Arogya-Sanjeevani-Policy

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

SALIENT FEATURES

ELIGIBILITY:
Any person aged between 18 years and 65 years can take this insurance for himself and his/her family consisting of Self, Spouse, dependent children, Parents and Parents-in-law, either on Individual Sum Insured basis or on floater basis. Beyond 65 years, only renewals are allowed.

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 continue to be covered along with parents till the age of 25 years. If the child is above 18 years of age and is financially independent, he or she shall be ineligible for coverage under the same policy in the subsequent renewals. However, a separate policy can be taken for him or her on expiry of the current policy for which continuity benefits will be provided.

SUM INSURED:
Various options are available as under:
Rs. 1 lacs, 1.5 lacs, 2 lacs, 2.5 lacs, 3 lacs, 3.5 lacs, 4 lacs, 4.5 lacs, 5 Lacs.

TERM OF POLICY:
One Year. Renewable annually.

COVERAGE
The covers listed below are in-built Policy benefits and shall be available to all Insured Persons in accordance with the procedures set out in this Policy.

Hospitalization
The company shall indemnify medical expenses incurred for Hospitalization of the Insured Person during the Policy year, up to the Sum Insured and Cumulative Bonus specified in the policy schedule, for,

Room Rent, Boarding, Nursing Expenses as provided by the Hospital/Nursing Home up to 2% of the sum insured subject to a maximum of Rs. 5000/- per day.

Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) expenses up to 5% of the sum insured subject to a maximum of Rs. 10,000/- per day.
Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialist Fees whether paid directly to the treating doctor / surgeon or to the hospital
Anesthesia, blood, oxygen, operation theater charges, surgical appliances, medicines and drugs, costs towards diagnostics, diagnostic imaging modalities and such similar other expenses.

Other Expenses
Expenses incurred on treatment of cataract subject to the sub limit as mentioned in clause V.3 below.
Dental treatment, necessitated due to disease or injury
Plastic surgery necessitated due to disease or injury
All the day care treatments
Expenses incurred on road Ambulance subject to a maximum of Rs. 2000/- per hospitalization.

Expenses of Hospitalization for a minimum period of 24 consecutive hours only shall be admissible. However, the time limit shall not apply in respect of Day Care Treatment

In case of admission to a room/ICU/ICCU at rates exceeding the aforesaid limits, the reimbursement/payment of all other expenses incurred at the Hospital, with the exception of cost of medicines, shall be effected in the same proportion as the admissible rate per day bears to the actual rate per day of Room Rent/ICU/ICCU charges.

AYUSH Treatment
The company shall indemnify medical expenses incurred for inpatient care treatment under Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems of medicines during each Policy Year up to the limit of sum insured as specified in the policy schedule in any AYUSH Hospital.

Cataract Treatment
The company shall indemnify medical expenses incurred for treatment of Cataract, subject to a limit of 25% of Sum Insured or Rs. 40,000/-, whichever is lower, per each eye in one policy year.

Pre Hospitalization
The company shall indemnify pre-hospitalization medical expenses incurred, related to an admissible hospitalization requiring inpatient care, for a fixed period of 30 days prior to the date of admissible hospitalization covered under the policy.

Post Hospitalization
The company shall indemnify post hospitalization medical expenses incurred, related to an admissible hospitalization requiring inpatient care, for a fixed period of 60 days from the date of discharge from the hospital, following an admissible hospitalization covered under the policy.

The following procedures:
will be covered (wherever medically indicated) either as inpatient care or as part of day care treatment in a hospital up to 50% of Sum Insured, specified in the policy schedule, during the policy period:

Treatment Methods & Advancement in Technology

A. Uterine Artery Embolization & High Intensity Focused Ultrasound (HIFU)
B. Balloon Sinuplasty
C. Deep Brain Stimulation
D. Oral Chemotherapy
E. Immunotherapy- Monoclonal Antibody to be given as injection
F. Intra vitreal Injections
G. Robotic Surgeries
H. Stereotactic Radio Surgeries
I. Bronchial Thermoplasty
J. Vaporization of the Prostate (Green laser treatment or holmium laser treatment)
K. Intra Operative Neuro Monitoring (IONM)
L. Stem Cell Therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered only

CUMULATIVE BONUS:
Cumulative Bonus will be increased by 5% in respect of each claim free policy year (where no claims are reported), provided the policy is renewed with the company without a break subject to maximum of 50% of the sum insured under the current policy year. If a claim is made in any particular year, the cumulative bonus accrued shall be reduced at the same rate at which it has accrued. However, sum insured will be maintained and will not be reduced in the policy year.

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.

First Thirty Days Waiting Period
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.

This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve months.

The within referred waiting period is made applicable to the enhanced sum insured in the event of granting higher sum insured subsequently.

Specific Disease/ Procedure Waiting Period
Expenses related to the treatment of the listed Conditions, surgeries/treatments as per Table A and Table B below, shall be excluded until the expiry of 24 months and 48 months respectively 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.

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

The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a specific exclusion.

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.
List of specific diseases/procedures:

Table A. 24 Months waiting period



Table B. 48 Months waiting period


B. 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:

Investigation & Evaluation
Expenses related to any admission primarily for diagnostics and evaluation purposes.

Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment.

Rest Cure, rehabilitation and respite care
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.

Obesity/Weight Control
Expenses related to the surgical treatment of obesity that does not fulfill all the below conditions:

Surgery to be conducted is upon the advice of the Doctor

The surgery/procedure conducted should be supported by clinical protocols

The member has to be 18 years of age or older and

Body Mass Index (BMI);
greater than or equal to 40 or 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:
Obesity-related cardiomyopathy
Coronary heart disease
Severe Sleep Apnoea
Uncontrolled Type2 Diabetes

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 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.

Hazardous or Adventure sports
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.

Breach of law
Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with criminal intent.

Excluded Providers
Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its 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.

Treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof.
Treatments received in health 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.

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.

Refractive Error
Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres.

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.

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

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

War (whether declared or not) and war like occurrence or invasion, acts of foreign enemies, hostilities, civil war, rebellion, revolutions, insurrections, mutiny, military or usurped power, seizure, capture, arrest, restraints and detainment of all kinds.

Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from or from any other cause or event contributing concurrently or in any other sequence to the loss, claim or expense. For the purpose of this exclusion:

Nuclear attack or weapons means the use of any nuclear weapon or device or waste or combustion of nuclear fuel or the emission, discharge, dispersal, release or escape of fissile/fusion material emitting a level of radioactivity capable of causing any Illness, incapacitating disablement or death.

Chemical attack or weapons means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing any Illness, incapacitating disablement or death.

Biological attack or weapons means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organisms and/or biologically produced toxins (including genetically modified organisms and chemically synthesized toxins) which are capable of causing any Illness, incapacitating disablement or death.

Any expenses incurred on Domiciliary Hospitalization and OPD Treatment

Treatment taken outside the geographical limits of India

In respect of the existing diseases, disclosed by the insured and mentioned in the policy schedule (based on insured's consent), policyholder is not entitled to get the coverage for specified ICD Codes.