Revised-Individual-Health-Insurance-Policy

KEY BENEFITS
The Policy provides cover on an Individual Sum Insured basis for an individual. The policy is offered on family package basis also, for family comprising of the Proposer, Spouse, Dependent Children, and Parents, with Individual Sum Insured for each family member. Policy is available under three plans based on age of entry into the policy.

SALIENT FEATURES

ELIGIBILITY:
Any person aged between 18 years and 65 years can take this insurance for himself/herself and his/her family consisting of Self, Spouse, Dependent Children and Parents on Individual Sum Insured basis.
Entry Age of Proposer and insured family members for different plans is as under:

Platinum: between 18 and 35 years. Children from the age of 91 days can be covered provided either or both of the parents are covered

Gold: between 36 and 60 years

Senior Citizen: between 61 and 65 years

An Insured Person will continue to be in the same plan that they were under at the time of entry into the policy, even if they cross the maximum age prescribed for that plan, provided the policies are renewed with us without break.

Dependent children between the age of 91 days 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 provided they are unmarried/unemployed and dependent. In the event of children becoming independent, employed, or getting married, a separate policy can be taken on expiry of the current policy for which continuity benefits will be provided.

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:
The various Sum Insured options available under the three plans are as follows:
Platinum : 2 Lakhs, 3 Lakhs, 5 Lakhs, 8 Lakhs, 10 Lakhs, 15 Lakhs, 20 Lakhs

Gold : 2 Lakhs, 3 Lakhs, 5 Lakhs, 8 Lakhs, 10 Lakhs

Senior Citizen :2 Lakhs, 3 Lakhs, 5 Lakhs

TERM OF POLICY:
One Year

COVERAGE
The Policy provides base coverage as described below in this section provided that the expenses are incurred on the written Medical Advice of a Medical Practitioner and are incurred on Medically Necessary Treatment of the Insured Person.

In-Patient Hospitalization Expenses Cover
We will pay the Reasonable and Customary Charges for the following Medical Expenses of an Insured Person in case of Medically Necessary Treatment taken during 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 up to 1% of Sum Insured per day or actual expenses whichever is less. These expenses will include nursing care, RMO charges, IV Fluids/Blood transfusion/injection administration charges and similar expenses.

Charges for accommodation in Intensive Care Unit (ICU)/ Intensive Cardiac Care Unit (ICCU) up to 2% of Sum Insured per day or actual expenses whichever is less.

The fees charged by the Medical Practitioner, Surgeon, Specialists, Consultants and Anaesthetists treating the Insured Person.

Operation theatre charges; Expenses incurred for Anaesthetics, Blood, Oxygen, Surgical Appliances and/or Medical Appliances; Cost of Artificial Limbs, cost of prosthetic devices implanted during surgical procedure like pacemaker, orthopaedic implants, infra cardiac valve replacements, vascular stents, relevant laboratory/ diagnostic tests, X-Ray and such other similar medical expenses related to the treatment.

All hospitalisation 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.

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 at rates exceeding the aforesaid limits in Clause 5.1.i, the reimbursement/payment of all associated medical expenses incurred at the Hospital shall be effected in the same proportion as the admissible rate per day bears to the actual rate per day of Room Rent.

Proportionate Deductions shall not be applied in respect of those hospitals where differential billing is not followed or for those expenses where differential billing is not adopted based on the room category.

No payment shall be made under 5.1 (iii) other than as part of the hospitalization bill. However, the bills raised by Surgeon, Anesthetist directly and not forming part of the hospital bill shall be paid provided a pre-numbered bill/receipt is produced in support thereof, when such payment is made ONLY by cheque/ credit card/debit card or digital/online transfer.

Other expenses covered:
Dental treatment, necessitated due to injury
Plastic surgery necessitated due to disease or injury
All day care treatments as per standard definition

Expenses in respect of the following specified illnesses will be restricted as detailed below:



Pre-Hospitalization and Post-Hospitalization Expenses
We will cover, on a reimbursement basis, the Insured Person's

Pre-hospitalization Medical Expenses incurred due to an Illness or Injury during the period up to 30 days prior to hospitalization; and

Post-hospitalization Medical Expenses incurred due to an Illness or Injury during the period up to 60 days after the discharge from the hospital,

Subject to a maximum of 10% of Sum Insured, provided that:
We have accepted a claim for primary In-patient Hospitalization under Section 5.1 above;

The Pre-hospitalization & Post-hospitalization Medical Expenses are related to the same Illness or Injury.

The date of admission to the Hospital for the purpose of this Benefit shall be the date of the Insured Person's first admission to the Hospital in relation to the same Any One Illness.

Domiciliary Hospitalization
We will cover, on a reimbursement basis, medical treatment for a period exceeding three days for such 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:

The condition of the patient is such that he/she is not in a condition to be moved to a hospital or
The patient takes treatment at home on account of non-availability of room in a hospital.
However, domiciliary hospitalization benefits shall not cover:

Expenses incurred for treatment for any of the following diseases:
Asthma
Bronchitis
Chronic Nephritis and Nephritic Syndrome
Diarrhoea and all type of Dysenteries including Gastroenteritis
Diabetes Mellitus and Insipidus
Epilepsy
Hypertension
All Psychiatric or Psychosomatic Disorders
Influenza, Cough and Cold
Pyrexia of unknown Origin for less than 10 days
Tonsillitis and Upper Respiratory Tract infection including Laryngitis and pharyngitis
Arthritis, Gout and Rheumatism

Ayurvedic Treatment
We will pay the Reasonable & Customary Charges incurred as in-patient for an Insured Person in case of Medically Necessary Treatment taken during Hospitalization subject to the condition that the hospitalization expenses are admissible only when the treatment has been undergone in an AYUSH Hospital.

Modern Treatment Methods & Advancement in Technologies
In case of an admissible claim 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:





Cost of Health Check-Up
We will cover expenses incurred towards cost of health check-up up to 1% of average Sum Insured of preceding 3 years, subject to a maximum of Rs. 5,000 per person per policy period for a block of every three claim-free years provided the health check-up is done at hospitals/diagnostic center authorized by us within a year from the date when it got due and the policy is in force. Payment under this benefit does not reduce the sum insured.

OPTIONAL COVERS

Road Ambulance Cover
We will cover the costs incurred up to Rs. 2500 per person per policy period on transportation of the Insured Person by road Ambulance to a Hospital for treatment in an Emergency following an Illness or Injury which occurs during the Policy Period. The necessity of use of an Ambulance must be certified by the treating Medical Practitioner and becomes payable if a claim has been admitted under Section 5.1 and the expenses are related to the same Illness or Injury.

We will also cover the costs incurred on transportation of the Insured Person by road Ambulance in the following circumstances up to the limits specified above under this cover, if:

it is medically required to transfer the Insured Person to another Hospital or diagnostic center during the course of Hospitalization for advanced diagnostic treatment in circumstances where such facility is not available in the existing Hospital;
it is medically required to transfer the Insured Person to another Hospital during the course of Hospitalization due to lack of super specialty treatment in the existing Hospital.

Daily Cash Allowance on Hospitalization
We will pay Daily Cash Allowance to the Insured Person for every continuous and completed period of 24 hours of Hospitalization, subject to the hospitalization claim being admissible under the policy, as per the table below:



EXCLUSIONS

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, provided the same are covered.

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.

B.PERMANENT EXCLUSIONS (Applicable for ALL Plans)
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.

a) Stem cell implantation/Surgery, harvesting, storage or any kind of Treatment using stem cells except as provided for in clause 5.5 (12) above; b) growth hormone therapy.

Congenital External Diseases or 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 child birth (Including complicated deliveries and caesarean 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.

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

Cost of routine medical examination and preventive health check-up unless as provided for in Base Cover 5.6.

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 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.

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

i. Routine eye-examination expenses, cost of spectacles, contact lenses;
ii. Cost of hearing aids; including optometric therapy;

Cochlear implants unless necessitated by an Accident or required intra-operatively.

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

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.

Obesity/ Weight Control : Expenses related to the surgical treatment of obesity that does not fulfil 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

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

Intentional self-inflicted Injury, attempted suicide.

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.

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.

Treatments other than Allopathy and Ayurvedic branches of medicine.

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.

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.

Unless used intra-operatively, any expenses incurred on prosthesis, corrective devices; 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 instruments used in treatment of sleep apnoea syndrome; Infusion pump, Oxygen concentrator, Ambulatory devices, sub cutaneous insulin pump and also any medical equipment, which are subsequently used at home. This is indicative and please refer to Annexure 1 in the Policy Wordings for the complete list of non-payable items.

Change of treatment from one system of medicine to another system unless recommended by the consultant/hospital under whom the treatment is taken.

Treatments including Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy, chondrocyte or osteocyte implantation, procedures using platelet rich plasma, Trans Cutaneous Electric Nerve Stimulation; Use of oral immunomodulatory/ supplemental drugs.

Artificial life maintenance including life support machine use, from the date of confirmation by the treating doctor that the patient is in a vegetative state.

A.WAITING PERIODS (Only Applicable for Gold & Senior Citizen Plans)
The Company shall not be liable to make any payment under the policy in connection with or in respect of any expenses till the expiry of waiting period mentioned below:

Pre-Existing Disease
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.

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.