 (Claim Process & Requirements).
e. All claims paid under any benefit except for those admitted under Section 3.11 (Health Check-up), Section 3.13 (Pharmacy and diagnostic services), Section
3.16 (Emergency Assistance Services except Medical Evacuation), Section 3.18 (Second Medical Opinion), Section 4.1 (Personal Accident Cover), Section
4.2 (Critical Illness Cover), Section 4.3 (e-Consultation), Section 4.4 (Premium Waiver) and Section 4.5 (Hospital Cash) shall reduce the Sum Insured for
the Policy Year in which the Insured Event in relation to which the claim is made has been occurred, unless otherwise specified in the respective section.
Thereafter only the balance Sum Insured after payment of claim amounts admitted shall be available for future claims arising in that Policy Year.
3.1. Inpatient Care
What is covered:
We will indemnify the Medical Expenses incurred for one or more of the following due to the Insured Person’s Hospitalization during the Policy Period
following an Illness or Injury:
a. Room Rent: Room boarding and nursing charges during Hospitalization as charged by the Hospital where the Insured Person availed medical
treatment;
b. Medical Practitioners’ fees, excluding any charges or fees for Standby Services;
c. Investigative tests or diagnostic procedures directly related to the Insured Event which led to the current Hospitalization;
d. Medicines, drugs as prescribed by the treating Medical Practitioner related to the Insured Event that led to the current Hospitalization;
e. Intravenous fluids, blood transfusion, injection administration charges, allowable consumables, and/or enteral feedings;
f. Operation theatre charges;
g. The cost of prosthetics and other devices or equipment, if implanted internally during Surgery;
h. Intensive Care Unit Charges.
Conditions - The above coverage is subject to fulfillment of following conditions:

a. The Hospitalization is for Medically Necessary Treatment and advised in writing by a Medical Practitioner.
b. If the Insured Person is admitted in a Hospital room where the room category opted or Room Rent incurred is higher than the eligibility as specified
in the Policy Schedule, then We shall be liable to pay only a pro-rated portion of the total Associated Medical Expenses (including surcharge or taxes
thereon) as per the following formula:
(Eligible Room Rent limit / Room Rent actually incurred) * total Associated Medical Expenses
Associated Medical Expenses shall include Room Rent, nursing charges, Medical Practitioners’ fees and operation theatre charges
c. We will pay the visiting fees or consultation charges for any Medical Practitioner visiting the Insured Person only if:
i. The Medical Practitioner’s treatment or advice has been specifically sought by the Hospital; and
ii. The visiting fees or consultation charges are included in the Hospital’s bill
3.2. Pre-hospitalization Medical Expenses
What is covered:
We will indemnify on Reimbursement basis only, the Insured Person’s Pre-hospitalization Medical Expenses incurred in respect of an Illness or Injury.
Conditions - The above coverage is subject to fulfilment of following conditions:

a. We have accepted a claim under Section 3.1 (Inpatient Care) or Section 3.4 (Day Care Treatment) or Section 3.5 (Domiciliary Hospitalization) or
Section 3.6 (Alternative Treatments) or Section 3.24 (Modern Treatments)

b. Pre-hospitalization Medical Expenses are incurred for the same condition for which We have accepted the Inpatient Care or Day Care Treatment or
Domiciliary Hospitalization or Alternative Treatments or Modern Treatments claim.
c. The expenses are incurred after the inception of the First Policy with Us. If any portion of these expenses is incurred before the inception of the First
Policy with Us, then We shall be liable only for those expenses incurred after the commencement date of the First Policy, irrespective of the initial
waiting period.
d. Pre-hospitalization Medical Expenses incurred on physiotherapy will also be payable provided that such physiotherapy is prescribed in writing by the
treating Medical Practitioner as Medically Necessary Treatment and is directly related to the same condition that led to Hospitalization.
e. Any claim admitted under this Section 3.2 shall reduce the Sum Insured for the Policy Year in which In-patient Care or Day Care Treatment or
Domiciliary Hospitalization or Alternative Treatments or Modern Treatments claim has been incurred.
Sub-limit:
a. We will pay above mentioned Pre-hospitalization Medical Expenses only for period up to 60 days immediately preceding the Insured Person’s
admission for Inpatient Care or Day Care Treatment or Domiciliary Hospitalization or Alternative Treatments or Modern Treatments.
3.3. Post-hospitalization Medical Expenses
What is covered:
We will indemnify on Reimbursement basis only, the Insured Person’s Post-hospitalization Medical Expenses incurred following an Illness or Injury.

a. We have accepted a claim under Section 3.1 (Inpatient Care) or Section 3.4 (Day Care Treatment) or Section 3.5 (Domiciliary Hospitalization) or
Section 3.6 (Alternative Treatments) or Section 3.24 (Modern Treatments)
b. Post-hospitalization Medical Expenses are incurred for the same condition for which We have accepted the Inpatient Care or Day Care Treatment or
Domiciliary Hospitalization or Alternative Treatments or Modern Treatments claim.
c. The expenses incurred shall be as advised in writing by the treating Medical Practitioner.
d. Post-hospitalization Medical Expenses incurred on physiotherapy will also be payable provided that such physiotherapy is prescribed in writing by
the treating Medical Practitioner as Medically Necessary Treatment and is directly related to the same condition that led to Hospitalization.
e. Any claim admitted under this Section 3.3 shall reduce the Sum Insured for the Policy Year in which In-patient Care or Day Care Treatment or
Domiciliary Hospitalization or Alternative Treatments or Modern Treatments claim has been incurred.
Sub-limit:
a. We will pay Post-hospitalization Medical Expenses only for up to 90 days immediately following the Insured Person’s discharge from Hospital or Day
Care Treatment or Domiciliary Hospitalization or Alternative Treatments or Modern Treatments.
3.4. Day Care Treatment
What is covered:
We will indemnify the Medical Expenses incurred on the Insured Person’s Day Care Treatment during the Policy Period following an Illness or Injury. List of
Day Care Treatments which are covered under the Policy are provided in Annexure III.

a. The Day Care Treatment is advised in writing by a Medical Practitioner as Medically Necessary Treatment.
b. Only those Day Care Treatments are covered that are mentioned under list of Day Care Treatments under Annexure III.
c. If We have accepted a claim under this benefit, We will also indemnify the Insured Person’s Pre-hospitalization Medical Expenses and Post-
hospitalization Medical Expenses in accordance with Sections 3.2 and 3.3 above.
What is not covered:

OPD Treatment and Diagnostic Services costs are not covered under this benefit.
3.5. Domiciliary Hospitalization
What is covered:
We will indemnify on Reimbursement basis only, the Medical Expenses incurred for the Insured Person’s Domiciliary Hospitalization during the Policy
Period following an Illness or Injury.

a. The Domiciliary Hospitalization continues for at least 3 consecutive days in which case We will make payment under this benefit in respect of Medical
Expenses incurred from the first day of Domiciliary Hospitalization;
b. The treating Medical Practitioner confirms in writing that the Insured Person’s condition was such that the Insured Person could not be transferred to
a Hospital OR the Insured Person satisfies Us that a Hospital bed was unavailable.
c. If We have accepted a claim under this benefit, We will also indemnify the Insured Person’s Pre-hospitalization Medical Expenses and Post-
hospitalization Medical Expenses in accordance with Sections 3.2 and 3.3 above.
3.6. Alternative Treatments
What is covered:
We will indemnify the Medical Expenses incurred on the Insured Person’s Hospitalization for Inpatient Care during the Policy Period on treatment taken
under Ayurveda, Unani, Siddha and Homeopathy.

The treatment should be taken in AYUSH Hospital.
a. Pre-hospitalization Medical Expenses incurred for up to 60 days immediately preceding the Insured Person’s admission and Post-hospitalization
Medical Expenses incurred for up to 90 days immediately following the Insured Person’s discharge will also be indemnified under this benefit in
accordance with Sections 3.2 and 3.3 above, provided that these Medical Expenses relate only to Alternative Treatments and not Allopathy.
b. Section 5.2.12 of the Permanent Exclusions (other than for Yoga) shall not apply to the extent this benefit is applicable.
3.7. Living Organ Donor Transplant
What is covered:
We will indemnify the Medical Expenses incurred for a living organ donor’s treatment as an Inpatient for the harvesting of the organ donated.

a. The donation conforms to the Transplantation of Human Organs Act 1994 and any amendments thereafter and the organ is for the use of the Insured
Person.
b. The organ transplant is certified in writing by a Medical Practitioner as Medically Necessary Treatment for the Insured Person.
c. We have accepted the recipient Insured Person’s claim under Section 3.1 (Inpatient Care).

a. Stem cell donation whether or not it is Medically Necessary Treatment except for Bone Marrow Transplant.
b. Pre-hospitalization Medical Expenses or Post-hospitalization Medical Expenses of the organ donor.
c. Screening or any other Medical Expenses related to the organ donor, which are not incurred during the duration of Insured Person’s Hospitalization
for organ transplant.
d. Transplant of any organ/tissue where the transplant is Unproven/Experimental Treatment or investigational in nature.
e. Expenses related to organ transportation or preservation.
f. Any other medical treatment or complication in respect of the donor, which is directly or indirectly consequence to harvesting.
3.8. Emergency Ambulance
What is covered:
We will indemnify the costs incurred, on transportation of the Insured Person by road Ambulance to a Hospital for treatment in an Emergency following
an Illness or Injury.

a. The medical condition of the Insured Person requires immediate ambulance services from the place where the Insured Person is injured or is ill to a
Hospital where appropriate medical treatment can be obtained or;
b. The medical condition of the Insured Person requires immediate ambulance services from the existing Hospital to another Hospital with advanced
facilities as advised by the treating Medical Practitioner for management of the current Hospitalization.
c. This benefit is available for only one transfer per Hospitalization.
d. The ambulance service shall be offered by a healthcare or ambulance Service Provider.

e. We have accepted a claim under Section 3.1 (Inpatient Care) above.
f. We will cover expenses up to the amount specified in Your Policy Schedule.

The Insured Person’s transfer to any Hospital or diagnostic centre for evaluation purposes only.
3.9. Maternity Benefit
What is covered:
We will indemnify the Maternity Expenses incurred during the Policy Period.

a. This benefit is available only if:
i. The female Insured Person of Age 18 years or above is covered under a Family First Policy; or
ii. Both the Insured Person and his / her legally married spouse are covered under a Family Floater Policy.
b. This Benefit cannot be availed under an Individual Policy.
c. The female Insured Person in respect of whom a claim for Maternity Benefits is made must have been covered as an Insured Person for a period of 24
months of continuous coverage since the inception of the First Policy, with maternity as a benefit, with Us.
d. For the purposes of this benefit, We shall consider any eligibility period for maternity benefits served by the Insured Person under any previous policy
with Us.
e. The Maternity Expenses incurred are Reasonable and Customary Charges.
f. The Maternity Benefit may be claimed under the Policy in respect of eligible Insured Person(s) only twice during the lifetime of the Policy including
any Renewal thereafter for the delivery of a child or Medically Necessary and lawful termination of pregnancy up to maximum 2 pregnancies or
terminations.
g. Any treatment related to the complication of pregnancy or termination will be treated within the maternity sub limits.
h. On Renewal or incase of internal Portability, if an enhanced sub-limit is applicable under this benefit, 24 months of continuous coverage (as per
Section 3.9.c) would apply afresh to the extent of the increased benefit amount.
i. Clause 5.1.2.14, 5.1.2.15 under Permanent Exclusions is superseded to the extent covered under this Benefit.

a. Expenses incurred in respect of the harvesting and storage of stem cells for any purposes whatsoever;
b. Medical Expenses for ectopic pregnancy will be covered under the Section 3.1 (Inpatient Care) and shall not fall under the Maternity Benefit.
c. Sections 3.2 (Pre-hospitalization Medical Expenses) and Section 3.3 (Post- hospitalization Medical Expenses) are not payable under this benefit.
d. Any expenses to manage complications arising from or relating to pregnancy or termination of pregnancy within 24 months from the inception of
the First Policy with Us.
e. Pre-natal and post-natal Medical Expenses.
3.10. New Born Baby
What is covered:
We will cover the Medical Expenses incurred towards the medical treatment of the Insured Person’s New Born Baby from the date of delivery until the
expiry of the Policy Year, subject to continuous coverage of 24 months of that Insured Person since the inception of the First Policy which offers Maternity
Benefit with Us, without the requirement of payment of any additional premium

a. All the terms and conditions mentioned in Section 3.9 (Maternity Benefit) shall apply to this benefit as well.
b. The New Born Baby should be added as an endorsement within 90 days from date of delivery
c. We will indemnify the Reasonable and Customary Charges for Medical Expenses incurred for the below vaccination of the New Born Baby till the New
Born Baby completes one year from his/her birth.

Time interval Vaccination to be done (Age) Frequency
BCG (From birth to 1 weeks) 1
OPV (1 week) + IPV1 (6 week,10 weeks) 3
DPT (6& 10 week) 2
0-3 months
Hepatitis-B (0 & 6 week,) 2
Haemophilus influenzae type B (Hib) (6 & 10 Week) 2
Rota (6 & 10 Week) 2
OPV (6 month) + IPV (14 week) 2
DPT (14 week) 1
3-6 months Hepatitis-B (6 month) 1
Haemophilus influenzae type B (Hib) (14 week) 1
Rota (14 week) 1
MMR ( 9 Months) 1
9 months OPV (9 Months) 1
Typhoid(12 Months) 1
12 months Hepatitis A (12 Months) 1
d. If the Policy expires before the New Born Baby has completed one year, then Medical Expenses for balance vaccination shall not be covered and will
be covered only if the Policy is Renewed with the New Born Baby as an Insured Person and not otherwise.
e. On the expiry of the Policy Year We will cover the baby as an Insured Person under the Policy on request of the Proposer, subject to Our underwriting
policy and payment of the applicable additional premium.
3.11. Health Check-up
What is covered:
The Insured Person may avail a health check-up, only for Diagnostic Tests, up to a sub-limit as per the Plan applicable to the Insured Person as specified
in the Product Benefits Table.
Note – In case of silver plan, a pre-defined set of tests can be availed by the Insured Person. A list of eligible tests is attached in Annexure – IV.

a. Health check-up will be available on Cashless Facility basis only and will be arranged at Our empanelled Service Providers.

Any unutilized test or amount cannot be carried forward to the next Policy Year.
3.12. Re-fill Benefit
What is covered:
If the Base Sum Insured and increased Sum Insured under Loyalty Additions (Section 3.14) (if any) has been partially or completely exhausted due to claims
paid or accepted as payable for any Illness / Injury during the Policy Year under Section 3.1 or Section 3.4 or Section 3.5 or Section 3.6 or Section 3.7 or
Section 3.24, then We will provide an additional re-fill amount of maximum up to 100% of the Base Sum Insured.

a. The re-fill amount shall be utilized only for subsequent claims under Section 3.1 (In-patient Care) or Section 3.4 (Day Care Treatment) or Section
3.5 (Domiciliary Hospitalization) or Section 3.6 (Alternative Treatments) or Section 3.7 (Living Organ Donor Transplant) or Section 3.24 (Modern
Treatments) arising in that Policy Year for any or all Insured Person(s).
b. We will provide a re-fill amount only once in a Policy Year.
c. For Family Floater Policies, the re-fill amount will be available on a floater basis to all Insured Persons in that Policy Year.

a. If the re-fill amount is not utilized in whole or in part in a Policy Year, it cannot be carried forward to any extent in any subsequent Policy Year.
b. This benefit is not available under Family First Policy.
3.13. Pharmacy and Diagnostic Services
What is covered:
You may purchase medicines or avail diagnostic services from Our Service Provider through Our website or mobile application.

a. The cost for the purchase of the medicines or for availing diagnostic services shall be borne by You.
b. Further it is made clear that purchase of medicines from Our Service Provider is Your absolute discretion and choice.
3.14. Loyalty Additions
What is covered:
a. For an Individual Policy or Family Floater Policy, if the Policy is Renewed with Us without a break or if the Policy continues to be in force for the 2nd
Policy Year in the 2 year Policy Period respectively (if applicable), We will provide Loyalty Additions in the form of Cumulative Bonus by increasing
the Sum Insured applicable under the Policy by 10% of the Base Sum Insured of the immediately preceding Policy Year subject to a maximum of a
percentage as specified in the Policy Schedule. There will be no change in the sub-limits applicable to various benefits due to increase in Sum Insured
under this benefit.
b. For a Family First Policy, if the Policy is Renewed with Us without a break or if the Policy continues to be in force for the 2nd Policy Year in the 2 year
Policy Period respectively (if applicable), We will provide Loyalty Additions in the form of Cumulative Bonus by increasing the Sum Insured applicable
under the Policy by 10% of the Base Sum Insured of the immediately preceding Policy Year of each individual Insured Person only subject to a
maximum of a percentage as specified in the Policy Schedule. The increase shall not apply to the Floater Sum Insured stated in the Policy Schedule
as applicable under the Policy. There will be no change in the sub-limits applicable to any benefit due to increase in Sum Insured under this benefit.

a. If the Insured Person in the expiring Policy is covered under an Individual Policy and has an accumulated Cumulative Bonus in the expiring Policy
under this benefit, and such expiring Policy is Renewed with Us on a Family Floater Policy, then We will provide the credit for the accumulated
Cumulative Bonus to the Family Floater Policy.
b. If the Insured Person in the expiring Policy is covered under an Individual Policy and has an accumulated Cumulative Bonus in the expiring Policy
under this benefit, and such expiring Policy is Renewed with Us on a Family First Policy, then the accumulated Cumulative Bonus to be carried forward
for credit in the Renewing Policy would be the accumulated Cumulative Bonus for that Insured Person only.
c. If the Insured Persons in the expiring Policy are covered under a Family First Policy and have an accumulated Cumulative Bonus for each Insured
Person in the expiring Policy under this benefit, and such expiring Policy is Renewed with Us on a Family Floater Policy with same or higher Base
Sum Insured, then the accumulated Cumulative Bonus to be carried forward for credit in the Renewing Policy would be the least of the accumulated
Cumulative Bonus amongst all the Insured Persons.
d. If the Insured Persons in the expiring Policy are covered under a Family First Policy and have an accumulated Cumulative Bonus for each Insured
Person in the expiring Policy under this benefit, and such expiring Policy is Renewed with Us on an Individual Policy with same or higher Base Sum
Insured, then the accumulated Cumulative Bonus to be carried forward for credit in the Renewing Policy would be the accumulated Cumulative Bonus
for that Insured Person.
e. If the Insured Persons in the expiring Policy are covered on a Family Floater Policy and such Insured Persons Renew their expiring Policy with Us by
splitting the Floater Sum Insured stated in the Policy Schedule in to two or more floater / individual / Family First Policy, then We will provide the
credit of the accumulated Cumulative Bonus to the split Policy reduced proportionately.
f. If the Insured Persons covered on a Family Floater Policy are reduced at the time of Renewal, the applicable accumulated Cumulative Bonus shall also
be reduced proportionately.
g. In case the Base Sum Insured under the Policy is reduced at the time of Renewal, the applicable accumulated Cumulative Bonus shall also be reduced
in proportion to the Base Sum Insured. The maximum reduction in the accumulated Cumulative Bonus shall be limited to 50% of the accumulated
Cumulative Bonus. Post reduction in the Base Sum Insured and the accumulated Cumulative Bonus, if the accumulated Cumulative Bonus is equal
to or more than 100% of the revised Base Sum Insured, then there will be no further increase in the accumulated Cumulative Bonus upon Renewal
of such Policy.
h. In case the Base Sum Insured under the Policy is increased at the time of Renewal, the applicable accumulated Cumulative Bonus shall also be
increased in proportion to the Base Sum Insured. The maximum increase in the accumulated Cumulative Bonus shall be limited to 50% of the

accumulated Cumulative Bonus. Post increase in the Base Sum Insured and the accumulated Cumulative Bonus, if the accumulated Cumulative Bonus
is equal to or more than 100% of the revised Base Sum Insured, then there will be no further increase in the accumulated Cumulative Bonus upon
Renewal of such Policy.
i. This benefit is not applicable for Health Check-up, Pharmacy & diagnostic services, Emergency assistance services, Second Medical Opinion, Child
care benefits and any of the optional benefits (if opted for). Enhancement of Sum Insured due to Loyalty Additions benefit cannot be utilized for the
aforementioned benefits.
3.15. HIV / AIDS
What is covered:
We will indemnify the expenses incurred by the Insured Person for Hospitalization (including Day Care Treatment) due to condition caused by or associated
with HIV / AIDS up to the limit as specified in Your Policy Schedule.

a. The Hospitalization or Day Care Treatment is Medically Necessary and the Illness is the outcome of HIV / AIDS. This needs to be prescribed in writing
by a registered Medical Practitioner.
b. The coverage under this benefit is provided for opportunistic infections which are caused due to low immunity status in HIV / AIDS resulting in acute
infections which may be bacterial, viral, fungal or parasitic.
c. The patient should be a declared HIV positive.
d. This benefit is provided subject to a Waiting Period of 48 months from inception of the cover with Us, with HIV / AIDS covered as a benefit, for the
respective Insured Person.
e. Pre-hospitalization Medical Expenses incurred for up to 60 days, if falling within the Policy Period, immediately preceding the Insured Person’s
admission and Post-hospitalization Medical Expenses incurred for up to 90 days, if falling within the Policy Period, immediately following the Insured
Person’s discharge will also be indemnified under this benefit as per Section 3.2 & Section 3.3 respectively.

a. Chronic health conditions including ischemic heart disease, chronic liver disease, chronic kidney disease, cerebro-vascular disease/ stroke, bronchial
asthma and neoplasms which are not directly related to the patient’s immunity status would not be covered under this benefit.
b. Lifestyle diseases like diabetes, hypertension, heart diseases and dyslipidemia which are not related to HIV / AIDS would not be covered under this
benefit.
Sub-limit:
a. This benefit is covered up to a limit of Rs. 50,000.
b. Pre-hospitalization and Post-hospitalization Medical Expenses are also covered within the overall benefit sub-limit as specified above in point (a).
3.16. Emergency Assistance Services
What is covered:
This Policy provides a host of value added Emergency Medical Assistance and Emergency personal services as described below, on Cashless Facility basis.
a. Medical referral: Insured Person(s) will have tele-access to an operations center of Our Service Provider, who with their multilingual staff on duty
24(twenty-four) hours a day, 365(three hundred and sixty-five) days a year will provide reference of doctors in the vicinity where the Insured Person
is located for medical consultations. This medical consultation is only facilitated by Us / Our Service Provider and is independent judgment of medical
consultant. We do not assume any liability and shall not be deemed to assume any liability towards any loss or damage arising out of or in relation
to any opinion, advice, prescription, actual or alleged errors, omissions and representations made by the professional giving medical consultant.
b. Emergency medical evacuation: When an adequate medical facility is not available proximate to the Insured Person, as determined by the Insured
Person’s attending physician and agreed by Us / Our Service Provider, We/Our Service Provider will arrange and pay for ambulance services under
appropriate medical supervision, by an appropriate mode of transport as decided by Us / Our Service Provider’s consulting physician and patient’s
attending physician to the nearest medical facility capable of providing the required care.
c. Medical repatriation: We / Our Service Provider will arrange and pay for transportation under medical supervision to the Insured Person’s residence
or to a medical or rehabilitation facility near the Insured Person’s residence (as mentioned in the Policy Schedule) when the Insured Person’s attending
physician determines that transportation is medically necessary and is agreed by Us / Our Service Provider, at such time as the Insured Person is
medically cleared for travel by Us / Our Service Provider’s consulting physician and Insured Person’s attending physician.
d. Compassionate visit: When an Insured Person will be hospitalized for more than seven (7) consecutive days and has travelled without a companion
or doesn’t have a companion by his / her side, We / Our Service Provider will arrange and pay for travel of a family member or personal friend to
visit such Insured Person by providing an appropriate means of transportation via economy carrier transportation as determined by Us / Our Service
Provider. The family member or the personal friend is responsible to meet all travel document requirements, as may be applicable.

e. Care and/or transportation of minor children: One-way economy common carrier transportation, with attendants if required, will be provided to the
place of residence of minor child(ren) when they are left unattended as a result of medical emergency or death of an Insured person.
f. Return of mortal remains: In the event of death of Insured Person, We/Our Service Provider will arrange and pay for the return of mortal remains to
an authorized funeral home proximate to the Insured Person’s legal residence.
Conditions - Any coverage under this section 3.16 is subject to fulfilment of following conditions:
a. The services are provided when Insured Person(s) is/are traveling within India to a place which is at a minimum distance of 150(one hundred and
fifty) kilometers or more away from the residential address as mentioned in the Policy Schedule, and the travel is for less than 90(ninety) days period.

a. No claims for Reimbursement of expenses incurred for services arranged by Insured/Insured Person(s) will be entertained as the coverage under this
section 3.16 are on Cashless Facility basis only.
b. Emergency assistance service will not be provided in the following instances:
i. Travel undertaken specifically for securing medical treatment
ii. Services sought outside India.
iii. If Emergency is a result of injuries resulting from participation in acts of war or insurrection
iv. Commission of unlawful act(s).
v. Attempt at suicide /self-inflicted injuries.
vi. Incidents involving the use of drugs, unless prescribed by a physician
vii. Transfer of the insured person from one medical facility to another medical facility of similar capabilities and providing a similar level of care
c. We / Our Service Provider will not evacuate or repatriate an insured person in the following instances:
i. Without medical authorization from attending physician
ii. With mild lesions, simple injuries such as sprains, simple fractures, or mild sickness or similar such conditions which can be treated by local
doctors and do not prevent Insured Person(s) from continuing your trip or returning home as determined by Us / Our Service Provider’s
consulting physician and the Insured Person’s attending physician
iii. If the Insured Person is pregnant and beyond the end of the 28th week and with respect to the child born from the pregnancy, We / Our Service
Provider shall not evacuate or repatriate the Insured Person and the child who was born while the Insured Person was traveling beyond the 28th
week
iv. With mental or nervous disorders unless hospitalized
d. Specific exclusions:
i. Trips exceeding 90(ninety) days from declared residence.
While assistance services are available all over India, transportation response time is directly related to the location / jurisdiction where an event occurs. We
/ Our Service Provider is not responsible for failing to provide services or for delays in the delivery of services caused by reasons beyond Our reasonable
control, including without any limitation, strike, road traffic, the weather conditions, availability and accessibility of airports, flight conditions, availability of
hyperbaric chambers, pandemics and endemics, communications systems, absence of proper travel documents or where rendering of service is limited or
prohibited by local law, edict or regulation. Our / Our Service Provider’s performance of any obligation here in this section 3.16 shall be waived / excused
if such failure to perform is caused by an event, contingency, or circumstance beyond its reasonable control that prevents, hinders or makes impractical
the performance of services. Legal actions arising hereunder shall be barred unless written notice thereof is received by Us / Our Service Provider within
one (1) year from the date of event giving rise to such legal action. All consulting physicians and Our Service Provider are independent contractors and not
under the control of the Company. We / Our Service Provider are not responsible or liable for any service rendered herein through professionals to You.
3.17. Mental Disorders Treatment
What is covered:
We will indemnify the expenses incurred by the Insured Person for Inpatient treatment for Mental Illness up to the limit as specified in Your Policy Schedule.

a. Mental Disorders Treatment is only covered where patient is diagnosed by a qualified psychiatrist or a professional registered with the concerned State
Authority or a professional having a post-graduate degree (Ayurveda) in Mano Vigyan Avum Manas Roga or a post-graduate degree (Homoeopathy)
in Psychiatry or a post-graduate degree (Unani) in Moalijat (Nafasiyatt) or a post-graduate degree (Siddha) in Sirappu Maruthuvam.

b. The Hospitalization is for Medically Necessary Treatment.
c. The treatment should be taken in Mental Health Establishment, including Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy
establishment, by whatever name called, either wholly or partly, meant for the care of persons with mental illness, established, owned, controlled or
maintained by the appropriate Government, local authority, trust, whether private or public, corporation, co-operative society, organization or any
other entity or person, where persons with mental illness are admitted and reside at, or kept in, for care, treatment, convalescence and rehabilitation,
either temporarily or otherwise; and includes any general hospital or general nursing home established or maintained by the appropriate Government,
local authority, trust, whether private or public, corporation, co-operative society, organization or any other entity or person; but does not include a
family residential place where a person with mental illness resides with his relatives or friend.
d. The Insured Person in respect of whom a claim for any expenses or complications arising from Mental Illness is made must have been covered as
an Insured Person for a period of 36 months of continuous coverage since the inception of the First Policy, with Mental Illness as a benefit, with Us.
e. Pre-hospitalization Medical Expenses incurred for up to 60 days, if falling within the Policy Period, immediately preceding the Insured Person’s
admission and Post-hospitalization Medical Expenses incurred for up to 90 days, if falling within the Policy Period, immediately following the Insured
Person’s discharge will also be indemnified under this benefit as per Section 3.2 & Section 3.3 respectively.

a. The condition which is not clinically significant or is related to anxiety, bereavement, relationship or academic problems, acculturation difficulties or
work pressure.
b. Treatment related to intentional self inflicted Injury or attempted suicide by any means.
c. Mental retardation which is a condition of arrested or incomplete development of mind of a person, specially characterized by subnormality of
intelligence.
Sub-limit:
a. The following disorders / conditions shall be covered only up to the limit specified in the Policy Schedule. This sub-limit shall apply for all the following
disorders / conditions on cumulative basis.
Disorder / Condition Description

Severe depression is characterized by a persistent feeling of sadness or a lack of interest in outside stimuli.
Severe Depression
It affects the way one feels, thinks and behaves.
Schizophrenia is mental disorder, that distorts the way a person thinks, acts, expresses emotions, perceives
Schizophrenia reality, and relates to others. Schizophrenia result in combination of hallucinations, delusions, and
extremely disordered thinking and behavior that impairs daily functioning,
Bipolar disorder is a mental illness that brings severe high and low moods and changes in sleep, energy,
Bipolar Disorder
thinking, and behavior. It includes periods of extreme mood swings with emotional highs and lows.
Post-traumatic stress disorder is an anxiety disorder caused by very stressful, frightening or distressing
Post traumatic stress disorder
events. It includes flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event.
Eating disorder is a mental condition where people experience severe disturbances in their eating behaviors
Eating disorder
and related thoughts and emotions.
Generalized Anxiety Disorder is a mental health disorder characterized by a perpetual state of worry, fear,
Generalized anxiety disorder
apprehension, inability to relax.
Obsessive compulsive Obsessive-compulsive disorder is an anxiety disorder in which people have recurring, unwanted thoughts,
disorders ideas or sensations (obsessions) that make them feel driven to do something repetitively (compulsions).
Panic disorder is an anxiety disorder characterized by reoccurring unexpected panic attacks with sudden
Panic disorders periods of intense fear. It may include palpitations, sweating, shaking, shortness of breath, numbness, or a
feeling that something terrible is going to happen.
Personality disorder is a type of mental disorder in which people have a rigid and unhealthy pattern of
Personality disorders
thinking, functioning and behaving. It includes trouble in perceiving and relating to situations and people.
Conversion disorder is a type of mental disorder where mental or emotional distress causes physical
Conversion disorders
symptoms without the existence of an actual physical condition.
Dissociative disorders are mental disorders that involve experiencing a disconnection and lack of continuity
Dissociative disorders
between thoughts, memories, surroundings, actions and identity.
ICD codes for the above disorders / conditions are provided in Annexure V.

b. Pre-hospitalization and Post-hospitalization Medical Expenses are also covered within the overall benefit sub-limit as specified above in point (a).
3.18. Second Medical Opinion
What is covered:
If the Insured Person is diagnosed with a Specified Illness as defined under Section 2.73 or is planning to undergo a planned Surgery or a Surgical Procedure
for any Illness or Injury, the Insured Person can, at the Insured Person’s choice, obtain a Second Medical Opinion during the Policy Period.

a. Our Service Provider is contacted seeking the Second Medical Opinion.
b. The Second Medical Opinion will be arranged by Our Service Provider and will be based only on the information and documentation provided by the
Insured Person that will be shared with the Medical Practitioner.
c. This benefit can be availed only once by an Insured Person during a Policy Year for the same Specified Illness or planned Surgery.
d. By seeking the Second Medical Opinion under this Benefit the Insured Person is not prohibited or advised against visiting or consulting with any other
independent Medical Practitioner or commencing or continuing any treatment advised by such Medical Practitioner.
e. The Insured Person is free to choose whether or not to obtain the Second Medical Opinion, and if obtained then whether or not to act on it in whole
or in part.
f. The Second Medical Opinion under this Benefit shall be limited to defined criteria and not be valid for any medico legal purposes.

We do not assume any liability and shall not be deemed to assume any liability towards any loss or damage arising out of or in relation to any opinion,
advice, prescription, actual or alleged errors, omissions and representations made by the Medical Practitioner.
3.19. Child care Benefits
What is covered:
a. We will indemnify the Reasonable and Customary Charges, once during a Policy Period, incurred for the vaccination of the Insured Persons less than
12 years of Age.
b. We will also cover expenses towards one consultation for nutrition and growth provided to the child during a visit for vaccination.

a. The following vaccinations will be covered under this benefit:
Time interval Vaccination to be done (Age) Frequency

OPV (15 &18 months) 2
DPT (15-18 months) 1
1-2 years
Haemophilus influenzae type B (Hib) (15-18 months) 1
Meningococcal vaccine (24 months) 1
After 10 years Tetanus Toxoide 1
3.20. Specified Illness Cover (outside the geographical boundaries of India)
What is covered:
If an Insured Person suffers a Specified Illness as defined under Section 2.73 during the Policy Period, We will indemnify the Reasonable and Customary
Charges for Medical Expenses of the Insured Person incurred towards treatment of that Specified Illness that would otherwise have been payable under
Section 3.1 (Inpatient Care), on Cashless Facility basis only.

a. The symptoms of the Specified Illness first occur or manifest itself during the Policy Period and after completion of the 90 day from the inception of
b. The Specified Illness is diagnosed by a Medical Practitioner within India during the Policy Period and after completion of the 90 day from the
inception of the First Policy with Us.
c. Medical treatment for the Specified Illness is taken outside India within the Policy Period but only within those regions specified in the Policy Schedule.
d. Clause 5.2.9 under Permanent Exclusions is superseded to the extent covered under this Benefit.

a. Any claims for Reimbursement of the costs incurred in relation to the treatment of the Specified Illness or any claims which are not pre-authorized
by Us.
b. Any costs or expenses incurred in relation to any persons accompanying the Insured Person during any period of treatment, even if such persons are
also Insured Persons.
c. Any costs or expenses incurred on things that are not in direct relation to the Medical Expenses for treatment under this benefit like travel expenses,
etc shall not be covered.
d. Any costs or expenses incurred in relation to personal stay or transportation in the overseas location where treatment is being taken.
e. Sections 3.2 (Pre-hospitalization Medical Expenses) and Section 3.3 (Post- hospitalization Medical Expenses) are not payable under this benefit.
f. Any costs or expenses incurred by any organ donor in relation to harvesting of organs.
g. Any OPD Treatment taken outside India.
3.21. OPD Treatment and Diagnostic Services
What is covered:
We will indemnify the Reasonable and Customary Charges incurred for OPD Treatment and/or Diagnostic Services and/or prescribed medicines for the
OPD Treatment taken during the Policy Period.

a. Expenses under this benefit are covered for ayurvedic or homeopathic or unani or sidha or allopathic services only.
b. For treatment taken under ayurveda, homeopathy, unani or sidha (AYUSH), expenses are covered only if taken in a government Hospital or in any
institute recognized by government and/or accredited by Quality Council of India/National Accreditation Board on Health.
c. The OPD Treatment and/or Diagnostic Services are Medically Necessary and follow the written advice of a Medical Practitioner.
d. Diagnostic Services are performed on an outpatient basis with or without local anesthetics for topical, infiltration, nerve block anesthesia and require
Hospitalization for less than 24 hours.
e. If the Policy is Renewed with Us without any break and there is a unutilized amount (not used by the Insured Person) under the applicable sub-limit
(as specified in the Product Benefits Table) in a Policy Year, then We will carry forward 80% of this unutilized amount to the immediately succeeding
Policy Year, provided that the total amount (including the unutilized amount available under this Benefit) shall at no time exceed 2.5 times the
amount of the entitlement in respect of this Benefit under the Plan applicable to the Insured Person.
3.22. Emergency Medical Evacuation (outside the geographical boundaries of India)
What is covered:
We will indemnify the Reasonable and Customary Charges for the Insured Person’s Medical Evacuation in an Emergency and for which medical facilities are
not available locally, but within the regions specified in the Policy Schedule during the Policy Period on Cashless Facility basis only.

a. We will provide this benefit from the Hospital where the Insured Person is admitted (required for stabilization) to a Hospital where adequate treatment
is available, if necessary treatment is not available locally or Medical Evacuation is Medically Necessary for saving the life of the Insured Person.
b. The treating Medical Practitioner has advised that Medical Evacuation is Medically Necessary.
c. We or Our Service Provider has approved the request for Medical Evacuation.
d. We or Our Service Provider, will arrange for the evacuation utilizing the means best suited to do so, based on the medical severity of Insured Person(s)
condition.
e. We will also cover the costs of transportation of an attending Medical Practitioner if the treating Medical Practitioner has advised that it is Medically
Necessary.
f. Under this benefit We will cover expenses for services provided and/or arranged by Us for the transportation of the Insured Person and shall include
medical services and cost for medical supplies necessarily incurred as a result of the Emergency Medical Evacuation.
g. We shall be liable only if the treating Medical Practitioner confirms that necessary medical treatment can’t be provided at the Hospital where the
Insured Person is situated at the time of Emergency.

a. Any costs or expenses incurred in relation to any persons accompanying the Insured Person to be evacuated, even if such persons are also Insured
Person(s).

b. Any expenses (other than necessary Medical Expenses) already included in the cost of a scheduled trip, including but not limited to the unutilized
portion of the return air ticket for the scheduled trip.
c. Any expenses for a service not approved and arranged by Us or Our authorized representative.
3.23. Emergency Hospitalization (outside the geographical boundaries of India)
What is covered:
If the Insured Person is required to be admitted in a Hospital in an Emergency condition, We will indemnify the Medical Expenses incurred on Hospitalization
of that Insured Person untill the Insured Person reaches a Medically Stable Condition during the Policy Period on Cashless Facility basis only.

a. The treating Medical Practitioner has advised that Hospitalization is Medically Necessary.
b. The Insured Person is required to be admitted in a Hospital in an Emergency when the Insured Person is outside India, but within those regions
specified in the Policy Schedule.
c. The Medical Expenses incurred are for one or more of the following:
i. Room Rent: Room boarding and nursing charges during Hospitalization as charged by the Hospital where the Insured Person availed medical
treatment;
ii. Medical Practitioners’ fees, excluding any charges or fees for Standby Services;
iii. Investigative tests or diagnostic procedures directly related to the Insured Event which led to the current Hospitalization;
iv. Medicines, drugs as prescribed by the treating Medical Practitioner related to the Insured Event that led to the current Hospitalization;
v. Intravenous fluids, blood transfusion, injection administration charges and /or allowable consumables;
vi. Operation theatre charges;
vii. The cost of prosthetics and other devices or equipment, if implanted internally during Surgery;
viii. Intensive Care Unit Charges.
3.24. Modern Treatments
What is covered:
a. The following procedures / treatments will be covered either as Inpatient Care or as part of Day Care Treatment as per Section 3.1 and Section 3.4
respectively, in a Hospital :
i. Uterine Artery Embolization and HIFU (High intensity focused ultrasound)
ii. Balloon Sinuplasty
iii. Deep Brain stimulation
iv. Oral chemotherapy
v. Immunotherapy- Monoclonal Antibody to be given as injection
vi. Intra vitreal injections
vii. Robotic surgeries
viii. Stereotactic radio surgeries
ix. BronchicalThermoplasty
x. Vaporisation of the prostrate (Green laser treatment or holmium laser treatment)
xi. IONM - (Intra Operative Neuro Monitoring)
xii. Stem cell therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered.
b. If We have accepted a claim under this benefit, We will also indemnify the Insured Person’s Pre-hospitalization Medical Expenses and Post-
hospitalization Medical Expenses in accordance with Sections 3.2 and 3.3 within the overall benefit sub-limit.
Special condition applicable for robotic surgeries:

A limit of maximum INR 1 Lac will apply to all robotic surgeries, except the following:
i. Robotic total radical prostatectomy
ii. Robotic cardiac surgeries
iii. Robotic partial nephrectomy
iv. Robotic surgeries for malignancies

4. Optional Benefits
The following optional benefits shall apply under the Policy only if it is specified in the Policy Schedule. Optional benefits can be selected by You only at the time
of issuance of the First Policy or at Renewal on payment of the corresponding additional premium.
The optional benefits ‘Personal Accident Cover’, ‘Critical Illness Cover’ and ‘Hospital Cash’ will be payable (only on Reimbursement basis) if the conditions
mentioned in the below sections are contracted or sustained by the Insured Person covered under these optional benefits during the Policy Period.
The applicable optional benefits will be payable subject to the terms, conditions and exclusions of this Policy and subject always to any sub-limits for the optional
benefit as specified in the Policy Schedule.
All claims for any applicable optional benefits under the Policy must be made in accordance with the process defined under Section 6.2.16 (Claim Process &
Requirements).
4.1. Personal Accident Cover
What is covered:
If the Insured Person covered under this optional benefit dies or sustains any Injury resulting solely and directly from an Accident occurring during the
Policy Period at any location worldwide, and while the Policy is in force, We will provide the benefits described below.
a. Accident Death (AD)
What is covered:
If the Injury due to Accident solely and directly results in the Insured Person’s death within 365 days from the occurrence of the Accident, We will
make payment of Personal Accident Cover Sum Insured specified in the Policy Schedule. If a claim is made under this optional benefit, the coverage
for that Insured Person under the Policy shall immediately and automatically cease. Any claim incurred before death of such Insured person shall be
admissible subject to terms and conditions under this Policy.
b. Accident Permanent Total Disability (APTD)
What is covered:
If the Injury due to Accident solely and directly results in the Permanent Total Disability of the Insured Person which means that the Injury results in
one or more of the following conditions within 365 days from the occurrence of an Accident, We will make payment of 125% of the Personal Accident
Cover Sum Insured as specified in the Policy Schedule.
i. Loss of use of limbs or sight

The Insured Person suffers from total and irrecoverable loss of:
a) The use of two limbs (including paraplegia and hemiplegia) OR
b) The sight in both eyes OR
c) The use of one limb and the sight in one eye
ii. Loss of independent living

The Insured Person is permanently unable to perform independently three or more of the following six activities of daily living.
a) Washing: the ability to maintain an adequate level of cleanliness and personal hygiene.
b) Dressing: the ability to put on and take off all necessary garments, artificial limbs or other surgical appliances that are medically necessary.
c) Feeding: the ability to transfer food from a plate or bowl to the mouth once food has been prepared and made available.
d) Toileting: the ability to manage bowel and bladder function, maintaining an adequate and socially acceptable level of hygiene.
e) Mobility: the ability to move indoors from room to room on level surfaces at the normal place of residence.
f) Transferring: the ability to move from a lying position in a bed to a sitting position in an upright chair or wheel chair and vice versa.

i. The Permanent Total Disability is proved through a disability certificate issued by a Medical Board duly constituted by the Central and/or the
State Government; and

ii. We will admit a claim under this optional benefit only if the Permanent Total Disability continues for a period of at least 6 continuous calendar
months from the commencement of the Permanent Total Disability unless it is irreversible, such as in case of amputation/loss of limbs etc; and
iii. If the Insured Person dies before a claim has been admitted under this optional benefit, no amount will be payable under this optional benefit,
however We will consider the claim under Section 4.1.a (Accident Death) subject to terms and conditions mentioned therein; and
iv. We will not make payment under Accident Permanent Total Disability more than once in the Insured Person’s lifetime for any and all Policy
Periods.
v. If a claim under this optional benefit is admitted, then coverage for the Insured Person will immediately and automatically cease under Section
4.1(Personal Accident Cover) and this optional benefit shall not be applied in respect of that Insured Person on any Renewal thereafter. However,
other applicable benefits can be Renewed in respect of the Insured Person.
c. Accident Permanent Partial Disability (APPD)
What is covered:
If the Injury due to Accident solely and directly results in the Permanent Partial Disability of the Insured Person which is of the nature specified in the
table below within 365 days from the occurrence of such Accident, We will make payment under this optional benefit in accordance with the table
below:

i. The Permanent Partial Disability is proved through a disability certificate issued by a Medical Board duly constituted by the Central and/or the
State Government; and
ii. We will admit a claim under this optional benefit only if the Permanent Partial Disability continues for a period of at least 6 continuous calendar
months from the commencement of the Permanent Partial Disability, unless it is irreversible; and
iii. If the Insured Person dies before a claim has been admitted under this optional benefit, no amount will be payable under this optional benefit,
however We will consider the claim under Section 4.1.a (Accident Death) subject to the terms and conditions mentioned therein.
iv. If a claim under this optional benefit has been admitted, then no further claim in respect of the same condition will be admitted under this
optional benefit.
v. If a claim under this optional benefit is paid and the entire Personal Accident Sum Insured specified in the Policy Schedule does not get utilized,
then the balance Personal Accident Cover Sum Insured shall be available for further claims under Section 4.1 (Personal Accident Cover) until the
entire Personal Accident Cover Sum Insured is consumed. The Personal Accident Cover Sum Insured specified in the first Policy Schedule shall
be a lifetime limit for the Insured Person and once this limit is exhausted, coverage for the Insured Person will immediately and automatically
cease under Section 4.1 (Personal Accident Cover) and this optional benefit shall not be applied in respect of that Insured Person on any Renewal
thereafter. However, other applicable benefits can be Renewed in respect of the Insured Person
Permanent Partial Disability Grid

% of Personal Accident
Cover Sum Insured
S. No. Nature of Disability payable
1 Loss or total and permanent loss of use of both the hands from the wrist joint 100%
2 Loss or total and permanent loss of use of both feet from the ankle joint 100%
3 Loss or total and permanent loss of use of one hand from the wrist joint and of one foot from the 100%
ankle joint
4 Loss or total and permanent loss of use of one hand from the wrist joint and total and permanent 100%
loss of sight in one eye
5 Loss or total and permanent loss of use of one foot from the ankle joint and total and permanent loss 100%
of sight in one eye
6 Total and permanent loss of speech and hearing in both ears 100%
7 Total and permanent loss of hearing in both ears 50%
8 Loss or total and permanent loss of use of one hand from wrist joint 50%
9 Loss or total and permanent loss of use of one foot from ankle joint 50%
10 Total and permanent loss of sight in one eye 50%
11 Total and permanent loss of speech 50%

Permanent Partial Disability Grid
% of Personal Accident
Cover Sum Insured
S. No. Nature of Disability payable
12 Permanent total loss of use of four fingers and thumb of either hand 40%
13 Permanent total loss of use of four fingers of either hand 35%
14 Uniplegia 25%
15 Permanent total loss of use of one thumb of either hand
a. Both joints 25%
b. One joint 10%
16 Permanent total loss of use of fingers of either hand
a. Three joints 10%
b. Two joints 8%
c. One joint 5%
17 Permanent total loss of use of toes of either foot
a. All toes- one foot 20%
b. Great toe- both joints 5%
c. Great toe- one joint 2%
d. Other than great toe, one toe 1%
4.2. Critical Illness Cover
What is covered:
If the Insured Person covered under this optional benefit is diagnosed for the first time with any of the following listed Critical Illnesses or if any of the
following Critical Illnesses occurs or manifests itself in the Insured Person during the Policy Period for the first time, We will pay the Critical Illness Sum
Insured specified in the Policy Schedule provided that the Insured Person survives the Survival Period of 30 days from the diagnosis of the Critical Illness
during the Policy Period.
a. 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 –

a) 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.
b) Any non-melanoma skin carcinoma unless there is evidence of metastases to lymph nodes or beyond;
c) Malignant melanoma that has not caused invasion beyond the epidermis;
d) 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
e) All Thyroid cancers histologically classified as T1N0M0 (TNM Classification) or below;
f) Chronic lymphocytic leukaemia less than RAI stage 3
g) Non-invasive papillary cancer of the bladder histologically described as TaN0M0 or of a lesser classification,
h) 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

b. Myocardial Infarction
(First Heart Attack of specific severity)
i. The first occurrence of heart attack or myocardial infarction, which means the death of a portion of the heart muscle as a result of inadequate
blood supply to the relevant area. The diagnosis for Myocardial Infarction should be evidenced by all of the following criteria:
a) A history of typical clinical symptoms consistent with the diagnosis of acute myocardial infarction (For e.g. typical chest pain)
b) New characteristic electrocardiogram changes
c) Elevation of infarction specific enzymes, Troponins or other specific biochemical markers.
a) Other acute Coronary Syndromes
b) Any type of angina pectoris
c) A rise in cardiac biomarkers or Troponin T or I in absence of overt ischemic heart disease OR following an intra-arterial cardiac procedure.
c. Open Chest CABG

i. The actual undergoing of heart surgery to correct blockage or narrowing in one or more coronary artery(s), by coronary artery bypass grafting
done via a sternotomy (cutting through the breast bone) or minimally invasive keyhole coronary artery bypass procedures. The diagnosis must
be supported by a coronary angiography and the realization of surgery has to be confirmed by a cardiologist.
i. Angioplasty and/or any other intra-arterial procedures
d. Open Heart Replacement or Repair of Heart Valves

i. The actual undergoing of open-heart valve surgery is to replace or repair one or more heart valves, as a consequence of defects in, abnormalities
of, or disease affected cardiac valve(s). The diagnosis of the valve abnormality must be supported by an echocardiography and the realization
of surgery has to be confirmed by a specialist medical practitioner. Catheter based techniques including but not limited to, balloon valvotomy/
valvuloplasty are excluded.
e. Coma of Specified Severity

i. A state of unconsciousness with no reaction or response to external stimuli or internal needs. This diagnosis must be supported by evidence of
all of the following:
a) no response to external stimuli continuously for at least 96 hours;
b) life support measures are necessary to sustain life; and
c) Permanent neurological deficit which must be assessed at least 30 days after the onset of the coma.
ii. The condition has to be confirmed by a specialist medical practitioner. Coma resulting directly from alcohol or drug abuse is excluded
f. Kidney Failure requiring Regular Dialysis

I. 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
g. Stroke resulting in Permanent Symptoms

I. Any cerebrovascular incident producing permanent neurological sequelae. This includes infarction of brain tissue, thrombosis in an intracranial
vessel, haemorrhage and embolisation from an extracranial source. Diagnosis has to be confirmed by a specialist medical practitioner and
evidenced by typical clinical symptoms as well as typical findings in CT Scan or MRI of the brain. Evidence of permanent neurological deficit
lasting for at least 3 months has to be produced.
i. Transient ischemic attacks (TIA)
ii. Traumatic injury of the brain
iii. Vascular disease affecting only the eye or optic nerve or vestibular functions.
h. Major Organ /Bone Marrow Transplant

I. The actual undergoing of a transplant of:
i. One of the following human organs: heart, lung, liver, kidney, pancreas, that resulted from irreversible end-stage failure of the relevant
organ, or

ii. Human bone marrow using haematopoietic stem cells. The undergoing of a transplant has to be confirmed by a specialist medical
practitioner.

i. Other stem-cell transplants
ii. Where only islets of langerhans are transplanted
i. Permanent Paralysis of Limbs

I. Total and irreversible loss of use of two or more limbs as a result of injury or disease of the brain or spinal cord. A specialist medical practitioner
must be of the opinion that the paralysis will be permanent with no hope of recovery and must be present for more than 3 months.
j. Motor Neuron Disease with Permanent Symptoms

I. Motor neuron disease diagnosed by a specialist medical practitioner as spinal muscular atrophy, progressive bulbar palsy, amyotrophic lateral
sclerosis or primary lateral sclerosis. There must be progressive degeneration of corticospinal tracts and anterior horn cells or bulbar efferent
neurons. There must be current significant and permanent functional neurological impairment with objective evidence of motor dysfunction that
has persisted for a continuous period of at least 3 months.
k. Multiple Sclerosis with Persisting Symptoms

I. The unequivocal diagnosis of Definite Multiple Sclerosis confirmed and evidenced by all of the following:
a) investigations including typical MRI findings which unequivocally confirm the diagnosis to be multiple sclerosis and
b) there must be current clinical impairment of motor or sensory function, which must have persisted for a continuous period of at least 6
months
II. Neurological damage due to SLE is excluded
l. Deafness
i. Total and irreversible loss of hearing in both ears as a result of illness or accident. This diagnosis must be supported by pure tone audiogram test
and certified by an Ear, Nose and Throat (ENT) specialist. Total means “the loss of hearing to the extent that the loss is greater than 90decibels
across all frequencies of hearing” in both ears.
m. End Stage Lung Failure

i. End stage lung disease, causing chronic respiratory failure, as confirmed and evidenced by all of the following:
a) FEV1 test results consistently less than 1 litre measured on 3 occasions 3 months apart; and
b) Requiring continuous permanent supplementary oxygen therapy for hypoxemia; and
c) Arterial blood gas analysis with partial oxygen pressure of 55mmHg or less (PaO2 < 55mmHg); and
d) Dyspnea at rest.
n. End Stage Liver Failure

i. Permanent and irreversible failure of liver function that has resulted in all three of the following:
a) Permanent jaundice; and
b) Ascites; and
c) Hepatic encephalopathy.
ii. Liver failure secondary to drug or alcohol abuse is excluded.
o. Loss of Speech
i. Total and irrecoverable loss of the ability to speak as a result of injury or disease to the vocal cords. The inability to speak must be established
for a continuous period of 12 months. This diagnosis must be supported by medical evidence furnished by an Ear, Nose, Throat (ENT) specialist.
p. Third Degree Burns

i. There must be third-degree burns with scarring that cover at least 20% of the body’s surface area. The diagnosis must confirm the total area
involved using standardized, clinically accepted, body surface area charts covering 20% of the body surface area.

q. Fulminant Viral Hepatitis
i. A sub-massive to massive necrosis of the liver by any virus, leading precipitously to liver failure.
This diagnosis must be supported by all of the following:
a) rapid decreasing of liver size; and
b) necrosis involving entire lobules, leaving only a collapsed reticular framework; and
c) rapid deterioration of liver function tests; and
d) deepening jaundice; and
e) hepatic encephalopathy.
Acute Hepatitis infection or carrier status alone does not meet the diagnostic criteria
r. Aplastic Anemia
i. Aplastic Anemia is chronic persistent bone marrow failure. A certified hematologist must make the diagnosis of severe irreversible aplastic
anemia. There must be permanent bone marrow failure resulting in bone marrow cellularity of less than 25% and there must be two of the
following:
a) Absolute neutrophil count of less than 500/mm³
b) Platelets count less than 20,000/mm³
c) Reticulocyte count of less than 20,000/mm³
The Insured Person must be receiving treatment for more than 3 consecutive months with frequent blood product transfusions, bone marrow
stimulating agents, or immunosuppressive agents or the Insured Person has received a bone marrow or cord blood stem cell transplant.
Temporary or reversible Aplastic Anemia is excluded and not covered under this Policy
s. Muscular Dystrophy
i. Muscular Dystrophy is a disease of the muscle causing progressive and permanent weakening of certain muscle groups. The diagnosis of
Muscular Dystrophy must be made by a consultant neurologist, and confirmed with the appropriate laboratory, biochemical, histological, and
electromyography evidence. The disease must result in the permanent inability of the Insured Person to perform (whether aided or unaided) at
least three (3) of the six (6)“Activities of Daily Living”.
Activities of Daily Living are defined as:

a) Washing : the ability to maintain an adequate level of cleanliness and personal hygiene
b) Dressing : the ability to put on and take off all necessary garments, artificial limbs or other surgical appliances that are Medically Necessary
c) Feeding : the ability to transfer food from a plate or bowl to the mouth once food has been prepared and made available
d) Toileting : the ability to manage bowel and bladder function, maintaining an adequate and socially acceptable level of hygiene
e) Mobility : the ability to move indoors from room to room on level surfaces at the normal place of residence
f) Transferring: the ability to move from a lying position in a bed to a sitting position in an upright chair or wheel chair and vice versa
t. Bacterial Meningitis
i. Bacterial meningitis is a bacterial infection of the meninges of the brain causing brain dysfunction. There must be an unequivocal diagnosis by a
consultant physician of bacterial meningitis that must be proven on analysis and culture of the cerebrospinal fluid. There must also be permanent
objective neurological deficit that is present on physical examination at least 3 months after the diagnosis of the meningitis infection.
Conditions applicable to ‘Critical Illness cover’:

a. We will not make payment under Section 4.2 (Critical Illness Cover) more than once in the Insured Person’s lifetime for any and all Policy Periods
b. The diagnosis of a Critical Illness must be verified in writing by a Medical Practitioner.
c. The Waiting Periods specified below shall be applicable to the Insured Person and claims shall be assessed accordingly. On Renewal, if the Critical
Illness Cover Sum Insured specified in the Policy Schedule is enhanced, the Waiting Periods would apply afresh to the extent of the increase in benefit
amount limit, subject to Underwriting Guidelines and in accordance with the existing guidelines of the IRDAI.

We shall not be liable to make any payment under this Policy for covered listed Critical Illnesses directly or indirectly caused by, based on, arising out
of or howsoever attributable to any of the following:
i. Pre-existing Diseases (Code- Excl01):
a. Expenses related to the treatment of a Pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 48
months of continuous coverage after the date of inception of the first Policy with Us.
b. In case of enhancement of Sum Insured the exclusion shall apply afresh to the extent of Sum Insured increase.
c. If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health
Insurance) regulations, then waiting period for the same would be reduced to the extent of prior coverage.
d. Coverage under the Policy after the expiry of 48 months for any Pre-existing Disease is subject to the same being declared at the time of
application and accepted by Us.
ii. 90 day Waiting Period:

a. Expenses related to the treatment of any Illness within 90 days from the first Policy commencement date shall be excluded except claims
arising due to an Accident, provided the same are covered.
b. This exclusion shall not, however, apply if the Insured Person has continuous coverage for more than twelve months
c. The within referred waiting period is made applicable to the enhanced Sum Insured in the event of granting higher Sum Insured subsequently.
d. If the Insured Person is diagnosed / undergoes a Surgical Procedure or any medical condition occurs falling under the definition of Critical
Illness as specified above that may result in a claim, then We shall be given written notice immediately and in any event within 7 days of
the aforesaid Illness/ condition/ Surgical Procedure.
e. We shall not be liable to make any payment under this optional benefit if the Insured Person does not survive the Survival Period.
f. If diagnosis of the Critical Illness takes place on or before the Policy expiry date specified in the Policy Schedule, but the Survival Period
expires after the Policy expiry date, such claims would be admissible if the Insured Person survives the Survival Period.
g. In the event of death of the Insured Person post the Survival Period, the immediate family member/relative of the Insured Person claiming
on Insured Person’s behalf must inform Us in writing immediately and send a copy of all the required documents to prove the cause of
death within 30 days of the death. We upon acceptance of the admission of claim under the Policy shall make payment to the Nominee/
legal heirs of the Insured Person.
h. If We have admitted a claim under this optional benefit for an Insured Person in any Policy Year, this optional benefit shall not be renewed
in respect of that Insured Person for any subsequent Policy Year, but the cover for this optional benefit will be renewable for other Insured
Persons.
4.3. e-Consultation
What is covered:
If the Insured Person is diagnosed with an Illness or is planning to undergo a planned Surgery or a Surgical Procedure, the Insured Person can, at the
Insured Person’s sole direction, obtain an e-Consultation during the Policy Period.

a. e-Consultation shall be requested through Our call centre or website chat.
b. e-Consultation will be arranged by Us (without any liabilities) and will be based solely on the information provided by the Insured Person.
c. e-Consultation must not be considered a substitute to medical opinion or advise nor shall be same pursued over a medical advice or opinion given
by treating physician or doctor
d. By seeking e-Consultation under this benefit, the Insured Person is not prohibited or advised against visiting or consulting with any other independent
Medical Practitioner or commencing or continuing any treatment advised by such Medical Practitioner.
e. The Insured Person is free to choose whether or not to obtain the e-Consultation, and if obtained then whether or not to act on it in whole or in part.
f. e-Consultation under this benefit shall not be valid for any medico-legal purposes.
g. We do not represent correctness of e-Consultation and shall not assume or deem to assume any liability towards any loss or damage arising out of or
in relation to any opinion, advice, prescription, actual or alleged errors, omissions and representations made by the Medical Practitioner.

4.4. Premium Waiver
What is covered:
If the Policyholder (who should also be an Insured Person) dies or is diagnosed or undergoes treatment for the first time, with any of the Specified Illness
as mentioned under Section 2.73 during the Policy Period, the cover under the Policy shall be automatically extended for a tenure of 1 Policy Year starting
from the end of that Policy Period.

a. This optional benefit is provided once in the lifetime in the Policy regardless of the number of years the Policy has served with Us.
b. The symptoms of the Specified Illness first occur or manifest itself during the Policy Period and after completion of the 90 day from the inception of
c. The Specified Illness is diagnosed by a Medical Practitioner during the Policy Period and after completion of the 90 day from the inception of the
First Policy with Us.
d. If We have admitted a claim under this optional benefit during the Policy Period, this optional benefit shall not be renewed for any subsequent Policy
Period.

a. This benefit is not available under Individual Policy.
4.5. Hospital Cash
What is covered:
If We have accepted an Inpatient Care Hospitalization claim under Section 3.1 (Inpatient Care), We will pay the Hospital Cash amount specified in the
Policy Schedule up to a maximum 30 days of Hospitalization during the Policy Year for the Insured Person for each continuous period of 24 hours of
Hospitalization from the first day of Hospitalization.

a. The Insured Person has been admitted in a Hospital for a minimum period of 48 hours continuously.
4.6. Enhanced Geographical Scope for International Coverage
What is covered:
This optional benefit shall be subject to all guidelines and conditions mentioned under Section 3.20 (Specified Illness cover), Section 3.22 (Emergency
Medical Evacuation – outside the geographical boundaries of India) and Section 3.23 (Emergency Hospitalization – outside the geographical boundaries
of India), without limitation to the geographical coverage in USA & Canada unlike specified under Section 3.20, Section 3.22 and Section 3.23.

a. Waiting Periods as specified under Section 5.1.1 shall apply afresh to the geographical coverage in USA & Canada when this Optional Cover is opted.
5. Exclusions
5.1. Standard exclusions
5.1.1. Waiting Periods
All the Waiting Periods shall be applicable individually for each Insured Person and claims shall be assessed accordingly. On Renewal, if the Sum
Insured or the benefit amount is enhanced, the Waiting Periods would apply afresh to the extent of the increased amount only. The Waiting Periods
set out below shall not apply to Section 3.11 (Health Check-up), Section 3.13 (Pharmacy and diagnostic services), Section 4.1 (Personal Accident
Cover), Section 4.2 (Critical Illness Cover), Section 4.3 (e-Consultation) and Section 4.4 (Premium Waiver). The Waiting Periods for Critical Illness
Cover have already been specified under Section 4.2 respectively.
We shall not be liable to make any payment under this Policy directly or indirectly caused by, based on, arising out of or howsoever attributable to
any of the following:
5.1.1.1. Pre-existing Diseases (Code-Excl01):
a. Expenses related to the treatment of a Pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 24
months (under gold & platinum Plans)/ 48 months (under Silver Plans) of continuous coverage after the date of inception of the first
Policy with Us.

c. If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health
Insurance) regulations, then waiting period for the same would be reduced to the extent of prior coverage.
d. Coverage under the Policy after the expiry of 24 months (under gold & platinum Plans)/ 48 months (under Silver Plans) for any Pre-
existing Disease is subject to the same being declared at the time of application and accepted by Us.
5.1.1.2. 30-day Waiting Period (Code-Excl03)
a. Expenses related to the treatment of any Illness within 30 days from the first Policy commencement date shall be excluded except
claims arising due to an Accident, provided the same are covered.
b. This exclusion shall not, however, apply if the Insured Person has continuous coverage for more than twelve months
c. The within referred waiting period is made applicable to the enhanced Sum Insured in the event of granting higher Sum Insured
subsequently.
5.1.1.3. Specified disease/procedure waiting period (Code- Excl02)
For all Insured Persons who are above 45 years of Age as on the date of inception of the First Policy with Us, the following specified
disease/procedure waiting period will be applicable.
a. Expenses related to the treatment of the listed conditions, surgeries/treatments shall be excluded until the expiry of 24 months of
continuous coverage after the date of inception of the first Policy with us. This exclusion shall not be applicable for claims arising due
to an Accident (covered from day 1 or Cancer (covered after 30-day waiting period).
c. If any of the specified disease/procedure falls under the waiting period specified for pre-Existing diseases, then the longer of the two
waiting periods shall apply.
d. The waiting period for listed conditions shall apply even if contracted after the Policy or declared and accepted without a specific
exclusion.
e. If the Insured Person is continuously covered without any break as defined under the applicable norms on portability stipulated by
IRDAI then waiting period for the same would be reduced to the extent of prior coverage.
f. List of specific diseases/procedures:
i. Pancreatitis and Stones in Biliary and Urinary System,
ii. Cataract, Glaucoma and other disorders of lens, disorders of Retina,
iii. Hyperplasia of Prostate, Hydrocele and spermatocele,
iv. Abnormal Utero-vaginal bleeding, female genital Prolapse, Endometriosis/Adenomyosis, Fibroids, PCOD, or any condition
requiring dilation and curettage or Hysterectomy,
v. Hemorrhoids, Fissure or Fistula or Abscess of anal and rectal region,
vi. Hernia of all sites,
vii. Osteoarthritis, Systemic Connective Tissue disorders, Dorsopathies, Spondylopathies, inflammatory Polyarthropathies, Arthrosis
such as RA, Gout, Intervertebral Disc disorders,
viii. Chronic kidney disease and failure,
ix. Varicose veins of lower extremities,
x. Disease of middle ear and mastoid including Otitis Media, Cholesteatoma, Perforation of Tympanic Membrane,
xi. All internal or external benign or In Situ Neoplasms/Tumours, Cyst, Sinus, Polyp, Nodules, Swelling, Mass or Lump,
xii. Ulcer, Erosion and Varices of Upper Gastro Intestinal Tract,
xiii. Tonsils and Adenoids, Nasal Septum and Nasal Sinuses,
xiv. Internal Congenital Anomaly.
5.1.2. Permanent Exclusions
We shall not be liable to make any payment under this Policy directly or indirectly caused by, based on, arising out of or howsoever attributable to
any of the following unless specifically mentioned elsewhere in the Policy. Sections 5.1.2.1 to 5.1.2.15 and 5.2.1 to 5.2.12 are not applicable to Section
4.1 (Personal Accident Cover) and Section 4.2 (Critical Illness Cover).
The permanent exclusions applicable to Section 4.1 (Personal Accident Cover) and Section 4.2 (Critical Illness Cover) have been specified separately
under Section 5.2.13 and Section 5.2.14 respectively.

5.1.2.1. Investigation & Evaluation (Code-Excl04)
a. Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.
b. Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.
5.1.2.2. Rest Cure, rehabilitation and respite care (Code-Excl05)
Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:
a. Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing,
dressing, moving around either by skilled nurses or assistant or non-skilled persons.
b. Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.
5.1.2.3. Obesity/ Weight Control (Code-Excl06)
Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:
a. Surgery to be conducted is upon the advice of the Doctor.
b. The surgery/Procedure conducted should be supported by clinical protocols.
c. The member has to be 18 years of age or older and;
d. Body Mass Index (BMI);
i. greater than or equal to 40 or
ii. greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive
methods of weight loss:
a) Obesity-related cardiomyopathy
b) Coronary heart disease
c) Severe Sleep Apnea
d) Uncontrolled Type2 Diabetes
5.1.2.4. Change-of-Gender treatments (Code-Excl07)
Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.
5.1.2.5. Cosmetic or plastic Surgery (Code-Excl08)
Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident, Burn(s) or
Cancer or as part of medically necessary treatment to remove a direct and immediate health risk to the insured. For this to be considered a
medical necessity, it must be certified by the attending Medical Practitioner.
5.1.2.6. Hazardous or Adventure sports (Code-Excl09)
Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports, including but
not limited to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving,
deep-sea diving.
5.1.2.7. Breach of law (Code-Excl10)
Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law
with criminal intent.
5.1.2.8. Excluded Providers (Code-Excl11)
Expenses incurred towards treatment in any Hospital or by any Medical Practitioner or any other provider specifically excluded by Us and
disclosed in Our website / notified to the Policyholders are not admissible. However, in case of life threatening situations or following an
Accident, expenses up to the stage of stabilization are payable but not the complete claim.
The complete list of excluded providers can be referred to on our website.

5.1.2.9. Treatment for, alcoholism, drug or substance abuse or any addictive condition and consequences thereof. (Code-Excl12)
5.1.2.10. Treatments received in heath hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing home
attached to such establishments or where admission is arranged wholly or partly for domestic reasons. (Code-Excl13)
5.1.2.11. Dietary supplements and substances that can be purchased without prescription, including but not limited to vitamins, minerals and
organic substances unless prescribed by a Medical Practitioner as part of Hospitalization claim or Day Care procedure (Code-Excl14)
5.1.2.12. Refractive Error (Code-Excl15)
Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres.
5.1.2.13. Unproven Treatments (Code-Excl16)
Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are
treatments, procedures or supplies that lack significant medical documentation to support their effectiveness.
5.1.2.14. Sterility and Infertility (Code-Excl17)
Expenses related to sterility and infertility. This includes:

a. Any type of contraception, sterilization
b. Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
c. Gestational Surrogacy
d. Reversal of sterilization
5.1.2.15. Maternity (Code-Excl18)
a. Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during
Hospitalization) except ectopic pregnancy;
b. Expenses towards miscarriage (unless due to an Accident) and lawful medical termination of pregnancy during the Policy Period.
5.2. Specific exclusions
5.2.1. Ancillary Hospital Charges

Charges related to a Hospital stay not expressly mentioned as being covered. This will include charges for admission, discharge, administration, RMO
charges, night charges, registration, documentation and filing, surcharges and service charges levied by the Hospital.
5.2.2. Circumcision:
Circumcision unless necessary for the treatment of a disease or necessitated by an Accident.
5.2.3. Conflict & Disaster:

Treatment for any Injury or Illness resulting directly or indirectly from nuclear, radiological emissions, war or war like situations (whether war is
declared or not), rebellion (act of armed resistance to an established government or leader), acts of terrorism.
5.2.4. External Congenital Anomaly:

Screening, counseling or treatment related to external Congenital Anomaly.
5.2.5. Dental/oral treatment:

Treatment, procedures and preventive, diagnostic, restorative, cosmetic services related to disease, disorder and conditions related to natural teeth
and gingiva except if required by an Insured Person while Hospitalized due to an Accident.
5.2.6. Hormone Replacement Therapy:

Treatment for any condition / illness which requires hormone replacement therapy.
5.2.7. Sexually transmitted Infections & diseases (other than HIV / AIDS):
Screening, prevention and treatment for sexually related infection or disease (other than HIV / AIDS).

5.2.8. Sleep disorders:
Treatment for any conditions related to disturbance of normal sleep patterns or behaviors.
5.2.9. Any treatment or medical services received outside the geographical limits of India.
5.2.10. Unrecognized Physician or Hospital:

a. Treatment or Medical Advice provided by a Medical Practitioner not recognized by the Medical Council of India or by Central Council of Indian
Medicine or by Central council of Homeopathy.
b. Treatment provided by anyone with the same residence as an Insured Person or who is a member of the Insured Person’s immediate family or
relatives.
c. Treatment provided by Hospital or health facility that is not recognized by the relevant authorities in India.
5.2.11. Artificial life maintenance for the Insured Person who has been declared brain dead or in vegetative state as demonstrated by:
a. Deep coma and unresponsiveness to all forms of stimulation; or
b. Absent pupillary light reaction; or
c. Absent oculovestibular and corneal reflexes; or
d. Complete apnea.
5.2.12. AYUSH Treatment

Any form of AYUSH Treatments, except as mentioned under Section 3.6
5.2.13. Permanent Exclusions for Personal Accident Cover

We shall not be liable to make any payment under any benefits under Section 4.1 (Personal Accident Cover) if the claim is attributable to, or based
on, or arises out of, or is directly or indirectly connected to any of the following:
a. Suicide or self inflicted Injury, whether the Insured Person is medically sane or insane.
b. Treatment for any Injury or Illness resulting directly or indirectly from nuclear, radiological emissions, war or war like situations (whether war is
c. Service in the armed forces, or any police organization, of any country at war or at peace or service in any force of an international body or
participation in any of the naval, military or air force operation during peace time.
d. Any change of profession after inception of the Policy or any Renewal which results in the enhancement of Our risk, if not accepted and endorsed
by Us on the Policy Schedule.
e. Committing an assault, a criminal offence or any breach of law with criminal intent.
f. Taking or absorbing, accidentally or otherwise, any intoxicating liquor, drug, narcotic, medicine, sedative or poison, except as prescribed by a
Medical Practitioner other than the Policyholder or an Insured Person.
g. Participation in aviation/marine activities (including crew) other than as a passenger in an aircraft/water craft that is authorized by the relevant
regulations to carry such passengers between established airports or ports.
h. Engaging in or taking part in professional/adventure sports or any hazardous pursuits, speed contest or racing of any kind (other than on foot),
bungee jumping, parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding, mountain or rock climbing necessitating the use of
guides or ropes, potholing, abseiling, deep sea diving, polo, snow and ice sports, hunting.
5.2.14. Permanent Exclusions for Critical Illness Cover

We shall not be liable to make any payment under Section 4.2 (Critical Illness Cover) directly or indirectly caused by, based on, arising out of or
howsoever attributable to any of the following unless specifically mentioned elsewhere in the Policy.
a. AYUSH Treatment:
Any covered Critical Illnesses diagnosed and/or treated by a Medical Practitioner who practices AYUSH Treatment.
b. Conflict & Disaster:
Treatment for any Injury or Illness resulting directly or indirectly from nuclear, radiological emissions, war or war like situations (whether war is
c. External Congenital Anomaly:
Screening, counseling or treatment related to External Congenital Anomaly.
d. Cosmetic or plastic Surgery (Code-Excl08)
Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident, Burn(s) or
Cancer or as part of medically necessary treatment to remove a direct and immediate health risk to the insured. For this to be considered a
medical necessity, it must be certified by the attending Medical Practitioner.

e. Unproven Treatments (Code-Excl16)
Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are treatments,
procedures or supplies that lack significant medical documentation to support their effectiveness.
f. Hazardous or Adventure sports (Code-Excl09)
Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports, including but not limited
to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.
g. Sterility and Infertility (Code-Excl17)
Expenses related to sterility and infertility. This includes:
i. Any type of contraception, sterilization
ii. Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
iii. Gestational Surrogacy
iv. Reversal of sterilization
h. Maternity (Code-Excl18)
i. Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during Hospitalization)
except ectopic pregnancy;
ii. Expenses towards miscarriage (unless due to an Accident) and lawful medical termination of pregnancy during the Policy Period.
i. Sexually transmitted Infections & diseases (other than HIV / AIDS):
Screening, prevention and treatment for sexually related infection or disease (other than HIV / AIDS).
j. Treatment for, alcoholism, drug or substance abuse or any addictive condition and consequences thereof. (Code-Excl12)
k. Breach of law (Code-Excl10)
Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with
criminal intent.
l. Treatments received in heath hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing home attached to
such establishments or where admission is arranged wholly or partly for domestic reasons. (Code-Excl13)
m. Unrecognized Physician or Hospital:
i. Treatment or Medical Advice provided by a Medical Practitioner not recognized by the Medical Council of India or by Central Council of
Indian Medicine or by Central council of Homeopathy.
ii. Treatment provided by anyone with the same residence as an Insured Person or who is a member of the Insured Person’s immediate family
or relatives.
iii. Treatment provided by Hospital or health facility that is not recognized by the relevant authorities in India.
5.2.15. Personal Waiting Periods:

Conditions specified for an Insured Person under Personal Waiting Period in the Policy Schedule will be subject to a Waiting Period of 24 months from
the inception of the First Policy with Us for that Insured Person and will be covered from the commencement of the third Policy Year for that Insured
Person as long as the Insured Person has been insured continuously under the Policy without any break.
6. General Terms and Clauses
6.1. Standard General Terms and Clauses
6.1.1. Free Look Period

The Free Look Period shall be applicable on new individual health insurance policies and not on renewals or at the time of porting/migrating the
policy.
The insured person shall be allowed free look period of fifteen days (thirty days for policies with a term of 3 years, if sold through distance marketing)
from date of receipt of the policy document to review the terms and conditions of the policy, and to return the same if not acceptable.
lf the insured has not made any claim during the Free Look Period, the insured shall be entitled to
a. a refund of the premium paid less any expenses incurred by the Company on medical examination of the insured person and the stamp duty
charges

6.1.2. Cancellation
a. The policyholder may cancel this policy by giving 30 days’ written notice and in such an event, the Company shall refund premium for the
unexpired policy period as detailed below.
Notwithstanding anything contained herein or otherwise, no refunds of premium shall be made in respect of Cancellation where, any claim has
been admitted or has been lodged or any benefit has been availed by the insured person under the policy.
1 year 2 years
Policy in-force up to Refund Premium (%) Policy in-force up to Refund Premium (%)
Up to 30 days 75% Up to 30 days 87.5%
31 to 90 days 50% 31 to 90 days 75%
91 to 180 days 25% 91 to 180 days 62.5%
exceeding 180 days 0% 181 to 365 days 50%
366 to 455 days 25%
456 to 545 days 12%
Exceeding 545 days 0%
b. The Company may cancel the policy at any time on grounds of misrepresentation non-disclosure of material facts, fraud by the insured person
by giving 15 days’ written notice. There would be no refund of premium on cancellation on grounds of misrepresentation, non-disclosure of
material facts or fraud.
In case of death of an Insured, pro-rate refund of the premium for the deceased insured will be refunded, provided there is no history of claim.
6.1.3. Renewal of Policy

The policy shall ordinarily be renewable except on grounds of fraud, misrepresentation by the insured person.
I. The Company shall endeavor to give notice for renewal. However, the Company is not under obligation to give any notice for renewal.
II. Renewal shall not be denied on the ground that the insured person had made a claim or claims in the preceding policy years.
III. Request for renewal along with requisite premium shall be received by the Company before the end of the policy period.
IV. At the end of the policy period, the policy shall terminate and can be renewed within the Grace Period of 30 days to maintain continuity of
benefits without break in policy. Coverage is not available during the grace period.
V. No loading shall apply on renewals based on individual claims experience.
6.1.4. Nomination
The policyholder is required at the inception of the policy to make a nomination for the purpose of payment of claims under the policy in the event of
death of the policyholder. Any change of nomination shall be communicated to the company in writing and such change shall be effective only when
an endorsement on the policy is made. ln the event of death of the policyholder, the Company will pay the nominee {as named in the Policy Schedule/
Policy Certificate/Endorsement (if any)} and in case there is no subsisting nominee, to the legal heirs or legal representatives of the policyholder
whose discharge shall be treated as full and final discharge of its liability under the policy.
6.1.5. Fraud
lf any claim made by the insured person, is in any respect fraudulent, or if any false statement, or declaration is made or used in support thereof, or if
any fraudulent means or devices are used by the insured person or anyone acting on his/her behalf to obtain any benefit under this policy, all benefits
under this policy and the premium paid shall be forfeited.
Any amount already paid against claims made under this policy but which are found fraudulent later shall be repaid by all recipient(s)/policyholder(s),
who has made that particular claim, who shall be jointly and severally liable for such repayment to the insurer.
For the purpose of this clause, the expression “fraud” means any of the following acts committed by the insured person or by his agent or the
hospital/doctor/any other party acting on behalf of the insured person, with intent to deceive the insurer or to induce the insurer to issue an insurance
policy: a) the suggestion, as a fact of that which is not true and which the insured person does not believe to be true; b) the active concealment of
a fact by the insured person having knowledge or belief of the fact; c) any other act fitted to deceive; and d) any such act or omission as the law
specially declares to be fraudulent
The Company shall not repudiate the claim and / or forfeit the policy benefits on the ground of Fraud, if the insured person / beneficiary can prove
that the misstatement was true to the best of his knowledge and there was no deliberate intention to suppress the fact or that such misstatement of
or suppression of material fact are within the knowledge of the insurer.

6.1.6. Possibility of Revision of Terms of the Policy Including the Premium Rates
The Company, with prior approval of lRDAl, may revise or modify the terms of the policy including the premium rates. The insured person shall be
notified three months before the changes are effected.
6.1.7. Withdrawal of Policy

I. ln the likelihood of this product being withdrawn in future, the Company will intimate the insured person about the same 90 days prior to expiry
of the policy.
II. lnsured Person will have the option to migrate to similar health insurance product available with the Company at the time of renewal with all the
accrued continuity benefits such as cumulative bonus, waiver of waiting period as per IRDAI guidelines, provided the policy has been maintained
without a break.
.
6.1.8. Redressal of Grievances:
ln case of any grievance the Insured Person may contact the company through:
Website: www.nivabupa.com
Toll free: 1860-500-8888
E-mail: Email us through our service platform https://rules.nivabupa.com/customer-service/ (Senior citizens may write to us at:
seniorcitizensupport@nivabupa.com)
Fax: 011-4174-3397
Courier: Customer Services Department
D-5, 2nd Floor, Logix Infotech Park
opp. Metro Station, Sector 59, Noida,
Uttar Pradesh, 201301
lnsured person may also approach the grievance cell at any of the company's branches with the details of grievance. If lnsured person is not
satisfied with the redressal of grievance through one of the above methods, Insured Person may contact the grievance officer at:
Head – Customer Services
D-5, 2nd Floor, Logix Infotech Park
opp. Metro Station, Sector 59, Noida,
Uttar Pradesh, 201301
Contact No: 1860-500-8888
Fax No: 011-4174-3397
Email ID: Email our Grievance officer through our Grievance Redressal platform https://transactions.nivabupa.com/pages/grievance-redressal.aspx
For updated details of grievance officer, kindly refer the link https://www.nivabupa.com/customer-care/health-services/grievance-redressal.aspx
If the Insured Person is not satisfied with the above, they can escalate to our Grievance Redressal officer through our platform https://
transactions.nivabupa.com/pages/grievance-redressal.aspx.
lf lnsured person is not satisfied with the redressal of grievance through above methods, the Insured Person may also approach the office of
lnsurance Ombudsman of the respective area/region for redressal of grievance as per lnsurance Ombudsman Rules 2017 (Refer below Annexure).
Grievance may also be lodged at IRDAI lntegrated Grievance Management System –bimabharosa.irdai.gov.in
6.1.9. Claim settlement (Provision for Penal interest)

I. The Company shall settle or reject a claim, as the case may be, within 30 days from the date of receipt of last necessary document.
II. ln the case of delay in the payment of a claim, the Company shall be liable to pay interest to the policyholder from the date of receipt of last
necessary document to the date of payment of claim at a rate 2% above the bank rate.
III. However, where the circumstances of a claim warrant an investigation in the opinion of the Company, it shall 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- ln such cases, the Company
shall settle or reject the claim within 45 days from the date of receipt of last necessary document.
IV. ln case of delay beyond stipulated 45 days, the Company shall be liable to pay interest to the policyholder at a rate 2% above the bank rate from
the date of receipt of last necessary document to the date of payment of claim.
(Explanation: “Bank rate” shall mean the rate fixed by the Reserve Bank of lndia (RBl) at the beginning of the financial year in which claim has
fallen due)

6.1.10. Moratorium Period
After completion of eight continuous years under the Policy no look back to be applied. This period of eight years is called as moratorium period.
The moratorium would be applicable for the sums insured of the first Policy and subsequently completion of 8 continuous years would be applicable
from date of enhancement of sums insured only on the enhanced limits. After the expiry of Moratorium Period no health insurance claim shall be
contestable except for proven fraud and permanent exclusions specified in the Policy contract. The policies would however be subject to all limits, sub
limits, co-payments, deductibles as per the Policy contract.
6.1.11. Multiple Policies

I. ln case of multiple policies taken by an insured person during a period from one or more insurers to indemnify treatment costs, the insured
person shall have the right to require a settlement of his/her claim in terms of any of his/her policies. ln all such cases the insurer chosen by the
insured person shall be obliged to settle the claim as long as the claim is within the limits of and according to the terms of the chosen policy.
II. lnsured person having multiple policies shall also have the right to prefer claims under this policy for the amounts disallowed under any other
policy / policies even if the sum insured is not exhausted. Then the insurer shall independently settle the claim subject to the terms and conditions
of this policy.
III. lf the amount to be claimed exceeds the sum insured under a single policy, the insured person shall have the right to choose insurer from whom
he/she wants to claim the balance amount.
IV. Where an insured person has policies from more than one insurer to cover the same risk on indemnity basis, the insured person shall only be
indemnified the treatment costs in accordance with the terms and conditions of the chosen policy
6.1.12. Disclosure of Information

The Policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of misrepresentation, mis-description or non-
disclosure of any material fact by the policyholder
(Explanation: “Material facts” for the purpose of this policy shall mean all relevant information sought by the company in the proposal form and other
connected documents to enable it to take informed decision in the context of underwriting the risk)
6.1.13. Condition Precedent to Admission of Liability

The terms and conditions of the policy must be fulfilled by the insured person for the Company to make any payment for claim(s) arising under the
policy.
6.1.14. Portability
The insured person will have the option to port the policy to other insurers by applying to such insurer to port the entire policy along with all the
members of the family, if any, at least 45 days before, but not earlier than 60 days from the policy renewal date as per IRDAI guidelines related to
portability. lf such person is presently covered and has been continuously covered without any lapses under any health insurance policy with an lndian
General/Health insurer, the proposed insured person will get the accrued continuity benefits in waiting periods as per IRDAI guidelines on portability
For Detailed Guidelines on portability, kindly refer the link https://www.irdai.gov.in/ADMINCMS/cms/whatsNew_Layout.aspx?page=PageNo3987&flag=1
6.1.15. Migration
The insured person will have the option to migrate the policy to other health insurance products/plans offered by the company by applying for
migration of the policy atleast 30 days before the policy renewal date as per IRDAI guidelines on Migration. lf such person is presently covered and
has been continuously covered without any lapses under any health insurance product/plan offered by the company, the insured person will get the
accrued continuity benefits in waiting periods as per IRDAI guidelines on migration.
For Detailed Guidelines on migration, kindly refer the link https://www.irdai.gov.in/ADMINCMS/cms/whatsNew_Layout.aspx?page=PageNo3987&flag=1
6.2. Specific Terms and Clauses
6.2.1. Automatic Cancellation

Individual Policy:
The Policy shall automatically terminate in the event of death of the Insured Person.
For Family Floater Policies:

The Policy shall automatically terminate in the event of the death of all the Insured Persons. .

Refund:
A refund in accordance with the table in Section 6.1.2.a shall be payable if there is an automatic cancellation of the Policy provided that no claim has
been made and e-consultation, Health Check-up, Emergency Assistance Services or Second Medical Opinion have not been availed under the Policy
by or on behalf of any Insured Person. We will pay the refund of premium to the Nominee named in the Policy Schedule or Your legal heirs or legal
representatives holding a valid succession certificate.
6.2.2. Loading on Premium

a. Based upon the disclosure of the health status of the persons proposed for insurance and declarations made in the Proposal or Insurance
Summary Sheet, We may apply a risk loading on the premium payable (excluding statutory levies and taxes) under the Policy. The maximum
risk loading applicable shall not exceed more than 250% of the premium.
b. These loadings will be applied from inception date of the First Policy and subsequent Renewal(s) with Us.
c. If a loading applies to the premium for the main Policy, such loading will also apply to the premium for the optional benefits selected except
under Section 4.1 (Personal Accident Cover) and Section 4.3 (e-consultation).
6.2.3. Other Renewal Conditions:
a. Continuity of benefits on Timely Renewal:

i. The Renewal premium is payable on or before the due date and in any circumstances before the expiry of Grace Period
ii. Renewal premium rates for this Policy may be further altered by Us including in the following circumstances:
A. You proposed to add an Insured Person to the Policy
B. You change any coverage provision
iii. Renewal premium will alter based on individual Age. The reference of Age for calculating the premium for Family Floater Policies shall be
the Age of the eldest Insured Person, and for Family First Policies it shall be the individual Age of each Insured Person of the family.
b. Reinstatement:
i. The Policy shall lapse after the expiration of the Grace Period. If the Policy is not Renewed within the Grace Period then We may agree to
issue a fresh Policy subject to Our underwriting criteria, as per Our Board approved underwriting policy and no continuing benefits shall be
available from the expired Policy.
ii. We will not pay for any Medical Expenses which are incurred between the date the Policy expires and the date immediately before the
reinstatement date of Your Policy.
iii. If there is any change in the Insured Person’s medical or physical condition, We may add exclusions or charge an extra premium from the
reinstatement date.
c. Disclosures on Renewal:
You shall make a full disclosure to Us in writing of any material change in the health condition or geographical location of any Insured Person at
the time of seeking Renewal of this Policy, irrespective of any claim arising or made. The terms and condition of the existing Policy will not be
altered.
d. Renewal for Insured Persons who have achieved Age 22:

If any Insured Person who is a child and has completed Age 22 years at the time of Renewal, then such Insured Person will have to take a separate
policy based on Our underwriting guidelines, as per Our Board approved underwriting policy as he/she will no longer be eligible to be covered
under a Family Floater Policy. In such cases, the credit of the Waiting Periods served under the Policy will be passed on to the separate policy
taken by such Insured Person.
e. Addition of Insured Persons on Renewal:

Where an individual is added to this Policy, either by way of endorsement or at the time of Renewal, the Pre-existing Disease clause, exclusions,
loading (if any) and Waiting Periods will be applicable considering such Policy Year as the first year of the Policy with Us for that Insured Person.
f. Changes to Sum Insured on Renewal:

You may opt for enhancement of Sum Insured at the time of Renewal, subject to underwriting. All Waiting Periods as defined in the Policy under
Section 5.1.1 shall apply afresh for this enhanced limit from the effective date of such enhancement.

6.2.4. Change of Policyholder
a. The Policyholder may be changed only at the time of Renewal. The new Policyholder must be a member of the Insured Person’s immediate
family. Such change would be solely subject to Our discretion and payment of premium by You. The Renewed Policy shall be treated as having
been Renewed without break. The Policyholder may be changed upon request in case of Your death, Your emigration from India or in case of
Your divorce during the Policy Period.
b. Any alteration in the Policy due to unavoidable circumstances as in case of the Policyholder’s death, emigration or divorce during the Policy
Period should be reported to Us immediately.
c. Renewal of such Policies will be according to terms and conditions of existing Policy.
6.2.5. Obligations in case of a minor

If an Insured Person is less than 18 years of Age, You or another adult Insured Person or legal guardian (in case of Your and all other adult Insured
Person’s demise) shall be completely responsible for ensuring compliance with all the terms and conditions of this Policy on behalf of that minor
Insured Person.
6.2.6. Authorization to obtain all pertinent records or information:

As a Condition Precedent to the payment of benefits, We and/or Our Service Provider shall have the authority to obtain all pertinent records or
information from any Medical Practitioner, Hospital, clinic, insurer, individual or institution to assess the validity of a claim submitted by or on behalf
of any Insured Person.
6.2.7. Policy Disputes

Any dispute concerning the interpretation of the terms, conditions, limitations and/or exclusions contained herein shall be governed by Indian law
and shall be subject to the jurisdiction of the Indian Courts.
6.2.8. Territorial Jurisdiction

All benefits are available in India only and all claims shall be payable in India in Indian Rupees only except for benefits and claims under Section 3.20
(Specified Illness cover), Section 3.22 (Emergency Medical Evacuation – outside the geographical boundaries of India) and Section 3.23 (Emergency
Hospitalization – outside the geographical boundaries of India).
6.2.9. Notices
Any notice, direction or instruction given under this Policy shall be in writing and delivered by hand, post, or facsimile to:
a. You/the Insured Person at the address specified in the Policy Schedule or at the changed address of which We must receive written notice.
b. Us at the following address:
Niva Bupa Health Insurance Company Limited
D-5, 2nd Floor, Logix Infotech Park (opp. Metro Station),
Sector 59, Noida, Uttar Pradesh, 201301
Fax No.: 011-4174-3397
c. No insurance agents, brokers or other person/entity is authorized to receive any notice on Our behalf.
d. In addition, We may send You/the Insured Person other information through electronic and telecommunications means with respect to Your
Policy from time to time.
6.2.10. Alteration to the Policy

This Policy constitutes the complete contract of insurance. Any change in the Policy will only be evidenced by a written endorsement signed and
stamped by Us. No one except Us can within the permission of the IRDAI change or vary this Policy.
6.2.11. Zonal pricing

For the purpose of calculating premium for silver and gold plan, following zones are available:
• Zone 1: All India coverage
• Zone 2: All India coverage (Co-payment applicable for Mumbai (including Navi Mumbai & Thane), Delhi NCR, Kolkata & Gujarat State).
If You select Zone 2, then 20% Co-payment will apply for treatment in Mumbai (including Navi Mumbai & Thane), Delhi NCR, Kolkata & Gujarat
State. This Zone-wise Co-payment shall not be applicable to any claim under Section 3.11 (Health Check-up), Section 3.13 (Pharmacy and diagnostic
services), Section 3.16 (Emergency Assistance Services), Section 3.18 (Second Medical Opinion), Section 3.20 (Specified Illness cover), Section 3.21
(OPD Treatment and Diagnostic Services), Section 4.1 (Personal Accident Cover), Section 4.2 (Critical Illness Cover), Section 4.3 (e-Consultation),
Section 4.4 (Premium Waiver) and Section 4.5 (Hospital Cash).

Note: Post choosing this option, zones can be changed only at the time of renewal on submission of proof of change in address or any other valid
reason.
For the purpose of calculating premium for platinum plan, the country has been divided into the following 3 zones based on the address provided
by You:
• Zone 1: Delhi (NCR), Surat, Kolkata, Mumbai (including Navi Mumbai & Thane)
• Zone 2: Pune, Ludhiana, Jaipur
• Zone 3: Rest of India
Note: Zone based Co-payment is not applicable for platinum plan.
6.2.12. Assignment
The Policy can be assigned subject to applicable laws.
6.2.13. Claim Cost Sharing Option / Conditions

The following claim cost sharing options shall apply under the Policy as per the plan in the Product Benefits Table and as specified in the Policy
Schedule and shall apply to all Insured Persons only if such options are selected by You in the Proposal Form and / or Information Summary Sheet.
These claim cost sharing options can be selected only at the time of issuance of the First Policy or at Renewal by You.
6.2.14. Co-payment
The Insured Person will bear a predetermined percentage of the admissible claim amounts subject to the Co-payment option chosen by You in the
Proposal Form and / or Information Summary Sheet irrespective of the Age of the Insured Person and the number of claims made.
Co-payment will not apply to any claim under Section 3.11 (Health Check-up), Section 3.13 (Pharmacy and diagnostic services), Section 3.16
(Emergency Assistance Services), Section 3.18 (Second Medical Opinion), Section 3.20 (Specified Illness cover), Section 3.21 (OPD Treatment and
Diagnostic Services), Section 4.1 (Personal Accident Cover), Section 4.2 (Critical Illness Cover), Section 4.3 (e-Consultation), Section 4.4 (Premium
Waiver) and Section 4.5 (Hospital Cash).
6.2.15. Annual Aggregate Deductible

The Insured Person shall bear on his/her own account an amount equal to the Deductible specified in the Policy Schedule for any and all admissible
claim amounts We assess to be payable by Us in respect of all claims made by that Insured Person under the Policy for a Policy Year. It is agreed that
Our liability to make payment under the Policy in respect of any claim made in that Policy Year will only commence once the Deductible has been
exhausted.
It is further agreed that:
a. The provisions in Section 6.2.14 on Co-payment (if opted) will apply to any amounts payable by Us in respect of a claim made by the Insured
Person after the Deductible has been exhausted.
b. Deductible will not apply to any claim under Section 3.11 (Health Checkup), Section 3.13 (Pharmacy and diagnostic services), Section 3.18 (Second
Medical Opinion), Section 4.1 (Personal Accident Cover), Section 4.2 (Critical Illness Cover), Section 4.3 (e-Consultation), Section 4.4 (Premium
Waiver) and Section 4.5 (Hospital Cash).
6.2.16. Claim Process & Requirements

The fulfillment of the terms and conditions of this Policy (including payment of full premium in advance by the due dates mentioned in the Policy
Schedule) in so far as they relate to anything to be done or complied with by You or any Insured Person, including complying with the following in
relation to claims, shall be Condition Precedent to admission of Our liability under this Policy.
6.2.16.1. Claims Administration:
On the occurrence or discovery of any Illness or Injury that may give rise to a claim under this Policy, the Claims Procedure set out below
shall be followed:
a. We advise You to submit all claims related document, including documents for claims within the Deductible amount, once the
Deductible limit has been exhausted.
b. The directions, advice and guidance of the treating Medical Practitioner shall be strictly followed.
c. We/Our Service Provider must be permitted to inspect the medical and Hospitalization records pertaining to the Insured Person’s
treatment and to investigate the circumstances pertaining to the claim.
d. We and Our Service Provider must be given all reasonable co-operation in investigating the claim in order to assess Our liability and
quantum in respect of the claim.

e. It is hereby agreed and understood that no change in the Medical Record provided under the Medical Advice information, by the
Hospital or the Insured Person to Us or Our Service Provider during the period of Hospitalization or after discharge by any means of
request will be accepted by Us. Any decision on request for acceptance of such change will be considered on merits where the change
has been proven to be for reasons beyond the claimant’s control.
6.2.16.2. Claims Procedure: On the occurrence or the discovery of any Illness or Injury that may give rise to a claim under this Policy, then as a
Condition Precedent to Our liability under the Policy the following procedure shall be complied with:
a. For Availing Cashless Facility: Cashless Facility can be availed only at Our Network Providers or Service Providers (as applicable). The
complete list of Network Providers is available on Our website and at Our branches and can also be obtained by contacting Us over the
telephone. In order to avail Cashless Facility, the following process must be followed:
i. Process for Obtaining Pre-Authorization
A. For Planned Treatment:
We must be contacted to pre-authorize Cashless Facility for planned treatment at least 72 hours prior to the proposed
treatment. Once the request for pre-authorisation has been granted, the treatment must take place within 15 days of the
pre-authorization date at a Network Provider.
B. In Emergencies:
If the Insured Person has been Hospitalized in an Emergency, We must be contacted to pre-authorize Cashless Facility
within 48 hours of the Insured Person’s Hospitalization or before discharge from the Hospital, whichever is earlier.
All final authorization requests, if required, shall be sent at least six hours prior to the Insured Person’s discharge from the Hospital.
Each request for pre-authorization must be accompanied with completely filled and duly signed pre-authorization form including all
of the following details:
I. The health card We have issued to the Insured Person at the time of inception of the Policy (if available) supported with KYC
document;
II. The Policy Number;
III. Name of the Policyholder;
IV. Name and address of Insured Person in respect of whom the request is being made;
V. Nature of the Illness/Injury and the treatment/Surgery required;
VI. Name and address of the attending Medical Practitioner;
VII. Hospital where treatment/Surgery is proposed to be taken;
VIII. Date of admission;
IX. First and any subsequent consultation paper / Medical Record since beginning of diagnosis of that treatment/Surgery;
X. Admission note;
XI. Treating Medical Practitioner certificate for Illness / Insured Event history with justification of Hospitalization.
If these details are not provided in full or are insufficient for Us to consider the request, We will request additional information or
documentation in respect of that request.
When We have obtained sufficient details to assess the request, We will issue the authorization letter specifying the sanctioned
amount, any specific limitation on the claim, applicable Deductible / Co-payment and non-payable items, if applicable, or reject the
request for pre-authorisation specifying reasons for the rejection.
In case of preauthorization request where chronicity of condition is not established as per clinical evidence based information,
We may reject the request for preauthorization and ask the claimant to claim as Reimbursement. Claim document submission for
Reimbursement shall not be deemed as an admission of Our liability.
Once the request for pre-authorisation has been granted, the treatment must take place within 15 days of the pre-authorization date
and pre-authorization shall be valid only if all the details of the authorized treatment, including dates, Hospital, locations, indications
and disease details, match with the details of the actual treatment received. For Hospitalization on a Cashless Facility basis, We will
make the payment of the amount assessed to be due, directly to the Network Provider / Service Provider.
We reserve the right to modify, add or restrict any Network Provider or Service Provider for Cashless Facility at Our sole discretion.
ii. Reauthorization
Cashless Facility will be provided subject to re-authorization if requested for either change in the line of treatment or in the
diagnosis or for any procedure carried out on the incidental diagnosis/finding prior to the discharge from the Hospital.

b. For Reimbursement Claims:
For all claims for which Cashless Facility has not been pre-authorized or for which treatment has not been taken at a Network Provider/
Service Provider or for which Cashless Facility is not available, We shall be given written notice of the claim along with the following
details within 48 hours of admission to the Hospital or before discharge from the Hospital, whichever is earlier:
i. The Policy Number;
ii. Name of the Policyholder;
iii. Name and address of the Insured Person in respect of whom the request is being made;
iv. Nature of Illness or Injury and the treatment/Surgery taken;
v. Name and address of the attending Medical Practitioner;
vi. Hospital where treatment/Surgery was taken;
vii. Date of admission and date of discharge;
viii. Any other information that may be relevant to the Illness/ Injury/ Hospitalization.
6.2.16.3. Claims Documentation:
For medical claims – Reimbursement Facility:
We shall be provided with the following necessary information and documentation in respect of all claims at Your/Insured Person’s expense
within 30 days of the Insured Event giving rise to a claim or within 30 days from the date of occurrence of an Insured Event or completion of
Survival Period (in case of Critical Illness Cover).
For medical claims – Cashless Facility:
We will be provided these documents by the Network Provider immediately following the Insured Person’s discharge from Hospital.
Necessary information and documentation for medical claims
a. Claim form duly completed and signed by the claimant.

b. Details of past medical history record, first and subsequent consultation.
c. Age / Identity proof document of Insured Person in case of claim approved under Cashless Facility (not required if submitted at the
time of pre-authorization request) and Policyholder in case of Reimbursement claim.
i. Self attested copy of valid age proof (passport / driving license / PAN card / class X certificate / birth certificate);
ii. Self attested copy of identity proof (passport / driving license / PAN card / voter identity card);
iii. Recent passport size photograph
d. Cancelled cheque/ bank statement / copy of passbook mentioning account holder’s name, IFSC code and account number printed on
it of Policyholder / nominee ( in case of death of Policyholder).
e. Original discharge summary.
f. Bar code sticker and invoice for implants and prosthesis (if used and only in case of Surgery/Surgical Procedure).
g. Original final bill from Hospital with detailed break-up and paid receipt.
h. Room tariff of the entitled room category (in case of a Non-Network provider and if room tariff is not a part of Hospital bill): duly
signed and stamped by the Hospital in which treatment is taken.
(In case You are unable to submit such document, then We shall consider the Reasonable and Customary Charges of the Insured
Person’s eligible room category of Our Network Provider within the same geographical area for identical or similar services.)
i. Original bills of pharmacy/medicines purchased, or of any other investigation done outside Hospital with reports and requisite
prescriptions.
j. For Medico-legal cases (MLC) or in case of Accident
i. MLC/ Panchnama / First Information Report (FIR) copy attested by the concerned Hospital / police station (if applicable);
ii. Original self-narration of incident in absence of MLC / FIR.
k. Original laboratory investigation, diagnostic, radiological & pathological reports with supporting prescriptions.
In the event of the Insured Person’s death during Hospitalization, written notice accompanied by a copy of the post mortem report (if
any) shall be given to Us regardless of whether any other notice has been given to Us.

For Personal Accident claims
Additional claim documentation for Personal Accident Cover under Section 4.1:
a. Accident Death
i. Copy of death certificate (issued by the office of Registrar of Births and Deaths or any other authorized legal institution)
ii. Copy of post mortem report wherever applicable
b. Accident Permanent Total Disability or Accident Permanent Partial Disability

i. Certificate of disability issued by a Medical Board duly constituted by the Central and/or the State Government.
For Critical Illness claims
Additional claim documentation for Critical Illness Cover under Section 4.2:
a. Treating Medical Practitioner’s certification for insured person’s survival post survival period.
For claims outside India
Additional claim documentation for claims incurring outside India:
a. Passport copy with entry and exit stamps

b. Additional documents as specified under each benefit
6.2.16.4. Claims Assessment & Repudiation:
a. At Our discretion, We may investigate claims to determine the validity of a claim. All costs of investigation will be borne by Us and all
investigations will be carried out by those individuals/entities that are authorized by Us in writing.
b. Payment for Reimbursement claims will be made to You. In the unfortunate event of Your death, We will pay the Nominee named in
the Policy Schedule or Your legal heirs or legal representatives holding a valid succession certificate.
c. We are not obliged to make payment for any claim or that part of any claim that could have been avoided or reduced if the Insured
Person had taken reasonable care, or that is brought about or contributed to by the Insured Person failing to follow the directions,
advice or guidance provided by a Medical Practitioner.
d. If a claim is made which extends in to two Policy Periods, then such claim shall be paid taking into consideration the available Sum
Insured in these Policy Periods. Such eligible claim amount will be paid to the Policyholder/Insured Person after deducting the extent
of premium to be received for the Renewal/due date of premium of the Policy, if not received earlier.
e. All admissible claims under this Policy shall be assessed by Us in the following progressive order:-
i. If a room has been opted in a Hospital for which the room category is higher than the eligible limit as applicable for that Insured
Person as specified in the Policy Schedule, then the Associated Medical Expenses payable shall be pro-rated as per the applicable
limits in accordance with Section 3.1.
ii. The Deductible (if applicable) shall be applied to claims that are either paid or payable under this Policy. Our liability to make
payment shall commence only once the amount of eligible claims as per policy terms and conditions exceeds the Deductible limit
within the same Policy Year.
iii. Co-payment (if applicable) as specified in the Policy Schedule shall be applicable on the amount payable by Us.
f. The claim amount assessed in Section 6.2.16.4 e above would be deducted from the amount mentioned against each benefit and Sum
Insured as specified in the Policy Schedule.
6.2.16.5. Delay in Claim Intimation or Claim Documentation:
If the claim is not notified to Us or claim documents are not submitted within the stipulated time as mentioned in the above sections, then
We shall be provided the reasons for the delay, in writing. We will condone such delay on merits where the delay has been proved to be for
reasons beyond the claimant’s control.

6.2.16.6. Claims process for Section 4.3 (e-Consultation):
After validation of Insured Person and Policy details, We will evaluate the information of the Insured Person from the perspective to check
eligibility of cover only and if the request is approved, We will facilitate arrangement as per the conditions specified under respective
benefits admissible to the Insured Person.
6.2.16.7. Claim process for Section 3.11 (Health Checkup)
a. The Insured Person shall seek appointment by contacting Our Service Provider.
b. Our Service Provider will facilitate Your appointment.
c. Reports of the medical tests can be collected directly from the Service Provider.
6.2.16.8. Claims process for Section 3.16.b and Section 3.22 (Emergency Medical Evacuation)
a. In the event of an Emergency, Our Service Provider shall be contacted immediately on the helpline number specified in the Insured
Person’s health card.
b. Our Service Provider will evaluate the necessity for evacuation of the Insured Person and if the request for Medical Evacuation is
approved by Us, the Service Provider shall pre-authorise the type of travel that can be utilized to transport the Insured Person and
provide information on the Hospital that may be approached for medical treatment of the Insured Person.
c. If the Service Provider pre-authorises the Medical Evacuation of the Insured Person by means of Air Transportation through an air
ambulance or commercial flight whichever is best suited, the Service Provider shall also arrange for the same to be provided to the
Insured Person unless there are any logistical constraints or the medical condition of the Insured Person prevents Emergency Medical
Evacuation.
d. It is agreed and understood that We shall not cover any claims for Reimbursement of the costs incurred in the evacuation or
transportation of the Insured Person or which are not pre-authorized by Our Service Provider.
6.2.16.9. Claim process for Section 3.18 (Second Medical Opinion)
a. In the event of submission of request for Second Medical Opinion, Our Service Provider shall be contacted immediately on the helpline
number specified in the Insured Person’s health card.
b. Our Service Provider will evaluate the information of the Insured Person and if the request for Second Medical Opinion is approved,
the Service Provider will facilitate arrangement as per conditions specified in the Section 3.18
6.2.16.10. Claim process for Section 3.20 (Specified Illness Cover)
a. In the event of the diagnosis of a Specified Illness, the Insured Person should call Us immediately and in any event before the
commencement of the travel for treatment overseas on the helpline number specified on in the Insured Person’s health card,
requesting for a pre-authorization for the treatment.
b. We will evaluate the request and the eligibility of the Insured Person’s Policy and call for more information or details, if required.
c. We will communicate directly to the Service Provider and the Insured Person whether the request for pre-authorization has been
approved or denied.
d. If the pre-authorization request is approved, Our Service Provider will directly settle the claim with the Hospital. Any additional costs
or expenses incurred by or on behalf of the Insured Person beyond the limits pre-authorized by the Service Provider or at any Non-
Network Hospital shall be borne by the Insured Person.
e. This benefit is available only as Cashless Facility through pre-authorization by Us.

6.2.16.11. Claims process for Section 3.23 (Emergency Hospitalization – outside the geographical boundaries of India)
a. The health card We provide will enable the Insured Person to access medical treatment at any Network Provider outside India, but
within those regions specified in the Policy Schedule, on a cashless basis only by the production of the card to the Network Provider
prior to admission, subject to the following:
i. In the event of an Emergency, the Insured Person or Network Provider shall call Our Service Provider immediately, on the helpline
number specified in the Insured Person’s health card, requesting for a pre-authorization for the medical treatment required.
ii. Our Service Provider will evaluate the request and the eligibility of the Insured Person under the Policy and call for more
information or details, if required. Our Service Provider will communicate directly to the Hospital whether the request for pre-
authorization has been approved or denied.
iii. If the pre-authorization request is approved, Our Service Provider will directly settle the claim with the Hospital. Any additional
costs or expenses incurred by or on behalf of the Insured Person beyond the limits pre-authorized by the Service Provider shall
be borne by the Insured Person.
iv. It is agreed and understood that We shall not cover any claims for Reimbursement of the costs incurred in relation to the
Hospitalization of the Insured Person while inside or outside India or any claims which are not pre-authorized by Us.
Disclaimer: Niva Bupa Health Insurance Company Limited (formerly known as Max Bupa Health Insurance Company Limited) (IRDAI Registration No. 145). ‘Bupa’ and
‘HEARTBEAT’ logo are registered trademarks of their respective owners and are being used by Niva Bupa Health Insurance Company Limited under license. Registered Office
Address: C-98, First Floor, Lajpat Nagar, Part 1, New Delhi-110024, Customer Helpline No.: 1860-500-8888. Fax: +91 11 41743397. Website: www.nivabupa.com.
CIN: U66000DL2008PLC182918. For more details on risk factors, terms and conditions, please read sales brochure carefully before concluding the sale.

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

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

GUWAHATI - Shri Somnath Ghosh
Jeevan Nivesh, 5th Floor,
Assam, Meghalaya, Manipur, Mizoram, Arunachal Pradesh, Nagaland
Nr. Panbazar over bridge, S.S. Road,
and Tripura
Guwahati – 781001(ASSAM).
Tel.: 0361 - 2632204 / 2602205
Email: bimalokpal.guwahati@cioins.co.in
HYDERABAD - Shri N. Sankaran
6-2-46, 1st floor, “Moin Court”,
Andhra Pradesh, Telangana, Yanam and part of Union Territory of
Lane Opp. Saleem Function Palace,
Puducherry
A. C. Guards, Lakdi-Ka-Pool, Hyderabad - 500 004.
Tel.: 040 - 23312122
Email: bimalokpal.hyderabad@cioins.co.in
JAIPUR - Shri Rajiv Dutt Sharma
Jeevan Nidhi – II Bldg., Gr. Floor,
Bhawani Singh Marg, Rajasthan
Jaipur - 302 005.
Tel.: 0141 - 2740363
Email: bimalokpal.jaipur@cioins.co.in
ERNAKULAM - Shri G. Radhakrishnan
2nd Floor, Pulinat Bldg.,
Opp. Cochin Shipyard, M. G. Road, Kerala, Lakshadweep, Mahe-a part of Union Territory of Puducherry
Ernakulam - 682 015.
Tel.: 0484 - 2358759 / 2359338
Email: bimalokpal.ernakulam@cioins.co.in
KOLKATA - Shri P. K. Rath
Hindustan Bldg. Annexe, 4th Floor,
West Bengal, Sikkim,
4, C.R. Avenue,
Andaman & Nicobar Islands
KOLKATA - 700 072.
Tel.: 033 - 22124339 / 22124340
Email: bimalokpal.kolkata@cioins.co.in
LUCKNOW Districts of Uttar Pradesh : Lalitpur, Jhansi, Mahoba, Hamirpur, Banda,
Office of the Insurance Ombudsman, Chitrakoot, Allahabad, Mirzapur, Sonbhabdra, Fatehpur, Pratapgarh,
6th Floor, Jeevan Bhawan, Phase-II, Jaunpur,Varanasi, Gazipur, Jalaun, Kanpur, Lucknow, Unnao, Sitapur,
Nawal Kishore Road, Hazratganj, Lakhimpur, Bahraich, Barabanki, Raebareli, Sravasti, Gonda, Faizabad,
Lucknow - 226 001. Amethi, Kaushambi, Balrampur, Basti, Ambedkarnagar, Sultanpur,
Tel.: 0522 - 2231330 / 2231331 Maharajgang, Santkabirnagar, Azamgarh, Kushinagar, Gorkhpur,
Email: bimalokpal.lucknow@cioins.co.in Deoria, Mau, Ghazipur, Chandauli, Ballia, Sidharathnagar
MUMBAI - Shri Bharatkumar S. Pandya
3rd Floor, Jeevan Seva Annexe,
Goa, Mumbai Metropolitan Region
S. V. Road, Santacruz (W),
(excluding Navi Mumbai & Thane)
Mumbai - 400 054.
Tel.: 69038821/23/24/25/26/27/28/28/29/30/31
Email: bimalokpal.mumbai@cioins.co.in

NOIDA - Shri Chandra Shekhar Prasad
State of Uttarakhand and the following Districts of Uttar Pradesh: Agra,
Aligarh, Bagpat, Bareilly, Bijnor, Budaun, Bulandshehar, Etah, Kannauj,
Bhagwan Sahai Palace
Mainpuri, Mathura, Meerut, Moradabad, Muzaffarnagar, Oraiyya, Pilibhit,
4th Floor, Main Road, Naya Bans, Sector 15,
Etawah, Farrukhabad, Firozbad, Gautam Buddh nagar, Ghaziabad,
Distt: Gautam Buddh Nagar, U.P-201301.
Hardoi, Shahjahanpur, Hapur, Shamli, Rampur, Kashganj, Sambhal,
Tel.: 0120-2514252 / 2514253
Amroha, Hathras, Kanshiramnagar, Saharanpur
Email: bimalokpal.noida@cioins.co.in
PATNA - Shri N. K. Singh
2nd Floor, Lalit Bhawan,
Bihar,
Bailey Road,
Jharkhand
Patna 800 001.
Tel.: 0612-2547068
Email: bimalokpal.patna@cioins.co.in
PUNE - Shri Vinay Sah
Jeevan Darshan Bldg., 3rd Floor,
Maharashtra, Areas of Navi Mumbai and Thane (excluding Mumbai
C.T.S. No.s. 195 to 198, N.C. Kelkar Road,
Metropolitan Region
Narayan Peth, Pune – 411 030.
Tel.: 020-41312555
Email: bimalokpal.pune@cioins.co.in
Council for Insurance Ombudsmen,

3rd Floor, Jeevan Seva Annexe,
S. V. Road, Santacruz (W),
Mumbai - 400 054.
E-mail: inscoun@cioins.co.in
Tel: 022 -69038800/69038812

ANNEXURE II – Product Benefit Table (all limits in INR unless defined as percentage)
Individual and Family Floater - Silver Plan (Renewal only)

Base Sum Insured (in Rs) 2 lacs 3 lacs
Benefits
Inpatient care Covered up to Sum Insured
Room rent Shared Room or 1% of the Base Sum Insured per day
Pre-Hospitalization Medical Expenses (60 days) Covered up to Sum Insured
Post-Hospitalization Medical Expenses (90 days) Covered up to Sum Insured
Alternative Treatment Covered up to Sum Insured
Day Care Treatment Covered up to Sum Insured
Domiciliary Hospitalization Covered up to Sum Insured
Maternity Benefit (covered for up to 2 pregnancies or
Covered up to Rs 20,000 Covered up to Rs 30,000
terminations) (1)
New Born Baby (covered uptill the end of Policy Year) (1) Covered up to Sum Insured
Vaccination of the new born baby Covered until new born baby completes one year, vaccinations as per annexure
Living Organ Donor Transplant Covered up to Sum Insured
Network Hospital: Covered up to Sum Insured
Emergency Ambulance
Non-network Hospital: Covered up to Rs. 2,000 per event
Re-fill benefit Reinstate up to base Sum Insured. Applicable for same & different illness as well
Pharmacy and diagnostic services Available through our empanelled service provider
HIV / AIDS (waiting period of 4 years) covered up to Rs 50,000
Emergency assistance services covered up to Sum Insured
Mental disorder treatment (waiting period of 3 years) Covered up to Sum Insured (sub-limit of Rs 50,000 applicable on few conditions)
Increase of 10% of expiring Base Sum Insured in a Policy Year; maximum up to 50% of Base
Loyalty Additions
Sum Insured
Health Check-up (2) Once in two years, tests as per annexure
Modern Treatments Covered up to Sum Insured with sub-limit of Rs. 1Lac on few robotic surgeries
Optional Benefits
Hospital Cash (3) Rs 1,500/day
Personal Accident cover (for insured aged 18 years & above
Personal Accident cover will be equal to 5 times of base Sum Insured
on individual basis)
Critical illness cover (for insured 18 years & above on
Critical illness cover will be equal to base Sum Insured
individual basis)
e-consultation Unlimited tele / online consultations
Premium Waiver One time premium waiver if the Policyholder dies or suffers from specified illness
Claim cost sharing options
Co-payment Options of 10% and 20% co-payment
Annual aggregate Deductible 1 lac/ 2 lacs / 3 lacs
(1) subject to a continuous coverage of 24 months of that Insured Person since the inception of the first Policy which offers Maternity benefit with Us.
(2) If the Policy is Renewed with Us without a break or if the Policy continues to be in force for the 2nd Policy Year in the 2 year Policy Period (if applicable)
(3) Hospital Cash - Minimum 48 hrs of continuous hospitalization required. Maximum coverage offered for 30 days/policy year/insured person. Payment
made from day one subject to hospitalization claim being admissible.

Individual and Family Floater - Gold Plan
Base Sum Insured (in Rs) 5 lacs 7.5 lacs 10 lacs 15 lacs 20 lacs 30 lacs 50 lacs
Benefits
Room rent Covered up to Sum Insured (except for Suite or above room category)
Covered Covered Covered Covered Covered Covered Covered
up to Rs up to Rs up to Rs up to Rs up to Rs up to Rs up to Rs
terminations) (1)
40,000 60,000 70,000 75,000 80,000 1,00,000 1,00,000
Emergency Ambulance
Loyalty Additions
Sum Insured
Annual, Annual, Annual, Annual, Annual, Annual, Annual,
Tests Tests Tests Tests Tests Tests Tests
covered up covered up covered up covered up covered up covered up covered up
Health Check-up (2) to worth to worth to worth to worth to worth to worth to worth
Rs 1,250 Rs 1,875 Rs 2,500 Rs 2,500 Rs 2,500 Rs 2,500 Rs 2,500
per Insured per Insured per Insured per Insured per Insured per Insured per Insured
Person Person Person Person Person Person Person
Optional Benefits
Personal Accident cover (for insured aged 18 years & Personal Accident cover will be equal to 5 times of base Sum Insured; subject to maximum of
above on individual basis) 50 lacs
Critical illness cover will be equal to base Sum Insured; subject to maximum of 10 lacs
individual basis)
(2) If the Policy is Renewed with Us without a break or if the Policy continues to be in force for the 2nd Policy Year in the 2 year Policy Period (if
applicable)

Individual and Family Floater - Platinum Plan
Base Sum Insured (in Rs) 15 lacs 20 lacs 50 lacs 1 Cr
Benefits
Room rent Covered up to Sum Insured
Maternity Benefit (covered for up to 2 pregnancies or Covered up to Rs Covered up to Rs Covered up to Rs Covered up to Rs
terminations) (1) 120,000 160,000 200,000 200,000
Emergency Ambulance Non-network Hospital: Covered up to Rs. 2,000 per event
Covered up to Rs Covered up to Rs Covered up to Rs Covered up to Rs
OPD Treatment and Diagnostic Services
15,000 20,000 35,000 50,000
Child Care Benefits (Vaccinations for children up to 12
years including one consultation for nutrition and growth Covered up to Sum Insured (As per annexure)
during the visit for vaccination)
Emergency Medical Evacuation (outside the geographical
Covered up to Sum Insured ( for worldwide excluding USA & Canada)
boundaries of India)
Emergency Hospitalization (outside the geographical
Specified Illness Cover (outside the geographical
boundaries of India) (2)
Covered, One opinion per Insured Person per Specified Illness / planned Surgery / Surgical
Second Medical Opinion
Procedure
Loyalty Additions
Sum Insured
Annual, tests covered Annual, tests covered Annual, tests covered Annual, tests covered
Health Check-up (3) up to worth Rs 3750 up to worth Rs 5000 up to worth Rs 5000 up to worth Rs 5000
per Insured Person per Insured Person per Insured Person per Insured Person
Optional Benefits
USA & Canada included for ‘Emergency Medical Evacuation’, ‘Emergency Hospitalization’ &
Enhanced Geographical Scope for International coverage
‘Specified illness cover’

Individual and Family Floater - Platinum Plan
Base Sum Insured (in Rs) 15 lacs 20 lacs 50 lacs 1 Cr
Personal Accident cover (for insured aged 18 years &
Personal Accident cover will be equal to 50 lacs
above on individual basis)
Critical illness cover will be equal to 10 lacs
individual basis)
(2) The symptoms of the Specified Illness first occur or manifest itself during the Policy Period and after completion of the 90 day from the inception of 1st
Policy with Us.
applicable)

Family First - Silver Plan
Base Sum Insured: 1Lacs, 2Lacs, 3Lacs, 4Lacs & 5Lacs per Insured Person
Floater Sum Insured – (available on a floating basis over Base Sum Insured): 3Lacs, 4Lacs,
5Lacs, 10Lacs &15Lacs.
Benefits
Room rent Rs 3,000 per day or Shared Room
Covered up to Rs 35,000 per Policy Year
terminations) (1)
Loyalty Additions
Sum Insured
Health Check-up (2) Once in two years, tests as per annexure
Optional Benefits
Personal Accident cover (for insured aged 18 years &
Personal Accident cover will be equal to 5 times of base Sum Insured
above on individual basis)
Critical illness cover will be equal to base Sum Insured
individual basis)
applicable)

Family First - Gold Plan
Base Sum Insured: 1Lacs, 2Lacs, 3Lacs, 4Lacs, 5Lacs, 10Lacs & 15Lacs per Insured Person
Floater Sum Insured – (available on a floating basis over Base Sum Insured): 3Lacs, 4Lacs,
5Lacs, 10Lacs, 15Lacs, 20Lacs, 30Lacs & 50Lacs
Benefits
Room rent Covered up to Sum Insured (except for Suite or above room category)
Covered up to Rs 50,000 per Policy Year
terminations) (1)
Emergency Ambulance
Loyalty Additions
Sum Insured
Health Check-up (2) Annual, Tests covered up to worth Rs 2,500 per Insured Person
Optional Benefits
individual basis)
applicable)

Family First - Platinum Plan
Base Sum Insured: 5Lacs, 10 Lacs & 15 Lacs per Insured Person
Floater Sum Insured: (available on a floating basis over Base Sum Insured): 15Lacs, 20 Lacs,
30 Lacs & 50 Lacs.
Benefits
Room rent Covered up to Sum Insured
Covered up to Rs 100,000
terminations) (1)
OPD Treatment and Diagnostic Services Covered up to Rs 35,000
Child Care Benefits (Vaccinations for children up to 12
years including one consultation for nutrition and growth Covered up to Sum Insured (As per annexure)
during the visit for vaccination)
Emergency Medical Evacuation (outside the geographical
Emergency Hospitalization (outside the geographical
Specified Illness Cover (outside the geographical
boundaries of India) (2)
Covered, One opinion per Insured Person per Specified Illness / planned Surgery / Surgical
Second Medical Opinion
Procedure
Loyalty Additions
Sum Insured
Health Check-up (3) Annual, tests covered up to worth Rs 5000 per Insured Person
Optional Benefits
USA & Canada included for ‘Emergency Medical Evacuation’, ‘Emergency Hospitalization’ &
Enhanced Geographical Scope for International coverage
‘Specified illness cover’

individual basis)
(2) The symptoms of the Specified Illness first occur or manifest itself during the Policy Period and after completion of the 90 day from the inception of 1st
Policy with Us.
applicable)

Annexure III - Day Care Treatments
S.No. Header Procedure Name S.No. Header Procedure Name

I Cardiology Related: 38 Other Operations On The Middle And Inner Ear
1 Coronary Angiography 39 Excision And Destruction Of Diseased Tissue Of The Nose
II Critical Care Related: 40 Other Operations On The Nose
2 Insert Non- Tunnel Cv Cath 41 Nasal Sinus Aspiration
3 Insert Picc Cath ( Peripherally Inserted Central Catheter ) 42 Foreign Body Removal From Nose
43 Other Operations On The Tonsils And Adenoids
4 Replace Picc Cath ( Peripherally Inserted Central Catheter )
44 Adenoidectomy
5 Insertion Catheter, Intra Anterior
45 Labyrinthectomy For Severe Vertigo
6 Insertion Of Portacath
46 Stapedectomy Under Ga
III Dental Related:
47 Stapedectomy Under La
7 Splinting Of Avulsed Teeth
48 Tympanoplasty (Type Iv)
8 Suturing Lacerated Lip
49 Endolymphatic Sac Surgery For Meniere's Disease
9 Suturing Oral Mucosa
50 Turbinectomy
10 Oral Biopsy In Case Of Abnormal Tissue Presentation
51 Endoscopic Stapedectomy
11 Fnac
52 Incision And Drainage Of Perichondritis
12 Smear From Oral Cavity
53 Septoplasty
IV ENT Related:
54 Vestibular Nerve Section
13 Myringotomy With Grommet Insertion
55 Thyroplasty Type I
Tympanoplasty (Closure Of An Eardrum Perforation/
14 56 Pseudocyst Of The Pinna - Excision
Reconstruction Of The Auditory Ossicles)
57 Incision And Drainage - Haematoma Auricle
15 Removal Of A Tympanic Drain
58 Tympanoplasty (Type Ii)
16 Keratosis Removal Under Ga
59 Reduction Of Fracture Of Nasal Bone
17 Operations On The Turbinates (Nasal Concha)
Tympanoplasty (Closure Of An Eardrum Perforation/ 60 Thyroplasty Type Ii
18
Reconstruction Of The Auditory Ossicles) 61 Tracheostomy
19 Removal Of Keratosis Obturans 62 Excision Of Angioma Septum
20 Stapedotomy To Treat Various Lesions In Middle Ear 63 Turbinoplasty
21 Revision Of A Stapedectomy 64 Incision & Drainage Of Retro Pharyngeal Abscess
22 Other Operations On The Auditory Ossicles 65 Uvulo Palato Pharyngo Plasty
Myringoplasty (Postaura/Endaural Approach As Well As 66 Adenoidectomy With Grommet Insertion
23
Simple Type -I Tympanoplasty) 67 Adenoidectomy Without Grommet Insertion
24 Fenestration Of The Inner Ear
68 Vocal Cord Lateralisation Procedure
25 Revision Of A Fenestration Of The Inner Ear
69 Incision & Drainage Of Para Pharyngeal Abscess
26 Palatoplasty
70 Tracheoplasty
27 Transoral Incision And Drainage Of A Pharyngeal Abscess V Gastroenterology Related:
28 Tonsillectomy Without Adenoidectomy Cholecystectomy And Choledocho-Jejunostomy/

71
29 Tonsillectomy With Adenoidectomy Duodenostomy/Gastrostomy/Expl Oration Common Bile Duct
30 Excision And Destruction Of A Lingual Tonsil Esophagoscopy, Gastroscopy, Duodenoscopy With
31 Revision Of A Tympanoplasty 72 Polypectomy/ Removal Of Foreign Body/Diathermy Of
Bleeding Lesions
32 Other Microsurgical Operations On The Middle Ear
73 Pancreatic Pseudocyst Eus & Drainage
33 Incision Of The Mastoid Process And Middle Ear
74 Rf Ablation For Barrett's Oesophagus
34 Mastoidectomy
75 Ercp And Papillotomy
35 Reconstruction Of The Middle Ear
76 Esophagoscope And Sclerosant Injection
36 Other Excisions Of The Middle And Inner Ear
Incision (Opening) And Destruction (Elimination) Of The Inner 77 Eus + Submucosal Resection
37
Ear 78 Construction Of Gastrostomy Tube

79 Eus + Aspiration Pancreatic Cyst 123 Piles
80 Small Bowel Endoscopy (Therapeutic) 124 A)Injection Sclerotherapy
81 Colonoscopy ,Lesion Removal 125 B)Piles Banding
82 Ercp 126 Liver Abscess- Catheter Drainage
83 Colonscopy Stenting Of Stricture 127 Fissure In Ano- Fissurectomy
84 Percutaneous Endoscopic Gastrostomy 128 Fibroadenoma Breast Excision
85 Eus And Pancreatic Pseudo Cyst Drainage 129 Oesophageal Varices Sclerotherapy
86 Ercp And Choledochoscopy 130 Ercp - Pancreatic Duct Stone Removal
87 Proctosigmoidoscopy Volvulus Detorsion 131 Perianal Abscess I&D
88 Ercp And Sphincterotomy 132 Perianal Hematoma Evacuation
89 Esophageal Stent Placement 133 Ugi Scopy And Polypectomy Oesophagus
90 Ercp + Placement Of Biliary Stents 134 Breast Abscess I& D
91 Sigmoidoscopy W / Stent 135 Feeding Gastrostomy
92 Eus + Coeliac Node Biopsy 136 Oesophagoscopy And Biopsy Of Growth Oesophagus
Ugi Scopy And Injection Of Adrenaline, Sclerosants Bleeding 137 Ercp - Bile Duct Stone Removal
93
Ulcers 138 Ileostomy Closure
VI General Surgery Related: 139 Colonoscopy
94 Incision Of A Pilonidal Sinus / Abscess 140 Polypectomy Colon
95 Fissure In Ano Sphincterotomy 141 Splenic Abscesses Laparoscopic Drainage
Surgical Treatment Of A Varicocele And A Hydrocele Of The 142 Ugi Scopy And Polypectomy Stomach
96
Spermatic Cord
143 Rigid Oesophagoscopy For Fb Removal
97 Orchidopexy
144 Feeding Jejunostomy
98 Abdominal Exploration In Cryptorchidism
145 Colostomy
99 Surgical Treatment Of Anal Fistulas
146 Ileostomy
100 Division Of The Anal Sphincter (Sphincterotomy)
147 Colostomy Closure
101 Epididymectomy
148 Submandibular Salivary Duct Stone Removal
102 Incision Of The Breast Abscess
149 Pneumatic Reduction Of Intussusception
103 Operations On The Nipple
150 Varicose Veins Legs - Injection Sclerotherapy
104 Excision Of Single Breast Lump
151 Rigid Oesophagoscopy For Plummer Vinson Syndrome
105 Incision And Excision Of Tissue In The Perianal Region
152 Pancreatic Pseudocysts Endoscopic Drainage
106 Surgical Treatment Of Hemorrhoids
153 Zadek's Nail Bed Excision
107 Other Operations On The Anus
154 Subcutaneous Mastectomy
108 Ultrasound Guided Aspirations
155 Excision Of Ranula Under Ga
109 Sclerotherapy,
156 Rigid Oesophagoscopy For Dilation Of Benign Strictures
110 Therapeutic Laparoscopy With Laser
157 Eversion Of Sac Unilateral/Bilateral
111 Infected Keloid Excision
158 Lord's Plication
112 Axillary Lymphadenectomy
159 Jaboulay's Procedure
113 Wound Debridement And Cover
160 Scrotoplasty
114 Abscess-Decompression
161 Circumcision For Trauma
115 Cervical Lymphadenectomy
162 Meatoplasty
116 Infected Sebaceous Cyst
163 Intersphincteric Abscess Incision And Drainage
117 Inguinal Lymphadenectomy
164 Psoas Abscess Incision And Drainage
118 Incision And Drainage Of Abscess
165 Thyroid Abscess Incision And Drainage
119 Suturing Of Lacerations
166 Tips Procedure For Portal Hypertension
120 Scalp Suturing
167 Esophageal Growth Stent
121 Infected Lipoma Excision
168 Pair Procedure Of Hydatid Cyst Liver
122 Maximal Anal Dilatation
169 Tru Cut Liver Biopsy

Photodynamic Therapy Or Esophageal Tumour And Lung 213 Culdotomy
170
Tumour 214 Salpingo-Oophorectomy Via Laparotomy
171 Excision Of Cervical Rib
215 Endoscopic Polypectomy
172 Laparoscopic Reduction Of Intussusception
216 Hysteroscopic Removal Of Myoma
173 Microdochectomy Breast
217 D&C
174 Surgery For Fracture Penis
218 Hysteroscopic Resection Of Septum
175 Sentinel Node Biopsy
219 Thermal Cauterisation Of Cervix
176 Parastomal Hernia
220 Mirena Insertion
177 Revision Colostomy
221 Hysteroscopic Adhesiolysis
178 Prolapsed Colostomy- Correction
222 Leep (Loop Electrosurgical Excision Procedure)
179 Testicular Biopsy
223 Cryocauterisation Of Cervix
180 Laparoscopic Cardiomyotomy( Hellers)
224 Polypectomy Endometrium
181 Sentinel Node Biopsy Malignant Melanoma
225 Hysteroscopic Resection Of Fibroid
182 Laparoscopic Pyloromyotomy( Ramstedt)
226 Lletz (Large Loop Excision Of Transformation Zone)
183 Excision Of Fistula-In-Ano
227 Conization
184 Excision Juvenile Polyps Rectum
228 Polypectomy Cervix
185 Vaginoplasty
229 Hysteroscopic Resection Of Endometrial Polyp
186 Dilatation Of Accidental Caustic Stricture Oesophageal
230 Vulval Wart Excision
187 Presacral Teratomas Excision
231 Laparoscopic Paraovarian Cyst Excision
188 Removal Of Vesical Stone
232 Uterine Artery Embolization
189 Excision Sigmoid Polyp
233 Laparoscopic Cystectomy
190 Sternomastoid Tenotomy
234 Hymenectomy( Imperforate Hymen)
191 Infantile Hypertrophic Pyloric Stenosis Pyloromyotomy
235 Endometrial Ablation
192 Excision Of Soft Tissue Rhabdomyosarcoma
236 Vaginal Wall Cyst Excision
193 Mediastinal Lymph Node Biopsy
237 Vulval Cyst Excision
194 High Orchidectomy For Testis Tumours
238 Laparoscopic Paratubal Cyst Excision
195 Excision Of Cervical Teratoma
239 Repair Of Vagina ( Vaginal Atresia )
196 Rectal-Myomectomy
240 Hysteroscopy, Removal Of Myoma
197 Rectal Prolapse (Delorme's Procedure)
241 Turbt
198 Detorsion Of Torsion Testis
242 Ureterocoele Repair - Congenital Internal
199 Eua + Biopsy Multiple Fistula In Ano
243 Vaginal Mesh For Pop
200 Cystic Hygroma - Injection Treatment
244 Laparoscopic Myomectomy
VII Gynecology Related:
245 Surgery For Sui
201 Operations On Bartholin’s Glands (Cyst)
246 Repair Recto- Vagina Fistula
202 Incision Of The Ovary
247 Pelvic Floor Repair( Excluding Fistula Repair)
203 Insufflations Of The Fallopian Tubes
248 Urs + Ll
204 Other Operations On The Fallopian Tube
249 Laparoscopic Oophorectomy
205 Dilatation Of The Cervical Canal
250 Normal Vaginal Delivery And Variants
206 Conisation Of The Uterine Cervix
VIII Neurology Related:
Therapeutic Curettage With Colposcopy/Biopsy/Diathermy/
207 251 Facial Nerve Physiotherapy
Cry Osurgery/
252 Nerve Biopsy
208 Laser Therapy Of Cervix For Various Lesions Of Uterus
253 Muscle Biopsy
209 Other Operations On The Uterine Cervix
Local Excision And Destruction Of Diseased Tissue Of The 254 Epidural Steroid Injection
210
Vagina And The Pouch Of Douglas 255 Glycerol Rhizotomy
211 Incision Of Vagina 256 Spinal Cord Stimulation
212 Incision Of Vulva

257 Motor Cortex Stimulation 303 Adjuvant Radiotherapy
258 Stereotactic Radiosurgery 304 Afterloading Catheter Brachytherapy
259 Percutaneous Cordotomy 305 Conditioning Radiothearpy For Bmt
260 Intrathecal Baclofen Therapy
306 Extracorporeal Irradiation To The Homologous Bone Grafts
261 Entrapment Neuropathy Release
307 Radical Chemotherapy
262 Diagnostic Cerebral Angiography
308 Neoadjuvant Radiotherapy
263 Vp Shunt
309 Ldr Brachytherapy
264 Ventriculoatrial Shunt
310 Palliative Radiotherapy
IX Oncology Related:
311 Radical Radiotherapy
265 Radiotherapy For Cancer
312 Palliative Chemotherapy
266 Cancer Chemotherapy
313 Template Brachytherapy
267 Iv Push Chemotherapy
314 Neoadjuvant Chemotherapy
268 Hbi-Hemibody Radiotherapy
315 Adjuvant Chemotherapy
269 Infusional Targeted Therapy
316 Induction Chemotherapy
270 Srt-Stereotactic Arc Therapy
317 Consolidation Chemotherapy
271 Sc Administration Of Growth Factors
318 Maintenance Chemotherapy
272 Continuous Infusional Chemotherapy
319 Hdr Brachytherapy
273 Infusional Chemotherapy
X Operations on the salivary glands & salivary ducts:
274 Ccrt-Concurrent Chemo + Rt
275 2d Radiotherapy 320 Incision And Lancing Of A Salivary Gland And A Salivary Duct
276 3d Conformal Radiotherapy Excision Of Diseased Tissue Of A Salivary Gland And A Salivary
321
277 Igrt- Image Guided Radiotherapy Duct
278 Imrt- Step & Shoot 322 Resection Of A Salivary Gland
279 Infusional Bisphosphonates 323 Reconstruction Of A Salivary Gland And A Salivary Duct
280 Imrt- Dmlc
324 Other Operations On The Salivary Glands And Salivary Ducts
281 Rotational Arc Therapy
XI Operations on the skin & subcutaneous tissues:
282 Tele Gamma Therapy
325 Other Incisions Of The Skin And Subcutaneous Tissues
283 Fsrt-Fractionated Srt
284 Vmat-Volumetric Modulated Arc Therapy Surgical Wound Toilet (Wound Debridement) And Removal Of
326
285 Sbrt-Stereotactic Body Radiotherapy Diseased Tissue Of The Skin And Subcutaneous Tissues
286 Helical Tomotherapy Local Excision Of Diseased Tissue Of The Skin And
327
287 Srs-Stereotactic Radiosurgery Subcutaneous Tissues
288 X-Knife Srs 328 Other Excisions Of The Skin And Subcutaneous Tissues
289 Gammaknife Srs Simple Restoration Of Surface Continuity Of The Skin And
329
Subcutaneous Tissues
290 Tbi- Total Body Radiotherapy
330 Free Skin Transplantation, Donor Site
291 Intraluminal Brachytherapy
331 Free Skin Transplantation, Recipient Site
292 Electron Therapy
332 Revision Of Skin Plasty
293 Tset-Total Electron Skin Therapy
Other Restoration And Reconstruction Of The Skin And
294 Extracorporeal Irradiation Of Blood Products 333
Subcutaneous Tiss
295 Telecobalt Therapy 334 Chemosurgery To The S
296 Telecesium Therapy Destruction Of Diseased Tissue In The Skin And Subcutaneous
335
297 External Mould Brachytherapy Tissues
298 Interstitial Brachytherapy 336 Reconstruction Of Deformity/Defect In Nail Bed
299 Intracavity Brachytherapy 337 Excision Of Bursirtis
300 3d Brachytherapy 338 Tennis Elbow Release
301 Implant Brachytherapy XII Operations on the Tongue:
302 Intravesical Brachytherapy

Incision, Excision And Destruction Of Diseased Tissue Of The 377 Removal Of Fracture Pins/Nails
339
Tongue
378 Removal Of Metal Wire
340 Partial Glossectomy
379 Closed Reduction On Fracture, Luxation
341 Glossectomy
380 Reduction Of Dislocation Under Ga
342 Reconstruction Of The Tongue
381 Epiphyseolysis With Osteosynthesis
343 Small Reconstruction Of The Tongue
382 Excision Of Various Lesions In Coccyx
XIII Ophthalmology Related:
383 Arthroscopic Repair Of Acl Tear Knee
344 Surgery For Cataract
384 Closed Reduction Of Minor Fractures
345 Incision Of Tear Glands
385 Arthroscopic Repair Of Pcl Tear Knee
346 Other Operations On The Tear Ducts
386 Tendon Shortening
347 Incision Of Diseased Eyelids
387 Arthroscopic Meniscectomy - Knee
348 Excision And Destruction Of Diseased Tissue Of The Eyelid
388 Treatment Of Clavicle Dislocation
349 Operations On The Canthus And Epicanthus
389 Haemarthrosis Knee- Lavage
350 Corrective Surgery For Entropion And Ectropion
390 Abscess Knee Joint Drainage
351 Corrective Surgery For Blepharoptosis
391 Carpal Tunnel Release
352 Removal Of A Foreign Body From The Conjunctiva
392 Closed Reduction Of Minor Dislocation
353 Removal Of A Foreign Body From The Cornea
393 Repair Of Knee Cap Tendon
354 Incision Of The Cornea
394 Orif With K Wire Fixation- Small Bones
355 Operations For Pterygium
395 Release Of Midfoot Joint
356 Other Operations On The Cornea
396 Orif With Plating- Small Long Bones
357 Removal Of A Foreign Body From The Lens Of The Eye
397 Implant Removal Minor
Removal Of A Foreign Body From The Posterior Chamber Of
358 398 K Wire Removal
The Eye
359 Removal Of A Foreign Body From The Orbit And Eyeball 399 Pop Application
Correction Of Eyelid Ptosis By Levator Palpebrae Superioris 400 Closed Reduction And External Fixation
360
Resection (Bilateral) 401 Arthrotomy Hip Joint
361 Correction Of Eyelid Ptosis By Fascia Lata Graft (Bilateral) 402 Syme's Amputation
403 Arthroplasty
362 Diathermy/Cryotherapy To Treat Retinal Tear
404 Partial Removal Of Rib
Anterior Chamber Paracentesis/ Cyclodiathermy/ 405 Treatment Of Sesamoid Bone Fracture
363 Cyclocryotherap Y/ Goniotomy/Trabeculotomy And Filtering 406 Shoulder Arthroscopy / Surgery
And Allied Operations To Treat Glaucoma
407 Elbow Arthroscopy
364 Enucleation Of Eye Without Implant 408 Amputation Of Metacarpal Bone
365 Dacryocystorhinostomy For Various Lesions Of Lacrimal Gland 409 Release Of Thumb Contracture
410 Incision Of Foot Fascia
366 Laser Photocoagulation To Treat Ratinal Tear
411 Calcaneum Spur Hydrocort Injection
367 Biopsy Of Tear Gland
412 Ganglion Wrist Hyalase Injection
368 Treatment Of Retinal Lesion
413 Partial Removal Of Metatarsal
XIV Orthopedics Related:
414 Repair / Graft Of Foot Tendon
369 Surgery For Meniscus Tear
415 Revision/Removal Of Knee Cap
370 Incision On Bone, Septic And Aseptic
416 Amputation Follow-Up Surgery
Closed Reduction On Fracture, Luxation Or Epiphyseolysis
371 417 Exploration Of Ankle Joint
With Osteosynthesis
418 Remove/Graft Leg Bone Lesion
372 Suture And Other Operations On Tendons And Tendon Sheath
419 Repair/Graft Achilles Tendon
373 Reduction Of Dislocation Under Ga 420 Remove Of Tissue Expander
374 Arthroscopic Knee Aspiration 421 Biopsy Elbow Joint Lining
375 Surgery For Ligament Tear 422 Removal Of Wrist Prosthesis
376 Surgery For Hemoarthrosis/Pyoarthrosis 423 Biopsy Finger Joint Lining

424 Tendon Lengthening 466 Ebus + Biopsy
425 Treatment Of Shoulder Dislocation 467 Thoracoscopy Ligation Thoracic Duct
426 Lengthening Of Hand Tendon 468 Thoracoscopy Assisted Empyaema Drainage
427 Removal Of Elbow Bursa XVIII Urology Related:
428 Fixation Of Knee Joint 469 Haemodialysis
429 Treatment Of Foot Dislocation 470 Lithotripsy/Nephrolithotomy For Renal Calculus
430 Surgery Of Bunion 471 Excision Of Renal Cyst
431 Intra Articular Steroid Injection 472 Drainage Of Pyonephrosis/Perinephric Abscess
432 Tendon Transfer Procedure 473 Incision Of The Prostate
433 Removal Of Knee Cap Bursa
474 Transurethral Excision And Destruction Of Prostate Tissue
434 Treatment Of Fracture Of Ulna
435 Treatment Of Scapula Fracture 475 Transurethral And Percutaneous Destruction Of Prostate Tissue
436 Removal Of Tumor Of Arm/ Elbow Under Ra/Ga
476 Open Surgical Excision And Destruction Of Prostate Tissue
437 Repair Of Ruptured Tendon
438 Decompress Forearm Space 477 Radical Prostatovesiculectomy
439 Revision Of Neck Muscle (Torticollis Release ) 478 Other Excision And Destruction Of Prostate Tissue
440 Lengthening Of Thigh Tendons 479 Operations On The Seminal Vesicles
441 Treatment Fracture Of Radius & Ulna 480 Incision And Excision Of Periprostatic Tissue
442 Repair Of Knee Joint 481 Other Operations On The Prostate
XV Other operations on the mouth & face: 482 Incision Of The Scrotum And Tunica Vaginalis Testis
External Incision And Drainage In The Region Of The Mouth, 483 Operation On A Testicular Hydrocele
443
Jaw And Face 484 Excision And Destruction Of Diseased Scrotal Tissue
444 Incision Of The Hard And Soft Palate
485 Other Operations On The Scrotum And Tunica Vaginalis Testis
445 Excision And Destruction Of Diseased Hard And Soft Palate
486 Incision Of The Testes
446 Incision, Excision And Destruction In The Mouth
487 Excision And Destruction Of Diseased Tissue Of The Testes
447 Other Operations In The Mouth
488 Unilateral Orchidectomy
XVI Plastic Surgery Related:
489 Bilateral Orchidectomy
448 Construction Skin Pedicle Flap
490 Surgical Repositioning Of An Abdominal Testis
449 Gluteal Pressure Ulcer-Excision
491 Reconstruction Of The Testis
450 Muscle-Skin Graft, Leg Implantation, Exchange And Removal Of A Testicular
492
451 Removal Of Bone For Graft Prosthesis
452 Muscle-Skin Graft Duct Fistula 493 Other Operations On The Testis
453 Removal Cartilage Graft 494 Excision In The Area Of The Epididymis
454 Myocutaneous Flap 495 Operations On The Foreskin
455 Fibro Myocutaneous Flap Local Excision And Destruction Of Diseased Tissue Of The
496
456 Breast Reconstruction Surgery After Mastectomy Penis
497 Amputation Of The Penis
457 Sling Operation For Facial Palsy
498 Other Operations On The Penis
458 Split Skin Grafting Under Ra
499 Cystoscopical Removal Of Stones
459 Wolfe Skin Graft
500 Catheterisation Of Bladder
460 Plastic Surgery To The Floor Of The Mouth Under Ga
501 Lithotripsy
XVII Thoracic surgery Related:
502 Biopsy Oftemporal Artery For Various Lesions
461 Thoracoscopy And Lung Biopsy
503 External Arterio-Venous Shunt
462 Excision Of Cervical Sympathetic Chain Thoracoscopic
504 Av Fistula - Wrist
463 Laser Ablation Of Barrett's Oesophagus
505 Ursl With Stenting
464 Pleurodesis
506 Ursl With Lithotripsy
465 Thoracoscopy And Pleural Biopsy
507 Cystoscopic Litholapaxy

508 Eswl 530 Surgery For Fournier's Gangrene Scrotum
509 Bladder Neck Incision 531 Surgery Filarial Scrotum
510 Cystoscopy & Biopsy 532 Surgery For Watering Can Perineum
511 Cystoscopy And Removal Of Polyp 533 Repair Of Penile Torsion
512 Suprapubic Cystostomy 534 Drainage Of Prostate Abscess
513 Percutaneous Nephrostomy 535 Orchiectomy
514 Cystoscopy And "Sling" Proced 536 Cystoscopy And Removal Of Fb
515 Tuna- Prostate
516 Excision Of Urethral Diverticulum
517 Removal Of Urethral Stone
518 Excision Of Urethral Prolapse
519 Mega-Ureter Reconstruction
520 Kidney Renoscopy And Biopsy
521 Ureter Endoscopy And Treatment
522 Vesico Ureteric Reflux Correction
523 Surgery For Pelvi Ureteric Junction Obstruction
524 Anderson Hynes Operation (Open Pyelopalsty )
525 Kidney Endoscopy And Biopsy
526 Paraphimosis Surgery
527 Injury Prepuce- Circumcision
528 Frenular Tear Repair
529 Meatotomy For Meatal Stenosis

ANNEXURE IV – List of tests covered under health check-up for Heartbeat Silver
Age Band <= 35 years Age Band 36 - 50 years Age Band > 50 years
Complete Blood Count Complete Blood Count Complete Blood Count
Urine Routine Analysis Urine Routine Analysis Urine Routine Analysis
Random Blood Sugar HBA1C ESR
Serum Cholesterol Serum Cholesterol HBA1C
Serum LDL Serum LDL Serum Cholesterol
Serum Creatinine Serum HDL
Urea Serum LDL
Kidney Function Test
Urea
ANNEXURE V - ICD codes for the specified disorders / conditions
Disorder / Condition ICD Codes

F33.0, F33.1, F33.2, F33.4, F33.5, F33.6, F33.7, F33.8, F33.9, O90.6, F34.1, F32.81, F32.0, F32.1, F32.2, F32.4,
Severe Depression F32.5, F32.6, F32.7, 32.8, F32.9, F33.9, F30.0, F30.1, F30.2, F30.4, F30.5, F30.6, F30.7, F30.8, F30.9, F32.3,
F33.3, F43.21, F32.8, F33.40, F32.9
Schizophrenia F20.0, F20.1, F20.2, F20.3, F20.5, F21, F22, F23, F24, F20.8, F25.0, F25.1, F25.8, F25.9
Bipolar Disorder F31.0, F31.1, F31.2, F31.4, F31.5, F31.6, F31.7, F31.8, F31.9
Post traumatic stress disorder F43.0, F43.1, F43.2, F43.8, F43.9
Eating disorder F50.0, F50.2, F50.8, F98.3, F98.21, F50.8
Generalized anxiety disorder F40.1, F41.0, F40.2, F40.8, F40.9, F41.1, F41.3, F41.8
Obsessive compulsive disorders F42
Panic disorders F41.1, F40.1, F60.7, F93.0, F94.0
Personality disorders F60.0, F60.1, F60.2, F60.3, F60.4, F60.8, F60.6, F60.7, F60.5
Conversion disorders F44.4, F44.5, F44.6, F44.7
Dissociative disorders F44.5, F44.8, F48.1, F44.1, F44.2

ANNEXURE VI
The expenses that are not covered or subsumed into room charges / procedure charges / costs of treatment
List I – Expenses not covered
Sl. No. Item Sl. No. Item

1 Baby Food 35 Oxygen Cylinder (For Usage Outside The Hospital)
2 Baby Utilities Charges 36 Spacer
3 Beauty Services 37 Spirometre
4 Belts/ Braces 38 Nebulizer Kit
5 Buds 39 Steam Inhaler
6 Cold Pack/Hot Pack 40 Armsling
7 Carry Bags 41 Thermometer
8 Email / Internet Charges 42 Cervical Collar
9 Food Charges (Other Than Patient's Diet Provided By Hospital) 43 Splint
10 Leggings 44 Diabetic Foot Wear
11 Laundry Charges 45 Knee Braces (Long/ Short/ Hinged)
12 Mineral Water 46 Knee Immobilizer/Shoulder Immobilizer
13 Sanitary Pad 47 Lumbo Sacral Belt
14 Telephone Charges 48 Nimbus Bed Or Water Or Air Bed Charges
15 Guest Services 49 Ambulance Collar
16 Crepe Bandage 50 Ambulance Equipment
17 Diaper Of Any Type 51 Abdominal Binder
18 Eyelet Collar 52 Private Nurses Charges- Special Nursing Charges
19 Slings 53 Sugar Free Tablets
Creams Powders Lotions (Toiletries Are Not Payable, Only
20 Blood Grouping And Cross Matching Of Donors Samples 54
Prescribed Medical Pharmaceuticals Payable)
21 Service Charges Where Nursing Charge Also Charged 55 Ecg Electrodes
22 Television Charges 56 Gloves
23 Surcharges 57 Nebulisation Kit
Any Kit With No Details Mentioned [Delivery Kit, Orthokit,
24 Attendant Charges 58
Recovery Kit, Etc]
Extra Diet Of Patient (Other Than That Which Forms Part Of Bed
25 59 Kidney Tray
Charge)
26 Birth Certificate 60 Mask
27 Certificate Charges 61 Ounce Glass
28 Courier Charges 62 Oxygen Mask
29 Conveyance Charges 63 Pelvic Traction Belt
30 Medical Certificate 64 Pan Can
31 Medical Records 65 Trolly Cover
32 Photocopies Charges 66 Urometer, Urine Jug
33 Mortuary Charges 67 Ambulance
34 Walking Aids Charges 68 Vasofix Safety

List II – Items that are to be subsumed into Room Charges

1 Baby Charges (Unless Specified/Indicated) 20 Luxury Tax
2 Hand Wash 21 Hvac
3 Shoe Cover 22 House Keeping Charges
4 Caps 23 Air Conditioner Charges
5 Cradle Charges 24 Im Iv Injection Charges
6 Comb 25 Clean Sheet
7 Eau-De-Cologne / Room Freshners 26 Blanket/Warmer Blanket
8 Foot Cover 27 Admission Kit
9 Gown 28 Diabetic Chart Charges
10 Slippers 29 Documentation Charges / Administrative Expenses
11 Tissue Paper 30 Discharge Procedure Charges
12 Tooth Paste 31 Daily Chart Charges
13 Tooth Brush 32 Entrance Pass / Visitors Pass Charges
14 Bed Pan 33 Expenses Related To Prescription On Discharge
15 Face Mask 34 File Opening Charges
16 Flexi Mask 35 Incidental Expenses / Misc. Charges (Not Explained)
17 Hand Holder 36 Patient Identification Band / Name Tag
18 Sputum Cup 37 Pulseoxymeter Charges
19 Disinfectant Lotions
List III – Items that are to be subsumed into Procedure Charges

1 Hair Removal Cream 13 Surgical Drill
2 Disposables Razors Charges (For Site Preparations) 14 Eye Kit
3 Eye Pad 15 Eye Drape
4 Eye Sheild 16 X-Ray Film
5 Camera Cover 17 Boyles Apparatus Charges
6 Dvd, Cd Charges 18 Cotton
7 Gause Soft 19 Cotton Bandage
8 Gauze 20 Surgical Tape
9 Ward And Theatre Booking Charges 21 Apron
10 Arthroscopy And Endoscopy Instruments 22 Torniquet
11 Microscope Cover 23 Orthobundle, Gynaec Bundle
12 Surgical Blades, Harmonicscalpel,Shaver

List IV – Items that are to be subsumed into costs of treatment

1 Admission/Registration Charges 10 Hiv Kit
2 Hospitalisation For Evaluation/ Diagnostic Purpose 11 Antiseptic Mouthwash
3 Urine Container 12 Lozenges
4 Blood Reservation Charges And Ante Natal Booking Charges 13 Mouth Paint
5 Bipap Machine 14 Vaccination Charges
6 Cpap/ Capd Equipments 15 Alcohol Swabes
7 Infusion Pump– Cost 16 Scrub Solution/Sterillium
8 Hydrogen Peroxide\Spirit\ Disinfectants Etc 17 Glucometer & Strips
9 Nutrition Planning Charges - Dietician Charges- Diet Charges 18 Urine Bag

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Heart Beat –

2. Definitions & Interpretation

Product Name: Heart Beat | Product UIN: NBHHLIP23113V072223

2.18. Maternity Expense shall include:

Product Name: Heart Beat | Product UIN: NBHHLIP23113V072223

2.28. Pre-existing Disease means any condition, ailment, injury or disease

Product Name: Heart Beat | Product UIN: NBHHLIP23113V072223

2.36. Age means age as on last birthday.

2.38. AYUSH Hospital:

Product Name: Heart Beat | Product UIN: NBHHLIP23113V072223

Product Name: Heart Beat | Product UIN: NBHHLIP23113V072223

2.73. Specified Illness means the following Illnesses or procedures:

Product Name: Heart Beat | Product UIN: NBHHLIP23113V072223

Product Name: Heart Beat | Product UIN: NBHHLIP23113V072223

2.75. Suite Room means

2.76. Sum Insured

2.79. We/Our/Us means Niva Bupa Health Insurance Company Limited.

Product Name: Heart Beat | Product UIN: NBHHLIP23113V072223

The benefits available under this Policy are described below.

3.1. Inpatient Care

Conditions - The above coverage is subject to fulfillment of following conditions:

3.2. Pre-hospitalization Medical Expenses

Conditions - The above coverage is subject to fulfilment of following conditions:

Product Name: Heart Beat | Product UIN: NBHHLIP23113V072223

3.3. Post-hospitalization Medical Expenses

Conditions - The above coverage is subject to fulfilment of following conditions:

3.4. Day Care Treatment

Conditions - The above coverage is subject to fulfilment of following conditions:

What is not covered:

3.5. Domiciliary Hospitalization

Product Name: Heart Beat | Product UIN: NBHHLIP23113V072223

3.6. Alternative Treatments

Conditions - The above coverage is subject to fulfilment of following conditions:

3.7. Living Organ Donor Transplant

Conditions - The above coverage is subject to fulfilment of following conditions:

What is not covered:

3.8. Emergency Ambulance

Conditions - The above coverage is subject to fulfilment of following conditions:

Product Name: Heart Beat | Product UIN: NBHHLIP23113V072223

What is not covered:

3.9. Maternity Benefit

Conditions - The above coverage is subject to fulfilment of following conditions:

What is not covered:

3.10. New Born Baby

Conditions - The above coverage is subject to fulfilment of following conditions:

Product Name: Heart Beat | Product UIN: NBHHLIP23113V072223

3.11. Health Check-up

Conditions - The above coverage is subject to fulfilment of following conditions:

What is not covered:

3.12. Re-fill Benefit

Conditions - The above coverage is subject to fulfilment of following conditions:

Product Name: Heart Beat | Product UIN: NBHHLIP23113V072223

3.13. Pharmacy and Diagnostic Services

Conditions - The above coverage is subject to fulfilment of following conditions:

3.14. Loyalty Additions

Conditions - The above coverage is subject to fulfilment of following conditions:

Product Name: Heart Beat | Product UIN: NBHHLIP23113V072223

3.15. HIV / AIDS

Conditions - The above coverage is subject to fulfilment of following conditions: