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The Policy can be taken by a Gramin (Village Dweller) for covering himself and his family and / or an organization such as NGOs, Financial Institutions for covering its rural clientele.
1. Who can take the Policy?
The Policy can be taken by a Gramin (Village Dweller) for covering himself and his family and / or an organization such as NGOs, Financial Institutions for covering its rural clientele. e.g. A Bank can take this policy for covering Kisan Credit Card Holders
2. Eligibility
Entry age for you (the proposer) is 18 years and you can opt for this policy up to the age of 65 years.
Policy renewals will be for your lifetime.
Entry age for dependent children is 6 months.
No pre-acceptance medical tests up to 45 years of age , however, if you are above 45 years, then,
you may require to undergo medical tests ( BP, Fasting Sugar, ECG) at our listed diagnostic centers, 50% cost of which will be borne by us in case of accepted proposals
Maximum of 2 Adults and 2 Dependent Children (up to 25 years of age) can be covered under the Policy.
3. What is covered under the Policy?
The Policy comprises of three sections.
1. SECTION A - PERSONAL ACCIDENT
The following benefits shall become payable under this section. The cover shall be applicable to both the Insured and his/ her family members.
Benefits under Section A
2. SECTION B - CRITICAL ILLNESS
The following Critical Illnesses and Surgical Procedures shall be covered up to the Sum Insured as selected by you when this section is opted for under the Policy.
Critical Illnesses may be capped in number upon request of the Policyholder and acceptance from us in lieu of a rebate in premium.
3. SECTION C- HOSPITAL CASH
A Daily Allowance as under would be payable upon hospitalization, subject to your minimum hospital stay of 2 days, for a maximum number of days as opted by you when you opt for coverage under this Section. The choice would be given to you to opt for any of the following options
Double Benefit: The amount as chosen by you from the above options shall be doubled when you/ your family member is admitted in an ICU. Such double benefit shall be available under the Policy for a maximum of 7 days.
You can choose to cover Hospital Cash for a maximum of 15, 30, 45, 90 or 180 days as per your requirement.
Benefit Schedule
Extensions/ Endorsement under the Policy
Pre-existing diseases: With this extension, the pre-existing diseases can be covered under the Policy on payment of additional premium.
What is not covered under the Policy?
We shall not be liable to make any payment for any claim directly or indirectly caused by, based on, arising out of or howsoever attributable to any of the following:
SPECIFIC EXCLUSIONS TO SECTION 2- CRITICAL ILLNESSES
1. Any Illness, sickness or disease , other than specified as Critical Illness, as mentioned in the policy schedule, or
2. Any Critical Illness of which, the signs or symptoms first occurred prior to or within Ninety (90) days following the Policy Issue Date unless credits towards such time bound exclusion has been accrued in similar health insurance Policy from Us or any of the other Indian Insurers
3. Any Critical Illness based on a Diagnosis made by You or Your Family Member or anyone who is living in the same household as You or by a herbalists, acupuncturist or other non-traditional health care provider; and
4. Cosmetic or plastic surgery or any elective surgery or cosmetic procedure that improve physical appearance, surgical and non-surgical treatment of obesity (including morbid obesity) and weight
control programs, or treatment of an optional nature;
5. Special nursing care, routine health checks or convalescence, Custodial Care, general debility, lethargy, rest cure;
6. Any investigation(s) or treatments not directly related to a Covered Illness or Covered Injury or the conditions or diagnosis necessitating hospital admission;
SPECIFIC EXCLUSIONS TO SECTION 3- HOSPITAL CASH
1. Period, or for which care, treatment or advice was sought, recommended by or received from a Physician or for which a claim has or could have been made under any earlier policy
2. Any routine or prescribed medical check up or examination. Medical Expenses relating to any hospitalization for diagnostic, X-ray or laboratory examinations not consistent with or incidental
to the diagnosis and treatment of the positive existence or presence of any Illness or accidental Bodily Injury for which hospitalization is required.
3. Any Sickness that has been classified as an Epidemic by the Central or State Government Convalescence, general debility, nervous or other breakdown, rest cure, congenital diseases or defect or anomaly, sterility, sterilization or infertility (diagnosis and treatment), any sanatoriums, spa or rest cures or long term care or hospitalization undertaken as a preventive or recuperative measure.
For all Insured Persons, the following conditions will be covered subject to a waiting period of 24 months from the date of commencement of coverage. Stones in the urinary system; Stones in biliary system; Surgery on tonsils / adenoids; Uterine Polyps; Any type of breast lumps; Treatment of Spondylosis /Spondylitis - any type; Inter Vertebral Disc Prolapse (IVDP) and such other degenerative disorders; Cataract; Benign prostatic hypertrophy; Hysterectomy / Myomectomy done due to Menorrhagia / fibroids; Fistula in ano; Fissure in ano; Piles; Hernia; Hydrocele; Sinusitis; Knee / hip joint replacement; Chronic Renal Failure(CRF) or end stage renal failure; Any type of Carcinoma / sarcoma / blood cancer; Osteo Arthritis of any joint; Gastric and duodenal Ulcers; Varicocele; Spermatocele; Dilatation and Curettage (D&C); Diabetic Nephropathy and Retinopathy; Mastoidectomy (operation to remove piece of bone behind the ear); Tympanoplasty (Surgery to repair tympanic membrane i.e. eardrum); Gout; Rheumatism; Varicose veins & Varicose ulcers; Internal congenital anomaly
4. Any natural peril including but not limited to avalanche, earthquake, volcanic eruptions or any kind of natural hazard.
5. Sickness requiring Hospitalization within the first 30 days from the commencement date of the Policy Period unless the Policy is renewed without interruption and with the Company or is a renewal of similar existing health insurance policy from any of other Indian insurers and We have accepted Your proposal with portability.
6. The treatment of cataracts, benign prostatic hypertrophy, hysterectomy, Menorrhagia, Fibromyoma, D&C, Endometriosis, Hernia of all types, Hydrocele, fistulae, hemorrhoid's, Anal fissure ,stones in the urinary and biliary systems, surgery on ears, tonsils or sinuses, skin and all internal tumors/cysts/nodules/polyps of any kind including breast lumps, gastric or duodenal ulcer, backache, prolapsed intervertebral disc, joint replacement, Gastric or Duodenal ulcer, Arthritis, Varicose Veins, Varicose Ulcers, Spondylitis during the first two years of commencement of policy unless due credit for the same have been accrued in previous health insurance policy from us or any of the Indian Insurers.
GENERAL EXCLUSIONS UNDER THE POLICY
We will not be liable for:-
1. Any payment in case of more than one claim under the Policy during any one period of insurance
by which the maximum liability of the Company in that period exceeds the Sum Insured.
2. Pre-existing diseases (unless endorsed otherwise) will not be covered until 48 months of continuous coverage have elapsed, since inception of the first Policy with Us; but: If the You are presently covered and have been continuously covered without any break under:
i. an individual health insurance plan with an Indian insurer for the reimbursement of medical costs for inpatient treatment in a Hospital,
ii. any other similar health insurance plan from Us, then, Pre-existing diseases exclusion of the Policy stands deleted and shall be replaced entirely with the following:
a) The waiting period for all Pre-existing diseases shall be reduced by the number of Your continuous preceding years of coverage under the previous health insurance policy;
b) If the proposed Sum Insured for You is more than the Sum Insured applicable under the previous health insurance policy, then the reduced waiting period shall only apply to the extent of the Sum Insured under the previous health insurance policy.
3. Death or disablement due to child birth or from pregnancy or in consequence thereof.
4. Payment of compensation in respect of injury, disablement or death, hospitalization resulting -
a. From intentional self-injury, suicide or attempted suicide.
b. Whilst under the influence of liquor or drugs or other intoxicants.
c. Emotional distress
d. Whilst engaging in aviation or ballooning whilst mounting into, dismounting from or travelling in any aircraft or balloon other than as a passenger (fare paying or otherwise) in any duly licensed standard type of aircraft anywhere in the world.
e. Directly or indirectly, caused by venereal disease, AIDS or insanity.
f. Arising or resulting from committing any breach of law or participating in an actual or attempted felony, riot, crime, misdemeanor or civil commotion.
g. Whilst engaging in racing, hunting, mountaineering, ice hockey, winter sports and the like.
h. Due to war or ionizing radiation or nuclear perils.
i. Whilst working in underground mines or explosive mines, electric installation with high tension supply, or as jockey or circus personnel or any such occupations of similar hazard.
j. Congenital anomalies or any complications or conditions arising therefrom; or
5. Any loss resulting directly or indirectly, contributed or aggravated or prolonged by childbirth or from pregnancy ( except Ectopic Pregnancy)
6. Any treatment not performed by a Physician or any treatment of a purely experimental nature.
7. Circumcision, cosmetic or aesthetic treatments of any description change of life surgery or treatment, plastic surgery (unless necessary for the treatment of Illness or accidental Bodily Injury as a direct result of the insured event and performed within 6 months of the same).
8. Dental treatment or surgery of any kind unless necessitated by Accidental Bodily Injury.
9. Hospitalization for the sole purpose of traction, physiotherapy or any ailment for which hospitalization is not warranted due to advancement in medical technology
10. Naval or military operations of the armed forces or airforce and participation in operations requiring the use of arms or which are ordered by military authorities for combating terrorists, rebels and the like.
11. All kind of Alternate Treatment
