Revised-Super-Top-Up-Medicare-Policy

KEY BENEFITS
This Policy covers aggregate hospitalization expenses in respect of all covered hospitalization(s) of Insured Person/s during the policy period exceeding the Threshold Level up to a Sum Insured stated in the Policy Schedule.

The Policy provides cover on an Individual or Family Floater basis. A separate Sum Insured for each Insured Person is provided under Individual Sum Insured basis while under Family Floater basis, the Sum Insured limit is shared by the whole family of the Proposer as specified in the Policy Schedule and our total liability for the family cannot exceed the Sum Insured in a Policy period.

The claim payable under this Policy will be the amount by which the aggregate of such Covered Expenses in respect of hospitalizations with dates of admission falling within the policy period exceeds the higher of the following:

the Threshold Level opted for the Insured Person/family as applicable and stated in the schedule or the amount received/receivable under any/all Health Insurance Policies (whether or not issued by the Company)/ Reimbursement Scheme and including any amount paid earlier under this policy covering the Insured person/Family as applicable for such Covered Expenses, subject to Basis of Payment Clause no. 7.7.6.F of the Policy.

COVERAGE AT A GLANCE:



SALIENT FEATURES

ELIGIBILITY
Any person aged between 18 years and 80 years can take this insurance for himself and his/her family. Beyond 80 years, only renewals are allowed

Allowed Relationships in a Family to be covered under a single policy:
Individual Sum Insured Basis: Self (Proposer), Spouse, Dependent Children and Parents
Family Floater Basis: Self (Proposer), Spouse, Dependent Children

Entry Age: Adults: 18 years to 80 Years
Dependent Children: between the age of 3 months and 18 years shall be covered provided either or both parents are covered concurrently.
Children above 18 years will cease to be covered if they are employed/self-employed or married. However, a separate policy can be taken for him or her on expiry of the current policy for which continuity benefits will be provided. For unmarried and unemployed girls, disabled children without income dependent upon Proposer, the age limit of 18 will not apply.
Male child up to 26 years can be covered provided they pursue full-time higher studies and submit bona fide Certificate from Educational Institution

Midterm Inclusion of family members is allowed at pro-rata premium only in case of: Newly married spouse within 60 (sixty) days of marriage New born baby, between the ages of 91 days to 180 days, born to mother insured under the policy.

SUM INSURED
Sum Insured options vary based on the Threshold/Deductible chosen by the Policyholder. The available choices are as under:



TERM OF POLICY: One Year. Renewable annually.

COVERAGE
The Policy provides base overages as described below:

In-patient Hospitalization Expenses Cover
We shall indemnify the Reasonable and Customary Charges for the following Medical Expenses of an Insured Person in case of Hospitalization provided that the admission date of the Hospitalization due to Illness or Injury is within the Policy Period:

Room, Boarding and Nursing expenses (all inclusive) incurred as provided by the Hospital/Nursing Home including nursing care, RMO charges, IV Fluids/Blood transfusion/injection administration charges and similar expenses.

The fees charged by the Medical Practitioner, Surgeon, Consultants, Specialists and anaesthetists treating the Insured Person; Anaesthetics, Blood, Oxygen, Operation Theatre Charges, surgical appliances, Medicines & Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy,
Radiotherapy, Artificial Limbs, cost of prosthetic devices implanted during surgical procedure like Pacemaker, relevant laboratory diagnostic tests & such similar expenses that are medically necessary.

All hospitalization expenses (excluding cost of organ) incurred for donor in respect of organ transplant to the Insured Person provided the donation conforms to The Transplantation of Human Organs Act 1994.

Ayurvedic treatment
The Company shall indemnify Reasonable & Customary medical expenses incurred for inpatient care treatment under Ayurveda system of medicine in an AYUSH hospital/ AYUSH Day care centre as defined in Section 3.4 and 3.5 above respectively.

Modern Treatment Methods & Advancement in Technologies:
In case of an admissible claims under Section 5.1, expenses incurred on the following procedures (wherever medically indicated) either as in-patient or as part of day care treatment in a hospital, shall be covered. The claim shall be subject to additional sub-limits indicated against them in the table below:





EXCLUSIONS

A. WAITING PERIOD - EXCLUSIONS
The Company shall not be liable to make any payment under the policy in connection with or in respect of following expenses till the expiry of waiting period mentioned below:

Pre-Existing Diseases
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.

In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.

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.

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.

B. PERMANENT EXCLUSIONS
The Company shall not be liable to make any payment under the policy, in respect of any expenses incurred in connection with or in respect of:

All expenses caused by or arising from or attributable to foreign invasion, act of foreign enemies, hostilities, warlike operations (whether war be declared or not or while performing duties in the armed forces of any country), civil war, public defence, rebellion, revolution, insurrection, military or usurped power.

All Illness/expenses caused by ionizing radiation or contamination by radioactivity from any nuclear fuel (explosive or hazardous form) or from any nuclear waste from the combustion of nuclear fuel nuclear, chemical or biological attack.

Congenital External Diseases, Defects or anomalies.

Sterility and Infertility - Expenses related to Sterility and Infertility. This includes:
Any type of contraception, sterilization
Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
Gestational Surrogacy
Reversal of sterilization

Maternity
Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalisation) except ectopic pregnancy; Expenses towards miscarriage (unless due to an accident) and lawful medical termination of pregnancy during the policy period.

Circumcision unless necessary for Treatment of an Illness or Injury not excluded hereunder or due to an Accident.

Investigation & Evaluation
Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded. Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.

Unproven Treatments - 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.

Change-of-Gender treatments - Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.

Cosmetic or Plastic Surgery - 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. For this to be considered a medical necessity, it must be certified by the attending Medical Practitioner.

Vaccination or inoculation of any kind unless it is post animal bite.

Cost of spectacles, contact lenses.

Cost of hearing aids

Dental treatment or surgery of any kind unless necessitated by accident and requiring hospitalization.

Rest Cure, rehabilitation and respite care - Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:

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.

Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.

Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof.

Intentional self-inflicted Injury, attempted suicide.

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.

Naturopathy Treatment, acupressure, acupuncture, magnetic and such other experimental treatment including drug experimental therapy, which is not based on established medical practice in India.

External and or durable Medical / Non-medical equipment of any kind used for diagnosis and/or treatment and/or monitoring and/or maintenance and/or support including CPAP, CAPD; Infusion pump, Oxygen concentrator, sub-cutaneous insulin pump, Ambulatory devices i.e. walker, crutches, Belts, Collars, Caps, Splints, Slings, Braces, Stockings of any kind, Diabetic foot wear, Glucometer/Thermometer and also any medical equipment, which are subsequently used at home.