Group Health Insurance: Customercare@magma-Hdi - Co.in

TRUTH MUST BE TOLD
GROUP HEALTH INSURANCE
www.magmahdi.com * customercare@magma-hdi.co.in
Magma HDI General Insurance Co. Ltd. | www.magmahdi.com | E-mail: customercare@magma-hdi.co.in | Toll Free: 1800 266 3202
| Registered Office: Development House, 24 Park Street, Kolkata – 700016. CIN: U66000WB2009PLC136327 | IRDAI Reg. No. 149
Group Health Insurance - MAGHLGP21234V022021 | Trade logos displayed above belong to Magma Fincorp Ltd. and HDI Global SE
respectively, and are being used by Magma HDI General Insurance Company Limited, under license. (PW-01-07-21)
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Policy Document
1. PREAMBLE
The insurance cover provided under this Policy up to the Sum Insured is and shall be subject to (a) the terms and conditions of
this Policy, (b) the receipt of premium, and (c) Disclosure to information and statements which the Policyholder/ Insured person
has provided in the proposal form for all persons to be insured. Please inform Us immediately of any change in the address,
nature of job, state of health, or of any other changes affecting any Insured Person.
If any claim arising as a result of an Illness or Injury that occurred during the Policy Period becomes payable, then We shall pay
the Benefits in accordance with the terms, conditions and exclusions of the Policy subject to availability of Sum Insured.
Section I. Interpretations & Definitions
The terms defined below have the meaning ascribed to them wherever they appear in this Policy and, where appropriate,
references to the singular include references to the plural, references to male include female and references to any statutory
enactment include subsequent changes, replacements or amendments to the same:
Accident: An accident means sudden, unforeseen and involuntary event caused by external, visible and violent means.
Act of God Perils means and includes lightening, storm, tempest, flood, inundation, subsidence, landslide, earthquake,
cyclone, tsunami, volcano and other similar calamities.
Adventure Sport means any sport or activity, which is potentially dangerous to the Insured Person whether he is trained in
such sport or activity or not. Such sport/activity includes without limitation stunt activities of any kind, adventure racing, base
jumping, biathlon, big game hunting, black water rafting, BMX stunt/obstacle riding, bobsleighing/using skeletons,
bouldering, boxing, canyoning, cavin/pot holing, cave tubing, rock climbing/trekking/mountaineering, cycle racing, cyclo
cross, drag racing, endurance testing, hand gliding, harness racing, skiing, high diving (above 5 meters), hunting, ice hockey,
ice speedway, jousting, judo, karate, kendo, lugging, risky manual labour, marathon running, martial arts, micro-lighting,
modern pentathlon, motor cycle racing, motor rallying, parachuting, paragliding/parapenting, piloting aircraft, polo, power
lifting, power boat racing, quad biking, river boarding, scuba diving, river bugging, rodeo, roller hockey, rugby, ski acrobatics,
ski doo riding, ski jumping, ski racing, sky diving, small bore target shooting, speed trials/ time trials, triathlon, water ski
jumping, weight lifting or wrestling any type and Professional Sports (Professional sports mean Athletics, Bowling, Cycling,
Football, Weightlifting, Cricket or any other sport for which a person getting compensated).
Age or Aged means age as on last birthday.
Alternative Treatments or AYUSH are forms of treatments other than treatment of "Allopathy" or "modern medicine" and
includes Ayurveda, Unani, Sidha and Homeopathy in the Indian context.
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 Governemnt AYUSH Hospital or

b. Teaching hospital attached to AYUSH College recognized by the Central Government/Central Council of Indian Medicine/
Central Council for 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 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.
AYUSH Day Care Centre means and includes Community Health Centre (CHC), Primary Health Centre (PHC), Dispensary, Clinic,
Poliyclinic or any such health centre which is registered with the local authorities, wherever applicable and having facilities for
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carrying out treatment procedures and medical or surgical/ para-surgical interventions or both under the supervision of registered
AYUSH Medical Practitioner(s) on day care basis without in-patient services and must comply with all the following criterion:
i. Having qualified registered AYUSH Medical Practitioner(s) in charge;

ii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures
are to be carried out;
iii. Mainitaining daily records of patient and making them accessible to the insurance company's authorized representative
Ambulance means a road vehicle operated by a licensed/ authorized service provider and equipped for the transport and
paramedical treatment of persons requiring medical attention
Annexure means the document attached and marked as Annexure to this Policy
Any One Illness: Any one illness means continuous period of illness and includes relapse within 45 days from the date of last
consultation with the Hospital/Nursing Home where treatment was taken. Cashless facility: 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. Condition
Precedent: Condition Precedent means a policy term or condition upon which the Insurer's liability under the policy is conditional
upon. Congenital Anomaly: 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
Co-Payment: 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 claims amount. A co-payment does not reduce the Sum
Insured.
Cover Start Date means the date on which the coverage under the Policy starts for respective Insured person.
Certificate of Insurance means the certificate issued by Us to the insured person confirming the coverage under the Policy.
Day Care Centre: A day care centre means any institution established for day care treatment of illness and/or injuries or a medical
setup with a hospital and which has been registered with the local authorities, wherever applicable, and is under supervision of a
registered and qualified medical practitioner and must comply with all minimum criteria as under:-
i) has qualified nursing staff under its employment;

ii) has qualified medical practitioner/s in charge;
iii) has fully equipped operation theatre of its own where surgical procedures are carried out;
iv) maintains daily records of patients and will make these accessible to the Insurance company's authorized personnel. Day C a r e
Treatment:
Day care treatment means medical treatment, and/or surgical procedure which is:
i. undertaken under General or Local Anaesthesia in a hospital/day care centre in less than 24 hrs because of technological
advancement, and
ii. which would have otherwise required hospitalization of more than 24 hours.
Treatment normally taken on an out-patient basis is not included in the scope of this definition.
Diagnostic Tests: Investigations, such as X-Ray or blood tests, to find the cause of the Insured Person's symptoms and medical
condition. Dental Treatment: Dental treatment means a treatment related to teeth or structures supporting teeth including
examinations, fillings (where appropriate), crowns, extractions and surgery.
Disclosure to information norm: The policy shall be void and all premium paid hereon shall be forfeited to the Company in the
event of misrepresentation, mis-description or non-disclosure of any material fact. Domiciliary Hospitalization:

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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:
i) the condition of the patient is such that he/she is not in a condition to be removed to a hospital, or
ii) the patient takes treatment at home on account of non-availability of room in a hospital.
Emergency means a severe Illness or Injury which results in symptoms which occur suddenly and unexpectedly, and requires
immediate care by a Medical Practitioner to prevent death or serious long term impairment of the Insured Person's health.
Emergency Care: Emergency care means management for an illness or injury which results in symptoms which occur suddenly and
unexpectedly, and requires immediate care by a medical practitioner to prevent death or serious long term impairment of the insured
person's health.
Family Floater Policy means a policy named as a Family Floater Policy in the Policy Schedule in terms of which, two or more
persons of Insured Person's family are covered as dependents to Insured Person. The definition of Family shall be as mentioned in
Policy Schedule/Certificate of Insurance. For a Floater policy, Sum Insured is available on Floater basis for the covered family
members. Insurer's liability for any and all claims with respect to all family members is limited to the Sum Insured.
Grace Period: 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.
Hospital: A hospital means any institution established for in-patient care and day care treatment of illness and / or injuries and which
has been registered as a hospital with the local authorities under Clinical Establishments (Registration and Regulation) Act 2010 or
under enactments specified under the Schedule of Section 56(1) of the said act Or complies with all minimum criteria as under:
i) Has qualified nursing staff under its employment round the clock;
ii) has at least 10 in-patient beds in towns having a population of less than 10,00,000 and at least 15 in-patient beds in all other
places;
iii) has qualified medical practitioner(s) in charge round the clock;
iv) has a fully equipped operation theatre of its own where surgical procedures are carried out;
v) maintains daily records of patients and makes these accessible to the insurance company's authorized personnel:
Only for the purposes of any claim or treatment permitted to be made or taken outside India
Hospital (outside India) means an institution (including nursing homes) established outside India for indoor medical care and
treatment of Illness and/or 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, and old age home.
Hospitalization :
Hospitalization means admission in a Hospital for a minimum period of 24 consecutive 'In-patient Care' hours except for specified
procedures/ treatments, where such admission could be for a period of less than 24 consecutive hours.
Illness: 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:
1. it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /or tests
2. it needs ongoing or long-term control or relief of symptoms
3. it requires rehabilitation for the patient or for the patient to be specially trained to cope with it
4. it continues indefinitely
5. it recurs or is likely to recur

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IRDAI means the Insurance Regulatory and Development Authority of India.
Injury: Injury means accidental physical bodily harm excluding illness or disease solely and directly caused by external, violent,
visible and evident means which is verified and certified by a Medical Practitioner.
Inpatient Care: Inpatient care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a
covered event.
Intensive Care Unit: 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.
Insured Person means the person(s) named in the Policy Schedule/ Certificate of Insurance who are covered under this Policy and
in respect of whom the appropriate premium has been received.
ICU Charges: 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.
Maternity expenses: Maternity expenses means:
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.
Medical Advice: Medical Advice means any consultation or advice from a Medical Practitioner including the issuance of any
prescription or follow-up prescription.
Medical Expenses: 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.
Medical Practitioner: 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 setup by the Government of India or a State Government
and is thereby entitled to practice medicine within its jurisdiction; and is acting within its scope and jurisdiction of licence. Medically
Necessary Treatment: Medically necessary treatment means any treatment, tests, medication, or stay in hospital or part of a stay in
hospital which:
i) is required for the medical management of the illness or injury suffered by the insured;
ii) must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration,
or intensity;
iii) must have been prescribed by a medical practitioner;
iv) must conform to the professional standards widely accepted in international medical practice or by the medical
community in India. Migration means the right accorded to health insurance policyholders (including all members under
family cover and members of group health policy), to transfer the credit gained for pre-existing conditions and time bound
exclusions, with the same insurer.
Network Provider: Network Provider means hospitals enlisted by an insurer, TPA or jointly by an Insurer and TPA to provide medical
services to an insured by a cashless facility.
New Born Baby: New born baby means baby born during the Policy Period and is aged up to 90 days.
Notification of Claim: Notification of claim means the process of intimating a claim to the insurer or TPA through any of the
recognized modes of communication.
Non-Network Provider: Non-Network means any hospital, day care centre or other provider that is not part of the network.
OPD treatment: OPD treatment means the one in which the Insured visits a clinic/ hospital or associated facility like a consultation
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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.
Policy means this Policy document, any annexures thereto and the Policy Schedule including endorsements, if any, Your statements in
the proposal form and the Information Summary Sheet as applicable.
Policy Start Date means the start date of the Policy as specified in the Policy Schedule.
Policy Expiry Date means the date on which the Policy expires as specified in the Policy Schedule.
Policy Period means the period between the Policy Start Date and the Policy Expiry Date as shown in the Policy Schedule.
Policy Year means a period of twelve consecutive months commencing from the Policy Start Date as specified in the Policy Schedule
or any anniversary thereof. Policyholder means the person named in the Policy Schedule as the policyholder and who has concluded
this Policy with Us.
Pre-Existing Disease: Pre-Existing Disease means 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.
Pre-hospitalization Medical Expenses: Pre- hospitalization Medical Expenses means medical expenses incurred during pre-
defined number of days preceding the hospitalization of the Insured Person, provided that:
i. Such Medical Expenses are incurred for the same condition for which the Insured Person's Hospitalization was required, and
ii. The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company. Primary Insured member
means Policyholder's employee or a member of covered group who satisfies and continues to satisfy the eligibility criteria as
specified in Policy Schedule and Certificate of Insurance.
Post-hospitalization Medical Expenses: 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:
i. Such Medical Expenses are for the same condition for which the insured person's hospitalization was required, and
ii. The inpatient hospitalization claim for such hospitalization is admissible by the insurance company.
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.
Rehabilitation includes treatment aimed at restoring health or mobility, or to allow a person to live an independent life, such as after
a stroke.
Reasonable and Customary Charges: 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.
Renewal: 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.
Room Rent means the amount charged by a Hospital towards Room and Boarding expenses and shall include the associated
medical expenses.
Policy Schedule means the schedule issued by Us along with this Policy mentioning the details of the Policyholder and Insured
person, period of Policy and other details. Any changes made to it shall be issued as Endorsement Schedule and shall be considered a
part of this Policy.

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Shared Accommodation means a Hospital room with two or more patient beds
Sum Insured means:
i) For an Individual Policy, the sum shown in the Policy Schedule/ Product Benefits Table against an Insured Person which
represents Our maximum, total and cumulative liability for any and all claims under the Policy during a Policy Year in respect of
that Insured Person.
ii) For a Family Floater Policy, the sum shown in the Policy Schedule/ Product Benefits Table which represents Our maximum, total
and cumulative liability for any and all claims under the Policy during a Policy Year in respect of any and all Insured
Persons.
Surgery or Surgical Procedure: 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 and
prolongation of life, performed in a hospital or day care centre by a medical practitioner.
Terrorism/Terrorist Activity means an act, including, but not limited to, the use of force or violence and/or the threat thereof, of
any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organisation(s) or Government(s),
committed for political, religious or ideological purposes or reasons including the intention to influence any government and/or to
put the public, or any section of the public, in fear.
TPA or Third Party Administrator means a company registered with the Authority, and engaged by an insurer, for a fee, by
whatever name called and as may be mentioned in the agreement, for providing health services.
Unproven/Experimental treatment: Unproven/Experimental treatment means the treatment including drug experimental
therapy which is not based on established medical practice in India, is treatment experimental or unproven.
We/Our/Us means MAGMA HDI General Insurance Company Ltd.
You/Your/Policyholder means the employer or legally constituted group named in the Schedule who has concluded this Policy
with Us.
Section II. Coverage under the Policy:
A. Base Covers:
The Benefits under this Policy are subject always to the Sum Insured, any subsidiary limit specified in the Policy Schedule/ Certificate of
Insurance, the terms, conditions, limitations and exclusions mentioned in the Policy and eligibility as per the insurance plan opted for
or as shown in the Policy Schedule/Certificate of Insurance.
Following covers are available as Base covers under the policy. Following Base covers are applicable to your Policy as mentioned in
Policy Schedule/ Certificate of Insurance.
Our maximum liability under each of the opted Base Covers will be a part of and up to Sum Insured as specified in Policy
Schedule/Certificate of Insurance for these covers.
1. Inpatient Care
We shall cover the Reasonable and Customary Charges for the following Medical Expenses incurred by Insured Person if during the
Policy Period, he/she requires Hospitalization on the written Medical Advice of a Medical Practitioner, for any Illness or Injury which is
contracted or sustained during the Policy Period and is covered under this Policy:
a) Medical Practitioners' fees

b) Room Rent and other boarding charges
c) ICU Charges
d) Operation theatre charges
e) Diagnostic procedures' charges
f) Medicines, drugs and other consumables as prescribed by the Medical Practitioner
g) Qualified Nurses' charges
h) Intravenous fluids, blood transfusion, injection administration charges
i) Anaesthesia, Blood, Oxygen, operation theatre charges, surgical appliances
j) The cost of prosthetics and other devices or equipment if implanted internally during a Surgical Procedure
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Day Care Treatment
Under this section, We will also cover the Medical Expenses incurred for Day Care Treatment on the written medical advice of a
Medical Practitioner following an Illness or Injury which occurs during the Policy Period, up to the limits specified in the Policy
Schedule/Certificate of Insurance. Any OPD treatment undertaken in a Hospital/Day Care Centre will not be covered under this
Benefit. Please refer to Annexure for list of Day Care Treatments.
2. Hospital Cash
If an Insured Person is Hospitalized during the Policy Period then We shall pay the daily cash amount specified in the Policy Schedule
/Certificate of Insurance for each continuous and completed period of 24 hours of Hospitalization provided that:
a. We shall not make any payment under this Benefit to You for more than the number of days of Hospitalisation as specified in Policy
Schedule /Certificate of Insurance
b. A deductible in terms of number of days per Hospitalization event will be applicable if and as specified in Policy Schedule
/Certificate of Insurance
c. We shall not make any payment under this Benefit for any diagnosis or treatment arising from or related to pregnancy (whether
uterine or extra uterine), childbirth including caesarean section, medical termination of pregnancy and/or any treatment related
to pre and post-natal care of the New Born Baby.
3. Outpatient Cover
We will cover the Reasonable and Customary Charges incurred for availing following services on an out-patient basis to assess
Insured Person's health condition for any Illness or injury as specified in Policy Schedule/Certificate of Insurance
- medically necessary consultations with a Medical Practitioner

- undergoing any Diagnostic Tests prescribed by the Medical Practitioner
- medicines purchased under and supported with a Medical Practitioner's prescription.
- Non surgical and minor surgical procedures which are neither in-patient nor day care procedures
The waiting periods as defined in Section III of this Policy will not be applicable for this Cover.
The amount payable under this Benefit shall be up to the limit shown in the Policy Schedule/Certificate of Insurance.
4. Critical Illness Cover
We shall pay the amount as specified in the Policy Schedule/Certificate of Insurance against this Benefit as a lump sum amount,
provided that:
i. The Insured Person is first diagnosed as suffering from a Critical Illness during the Policy Period, and
ii. The Insured Person survives for at least the number of days as defined in "Survival clause" under this benefit in Policy
Schedule/certificate of Insurance following such diagnosis.
We will not make any payment under this Benefit if the Insured Person is first diagnosed as suffering from a Critical Illness within 90
days of the inception of coverage of Insured Person under this Policy.
This Benefit can be availed by the Insured Person only once during his/her lifetime. A waiting period of 48 months will be applicable
for claim under this Benefit in case claim is for any of the Critical Illnesses which is a consequence of or arises out of any Pre-Existing
Disease.
If a claim becomes admissible under this Cover, it shall not be available for that Insured Person at the time of Renewal.
The waiting periods and as defined in Section III of this Policy will not be applicable for this Cover.
For the purpose of this Benefit, covered Critical Illness means:

1. Cancer of specified severity;
2. Kidney failure requiring regular dialysis;
3. Multiple Sclerosis with persistent symptoms
4. Major Organ/Bone marrow Transplant
5. Open Heart Replacement or Repair of Heart Valves
6. Open Chest CABG (Coronary Artery Bypass Graft)
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7. Stroke resulting in permanent symptoms
8. Permanent Paralysis of Limbs
9. Myocardial Infarction (First Heart Attack of specified severity)
10. Coma of specified severity
11. Parkinson's Disease
12. Benign Brain Tumor
13. Alzheimer's Disease
14. End Stage Liver failure
15. Surgery of Aorta
16. Deafness
17. Loss of Speech
18. Third Degree Burns
19. Motor Neuron Disease with Permanent Symptoms
20. Primary Pulmonary Hypertension
21. Pulmonary Artery Graft Surgery
22. Muscular Dystrophy
23. Systemic Lupus Erythematosis with Lupus Nephritis
24. Pneumonectomy
25. Medullary Cystic Disease
26. Angioplasty
27. Blindness
28. End Stage lung failure
29. Major Head Trauma
30. Cardiomyopathies
31. Terminal illness
32. Fulminant Hepatitis
33. Coronary Artery disease
34. Bacterial Meningitis
35. Multiple system Atrophy
Critical Illnesses as per below grid will be covered as per the plan option in the Policy:
Sr. Option Option Option Option Option Option

Name of Critical Illness
No. A B C D E F
1 Cancer of specified severity Yes Yes Yes Yes Yes Yes
2 Kidney failure requiring regular dialysis Yes Yes Yes Yes Yes Yes
3 Multiple Sclerosis with persistent symptoms Yes Yes Yes Yes Yes Yes
4 Major Organ Transplant Yes Yes Yes Yes Yes Yes
5 Heart Valve Replacement Yes Yes Yes Yes Yes Yes
6 Coronary Artery Bypass Graft Yes Yes Yes Yes Yes Yes
7 Stroke resulting in permanent symptoms Yes Yes Yes Yes Yes Yes
8 Permanent Paralysis of Limbs Yes Yes Yes Yes Yes Yes

Myocardial Infarction
9 (First Heart Attack of specified severity) Yes Yes Yes Yes Yes Yes
10 Coma of specified severity - Yes Yes Yes Yes Yes
11 Parkinson's Disease - Yes Yes Yes Yes Yes
12 Benign Brain Tumor - Yes Yes Yes Yes Yes

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13 Alzheimer's Disease - - Yes Yes Yes Yes
14 End Stage Liver failure - - Yes Yes Yes Yes
15 Surgery of Aorta - - Yes Yes Yes Yes
16 Deafness - - - Yes Yes Yes
17 Loss of Speech - - - Yes Yes Yes
18 Third Degree Burns - - - Yes Yes Yes
19 Motor Neuron Disease with Permanent Symptoms - - - - Yes Yes
20 Primary Pulmonary Hypertension - - - - Yes Yes
21 Pulmonary Artery Graft Surgery - - - - Yes Yes
22 Muscular Dystrophy - - - - Yes Yes
23 Systemic Lupus Erythematosis with Lupus Nephritis - - - - Yes Yes
24 Pneumonectomy - - - - Yes Yes
25 Medullary Cystic Disease - - - - Yes Yes
26 Angioplasty - - - - Yes Yes
27 Blindness - - - - Yes Yes
28 End Stage lung failure - - - - Yes Yes
29 Major Head Trauma - - - - Yes Yes
30 Cardiomyopathies - - - - Yes Yes
31 Terminal illness - - - - Yes Yes
32 Fulminant Hepatitis - - - - Yes Yes
33 Coronary Artery disease - - - - Yes Yes
34 Bacterial Meningitis - - - - Yes Yes
35 Multiple system Atrophy - - - - Yes Yes

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Definition of Critical Illnesses:
1. Cancer of Specified Severity
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.
The following are excluded –

• 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.
• Any non melanoma skin carcinoma unless there is evidence of metastases to lymph nodes or beyond;
• Malignant melanoma that has not caused invasion beyond the epidermis;
• 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
• All thyroid cancers histologically classified as T1N0M0 (TNM Classification) or below;
• Chronic lymphocytic leukemia less than RAI stage 3
• Non-invasive papillary cancer of the bladder histologically described as TaN0M0 or of a lesser classification,
• All Gastro-Intestinal Stromal Tumors histologically classified as T1N0M0 (TNM Classification) or below with mitotic count of
less than or equal to 5/50 HPFs
• All tumors in the presence of HIV infection.
2. Kidney Failure requiring regular dialysis
End stage renal disease presenting as chronic irreversible failure of both kidneys to function, as a result of which either
regular renal dialysis (hemodialysis or peritoneal dialysis) is instituted or renal transplantation is carried out. Diagnosis has to
be confirmed by a specialist medical practitioner.
3. Multiple Sclerosis with persisting symptoms
The unequivocal diagnosis of definite Multiple Sclerosis confirmed and evidenced by all of the following:
• Investigations including typical MRI findings, which unequivocally confirm the diagnosis to be multiple sclerosis and
• There must be current clinical impairment of motor or sensory function, which must have persisted for a continuous period of
at least 6 months.
Other causes of neurological damage such as SLE and HIV are excluded.
4. Major Organ/ Bone Marrow Transplant
The actual undergoing of a transplant of:

• One of the following human organs: heart, lung, liver, kidney, pancreas, that resulted from irreversible end-stage failure of
the relevant organ, or
• Human bone marrow using hematopoietic stem cells
The undergoing of a transplant has to be confirmed by a specialist medical practitioner.
The following are excluded:

a) Other stem-cell transplants
b) Where only islets of langerhans are transplanted
5. Open Heart Replacement or Repair of Heart Valves
The actual undergoing of open-heart valve surgery 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.

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6. Open Chest CABG (Coronary Artery Bypass Graft)
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.
a) Angioplasty and/or any other intra-arterial procedures
7. Stroke resulting in Permanent Symptoms
Any cerebrolvascular incident producing permanent neurological sequelae. This includes infarction of brain tissue, thrombosis in
an intra-cranial vessel, haemorrhage and embolisation from an extra cranial 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.
8. Permanent Paralysis of Limbs
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.
9. First Heart Attack of Specified Severity (Myocardial Infarction)
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 should be evidenced by all of the following criteria:

• A history of typical clinical symptoms consistent with the diagnosis of Acute Myocardial Infarction (for e.g. typical chest
pain).
• New characteristic electrocardiogram changes
• Elevation of infarction specific enzymes, Troponins or other specific biochemical markers.

• Non-ST-segment elevation myocardial infarction (NSTEMI) with elevation of Troponins I or T
• Other acute Coronary Syndromes
• Any type of Angina Pectoris
• A rise in cardiac biomarkers or Troponin T or I in absence of overt ischemic heart disease OR following an intra-arterial
cardiac procedure.
10. Coma of Specified Severity
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:

• No response to external stimuli continuously for at least 96 hours;
• Life support measures are necessary to sustain life.
• Permanent neurological deficit which must be assessed at least 30 days after the onset of the coma.
The condition has to be confirmed by a specialist medical practitioner.
Coma resulting directly from alcohol or drug abuse is excluded.

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11. Parkinson's Disease
The occurrence of Parkinson's Disease where there is an associated Neurological Deficit that results in Permanent Inability to
perform independently atleast three of the activities of daily living as defined below.
i. Transferring: The ability to move from bed to an upright chair or wheelchair and vice versa;
ii. Mobility: The ability to move indoors from room to room on level surfaces;
iii.Dressing: The ability to put on, take, secure and unfasten all garments and, as appropriate, any braces, artificial limbs or
other surgical appliances;
iv. Bathing/Washing: The ability to wash in the bath or shower (including getting in and out of the bath or shower) or wash
satisfactorily by other means
v. Feeding: The ability to feed oneself once food has been prepared and made available
vi.Toileting: the ability to use the lavatory or otherwise manage bowel and bladder functions so as to maintain a satisfactory
level of personal hygiene;
Parkinson's disease secondary to drug and/or alcohol abuse is excluded.
12.Benign Brain Tumor
1. Benign brain tumor is defined as a life threatening, non-cancerous tumor in the brain, cranial nerves or meninges within
the skull. The presence of the underlying tumor must be confirmed by imaging studies such as CT scan or MRI.
2. The brain tumor must result in at least one of the following and must be confirmed by the relevant medical specialist
i. Permanent neurological deficit with persisting clinical symptoms for a continuous period of at least 90 consecutive days
or
ii. Undergone surgical resection or radiation therapy to treat the brain tumor.
3. The following are excluded:

Cysts, Granulomas, Malformations in the arteries or veins of the brain, Haematomas, abscesses, pituitary tumors, tumors
of skull bones and tumors of the spinal cord.
13. Alzheimer's Disease
Clinically established diagnosis of Alzheimer's Disease (presenile dementia) resulting in a permanent inability to perform
independently three or more activities of daily living – bathing, dressing/undressing, getting to and using the toilet, transferring
from bed to chair or chair to bed, continence, eating/drinking and taking medication – or resulting in need of supervision and
permanent presence of care staff due to the disease. These conditions have to be medically documented for at least 3 months
14. 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 alcohol or drug misuse is excluded.
15. Surgery of Aorta
The actual undergoing of medically necessary surgery for a disease of the aorta needing excision and surgical replacement
of the diseased aorta with a graft. For the purpose of this definition aorta shall mean the thoracic and abdominal aorta but
not its branches. Traumatic injury of the aorta is excluded.
16.Deafness
Total and irreversible loss of hearing in both ears as a result of Illness or Accident. The diagnosis must be supported by pure
tone audiogram test and certified by an ear, nose and throat specialist (ENT specialist). Total means "the loss of hearing to
the extent that the loss is greater than 90 decibels across all frequencies of hearing" in both ears.
17. Loss of Speech
Total and irreversible loss of the ability to speak as a result of injury or disease to the vocal chords. The inability to speak must be
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established for a continuous period of 12 months. The diagnosis must be supported by medical evidence furnished by an Ear,
Nose, Throat (ENT) specialist.
All psychiatric related causes are excluded.
18. Major Burns (Third Degree Burns)
There must be Third Degree burns with scarring that covers at least 20% of the body's surface area. The diagnosis must confirm
that the total area involved using standardized, clinically accepted, body surface area charts covering 20% of body surface area.
19. Motor Neuron Disease with Permanent Symptoms
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.
20.Primary (Idiopathic) Pulmonary Hypertension
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.
The NYHA Classification of Cardiac Impairment are as follows:

a. Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms.
b. Class IV: Unable to engage in any physical activity without discomfort. Symptoms may be present even at rest.
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.
21. Pulmonary Artery Graft Surgery
The undergoing of surgery requiring median sternotomy on the advice of a Cardiologist for disease of the pulmonary artery
to excise and replace the diseased pulmonary artery with a graft
22.Muscular Dystrophy
A group of hereditary degenerative diseases of muscle characterised by weakness and atrophy of muscle. The diagnosis of
muscular dystrophy must be unequivocal and made by a Registered Doctor who is a consultant neurologist. The condition
must result in the inability of the Life Insured to perform (whether aided or unaided) at least 3 of the 6 "Activities of Daily
Living" for a continuous period of at least 6 months.
Activities of daily living:

• Washing: the ability to wash in the bath or shower (including getting into and out of the shower) or wash satisfactorily by
other means and maintain an adequate level of cleanliness and personal hygiene;
• Dressing: the ability to put on, take off, secure and unfasten all garments and, as appropriate, any braces, artificial limbs
or other surgical appliances;
• 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;
• Toileting: the ability to use the lavatory or otherwise manage bowel and bladder functions so as to maintain a satisfactory level of
personal hygiene;
• Feeding: the ability to feed oneself, food from a plate or bowl to the mouth once food has been prepared and made available.
• Mobility: The ability to move indoors from room to room on level surfaces at the normal place of residence
23.Systemic Lupus Erythematosus
A multi-system autoimmune disorder characterised by the development of autoantibodies directed against various self-antigens.
In respect of this Policy, systemic lupus erythematosus will be restricted to those forms of systemic lupus erythematosus which

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involve the kidneys (Class III to Class V Lupus Nephritis, established by renal biopsy, and in accordance with the WHO
Classification). The final diagnosis must be confirmed by a Registered Doctor specialising in Rheumatology and Immunology.
The WHO Classification of Lupus Nephritis:

Class I Minimal Change Lupus Glomerulonephritis
Class II Messangial Lupus Glomerulonephritis
Class III Focal Segmental Proliferative Lupus Glomerulonephritis
Class IV Diffuse Proliferative Lupus Glomerulonephritis
Class V Membranous Lupus Glomerulonephritis
24. Pneumonectomy
The undergoing of surgery on the advice of an appropriate Medical Specialist to remove an entire lung for disease or traumatic
injury suffered by the life assured.
The following conditions are excluded:

• Removal of a lobe of the lungs (lobectomy)
• Lung resection or incision
25.Medullary Cystic Disease
Medullary Cystic Disease where the following criteria are met:

a. the presence in the kidney of multiple cysts in the renal medulla accompanied by the presence of tubular atrophy and
interstitial fibrosis;
b. clinical manifestations of anaemia, polyuria, and progressive deterioration in kidney function; and
c. the Diagnosis of Medullary Cystic Disease is confirmed by renal biopsy.
d. Isolated or benign kidney cysts are specifically excluded from this benefit
26. Angioplasty
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).
I. Coronary arteries herein refer to left main stem, left anterior descending, circumflex and right coronary artery.
II.Diagnostic angiography or investigation procedures without angioplasty/stent insertion are excluded.
27. Blindness
I. Total, permanent and irreversible loss of all vision in both eyes as a result of illness or accident.
II. The Blindness is evidenced by:

i. corrected visual acuity being 3/60 or less in both eyes or ;
ii. the field of vision being less than 10 degrees in both eyes.
iii. The diagnosis of blindness must be confirmed and must not be correctable by aids or surgical procedure.
28. End Stage Lung Failure
End stage lung disease, causing chronic respiratory failure, as confirmed and evidenced by all of the following:
i. FEV1 test results consistently less than 1 litre measured on 3 occasions 3 months apart; and
ii. Requiring continuous permanent supplementary oxygen therapy for hypoxemia; and
iii. Arterial blood gas analysis with partial oxygen pressure of 55mmHg or less (PaO2 < 55mmHg); and
iv. Dyspnea at rest.
29. Major Head Trauma
Accidental head injury resulting in permanent Neurological deficit to be assessed no sooner than 3 months from the date of the
accident. This diagnosis must be supported by unequivocal findings on Magnetic Resonance Imaging, Computerized
Tomography, or other reliable imaging techniques. The accident must be caused solely and directly by accidental, violent, external
and visible means and independently of all other causes.

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I. The Accidental Head injury must result in an inability to perform at least three (3) of the following Activities of Daily Living either
with or without the use of mechanical equipment, special devices or other aids and adaptations in use for disabled persons. For
the purpose of this benefit, the word "permanent" shall mean beyond the scope of recovery with current medical knowledge and
technology.
II. The Activities of Daily Living are:

i. Washing: the ability to wash in the bath or shower (including getting into and out of the bath or shower) or wash satisfactorily
by other means;
ii. Dressing: the ability to put on, take off, secure and unfasten all garments and, as appropriate, any braces, artificial limbs or
iii. Transferring: the ability to move from a bed to an upright chair or wheelchair and vice versa;
iv. Mobility: the ability to move indoors from room to room on level surfaces;
v. Toileting: the ability to use the lavatory or otherwise manage bowel and bladder functions so as to maintain a satisfactory
level of personal hygiene;
vi. Feeding: the ability to feed oneself once food has been prepared and made available.
III. The following are excluded:

i. Spinal cord injury;
30. Cardiomyopathies
A diagnosis of cardiomyopathy by a Specialist Medical Practitioner (Cardiologist). There must be clinical impairment of heart
function resulting in the permanent loss of ability to perform physical activities for a minimum period of 30 days to at least Class 3
of the New York Heart Association classification's of functional capacity (heart disease resulting in marked limitation of physical
activities where less than ordinary activity causes fatigue, palpitation, breathlessness or chest pain) and LVEF of 40% or less.
The following conditions are excluded:

• Cardiomyopathy secondary to alcohol or drug abuse.
• All other forms of heart disease, heart enlargement and myocarditis
31. Terminal illness
The conclusive diagnosis of an illness that is expected to result in the death of the Insured Person within 6 months. This diagnosis
must be supported by a specialist and confirmed by the Company's appointed Doctor. The Company reserves the right for
independent assessment.
Terminal illness due to AIDS is excluded.
32. Fulminant Hepatitis
A sub-massive to massive necrosis of the liver by the Hepatitis virus, leading precipitously to liver failure. This diagnosis must be
supported by all of the following:
1) Rapid decreasing of liver size;
2) Necrosis involving entire lobules, leaving only a collapsed reticular framework;
3) Rapid deterioration of liver function tests;
4) Deepening jaundice; and
5) Hepatic encephalopathy.
Acute Hepatitis infection or carrier status alone does not meet the diagnostic criteria.
33. Coronary Artery Diseases
The narrowing of the lumen of at least one coronary artery by a minimum of 75% and of two others by a minimum of 60%, as
proven by coronary arteriography, regardless of whether or not any form of coronary artery Surgery has been performed.
Coronary arteries herein refer to left main stem, left anterior descending circumflex and right coronary artery.
34. Bacterial Meningitis
Bacterial meningitis causing inflammation of the membranes of the brain or spinal cord resulting in permanent neurological

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deficit lasting for a minimum period of 30 days. It should result in a permanent inability to perform at least three of the Activities of
Daily Living either with or without the use of mechanical equipment, special devices or other aids and adaptations in use for
disabled persons.
Permanent Neurological Deficit means Symptoms of dysfunction in the nervous system that is present on clinical examination and
expected to last throughout the insured person's life. Symptoms that are covered include numbness, increased sensitivity,
paralysis, localized weakness, difficulty with speech, inability to speak, difficulty in swallowing, visual impairment, difficulty in
walking, lack of coordination, tremor, seizures, lethargy, dementia, delirium and coma.
The Activities of Daily Living are:

i. Washing: the ability to wash in the bath or shower (including getting into and out of the bath or shower) or wash satisfactorily by
other means;
ii. Dressing: the ability to put on, take off, secure and unfasten all garments and, as appropriate, any braces, artificial limbs or
iii. Transferring: the ability to move from a bed to an upright chair or wheelchair and vice versa;
iv. Mobility: the ability to move indoors from room to room on level surfaces;
v. Toileting: the ability to use the lavatory or otherwise manage bowel and bladder functions so as to maintain a satisfactory level
of personal hygiene;
vi.Feeding: the ability to feed oneself once food has been prepared and made available.
35. Multiple System Atrophy
A diagnosis of multiple system atrophy by a Specialist Medical Practitioner (Neurologist). There must be evidence of permanent
clinical impairment for a minimum period of 30 days of either:
• Motor function with associated rigidity of movement; or
• The ability to coordinate muscle movement; or
• Bladder control and postural hypotension
5. Corona Protection Cover:
We shall pay the amount as specified in the Policy Schedule/Certificate of Insurance against this Benefit as a lump sum amount,
provided that:
i. The Insured Person is first diagnosed as suffering from a Covid-19 during the Policy Period, and
ii. The diagnosis of Covid-19 is done at a Diagnostic centre which is authorized by the Government of India
We will not make any payment under this Benefit if the Insured Person is first diagnosed as suffering from Covid-19 prior to the
inception of coverage of Insured Person under this Policy. The initial waiting period as mentioned in the Policy
Schedule/Certificate of Insurance will be applicable. Other waiting periods and as defined in Section III of this Policy will not be
applicable for this Cover.
We shall not make any payment for home or institutional quarantine for suspected Covid-19 disease. Positive diagnosis of Insured
person for Covid-19 is mandatory for claim admissibility.
COVID-19 here means, Corona virus disease as defined by the World Health Organization (WHO) and caused by the virus
SARS-CoV2.
<B. Extension covers:
Following extension covers are applicable to each insured person under this Policy. The coverage limits are specified in the Policy
Schedule/ Certificate of Insurance. The limits for these covers are applicable for each Insured Person and are included within the
Sum Insured limit, unless specified otherwise. All the waiting periods and Exclusions are applicable to these Extension Covers as
well unless specified otherwise.
Extension Covers wordings as applicable>
Section III. Exclusions
III.1 Waiting Periods: Following waiting periods will be applicable to each Insured Person under this Policy.

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a) First Thirty Days Waiting Period (Code- Excl03)
i. 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.
ii. This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve months.
iii. The within referred waiting period is made applicable to the enhanced sum insured in the event of granting higher sum
insured subsequently.
b) Specific Diseases Waiting Period (Code- Excl02):
a) Expenses related to the treatment of the following listed conditions, surgeries/treatments shall be excluded until the expiry of
24 months of continuous coverage, as may be the case after the date of inception of the first policy with the Insurer. This
exclusion shall not be applicable for claims arising due to an accident.
b) In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
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.
List of these diseases is:

1. Cataract
2. Stones in biliary and urinary systems
3. Hernia / Hydrocele
4. Hysterectomy for any benign disorder
5. Lumps / cysts / nodules / polyps / internal tumours
6. Gastric and Duodenal Ulcers
7. Surgery on tonsils / adenoids
8. Osteoarthrosis / Arthritis / Gout / Rheumatism / Spondylosis / Spondylitis / Intervertebral Disc Prolapse
9. Fissure / Fistula / Haemorrhoid
10. Sinusitis / Deviated Nasal Septum / Tympanoplasty / Chronic Suppurative Otitis Media
11. Benign Prostatic Hypertrophy
12. Knee/Hip Joint replacement
13. Dilatation and Curettage
14. Varicose veins
15. Dysfunctional Uterine Bleeding / Fibroids / Prolapse Uterus / Endometriosis
16. Chronic Renal Failure or end stage Renal Failure
17. Internal congenital anomalies/diseases/defects
18. HIV , AIDS
c) Pre Existing disease (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 above defined months for any pre-existing disease is subject to the same being
declared at the time of application and accepted by us.
III.2 Permanent Exclusions:
We will not be liable to make any payment under this Policy under any circumstances, for any claim in respect of any Insured
Person, directly or indirectly for, caused by or arising from or in any way attributable to any of the following permanent exclusions.
In case extension covers are opted, respective permanent exclusion(s) stand deleted to the extent of coverage as per terms and
conditions of that Extension cover.
1. Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof.(Code- Excl12).

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2. 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..
3. Any treatment modality other than Allopathic Treatment
4. Charges related to a Hospital stay not expressly mentioned as being covered,. Service charges levied by the Hospital under
whatever head. Complete list of these excluded expenses are mentioned in Annexure II of this Policy. The list is available on
our website www.magma-hdi.co.in
5. Artificial life maintenance, including life support machine used to sustain a person, , incurred after confirmation by the
treating doctor that the patient is in vegetative state.
6. Any charges incurred to procure any medical certificate, medical records, treatment or Illness/Injury related documents
pertaining to any period of Hospitalization/Day Care Treatment undertaken for any Illness or Injury.
7. Circumcision unless necessary for the treatment of an Illness or disease or necessitated by an Accident.
8. Treatment for any Illness or Injury resulting from nuclear or chemical contamination, war, participation in riot, revolution,
acts of terrorism or any similar event (other than natural disaster or calamity)
9. Treatment for any External Congenital Anomaly.
10. Obesity/ Weight Control: Code- Excl06
Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:
1) Surgery to be conducted is upon the advice of the Doctor
2) The surgery/Procedure conducted should be supported by clinical protocols
3) The member has to be 18 years of age or older and
4) Body Mass Index (BMI);
a) greater than or equal to 40 or
b) 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:
i. Obesity-related cardiomyopathy
ii. Coronary heart disease
iii. Severe Sleep Apnea
iv. Uncontrolled Type2 Diabetes
11. 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.
12. Refractive Error (Code-Excl15)
Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres.
13. Dental Treatment including Surgical Procedures for the treatment of bone disease when related to gum disease or damage, or
treatment for, or treatment arising from, disorders of the temporomandibular joint. This exclusion does not apply for Outpatient
Cover (Base cover Section 3)
EXCEPTION: We will pay for a Surgical Procedure wherein the Insured Person Hospitalized as a result of an Accident and which is
undertaken for Inpatient Care in a Hospital and carried out by a Medical Practitioner.
14. Any expenses for OPD treatment, or any expenses for drugs or dressings not prescribed for Insured Person's intake within
hospitalization period, except as included in Post-hospitalization Medical Expenses Extension cover. This exclusion does not apply
to Outpatient Cover (Base cover Section 3)
15. We will not pay for routine eye examinations, contact lenses spectacles, hearing aids, dentures and artificial teeth. This exclusion
does not apply for Outpatient Cover (Base cover Section 3)
16. Treatment 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
17. Any treatment arising from and/or taken for Crohn's Disease ,Ulcerative colitis, Cystic kidneys, Neurofibromatosis, Factor V
Leiden Thrombophilia, Familial Hypercholesterolemia, Haemophilia, Hereditary Fructose Intolerance, Hereditary
Hemochromatosis, Hereditary Spherocytosis.

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18. Private nursing/attendant's charges incurred during pre-hospitalization or post-hospitalization.
19. Drugs or treatment not supported by prescription.
20. Issue of fitness certificate and fitness examinations
21. External and/ or durable medical/non-medical equipment of any kind used for diagnosis and/ or treatment , CPAP, CAPD,
infusion pump.
22. Ambulatory devices, walkers, crutches, belts, collars, caps, splints, slings, braces, stockings of any kind, diabetic foot wear,
glucometer/thermometer and also any medical equipment which is subsequently used at home.
23. OPD treatment is not covered. However this exclusion does not apply for Outpatient Cover (Base cover Section 3)
24. All preventive care, vaccination including inoculation and immunizations, except if it is certified and recommended by the
attending Medical Practitioner as part of in-patient treatment. However this exclusion does not apply for Outpatient Cover
(Base cover Section 3).
25. 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
26. Maternity expenses (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.
27. Treatment for, or arising from, an Injury that is intentionally self-inflicted, including attempted suicide.
28. Change of Gender treatment (Code-Excl07):
Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite
sex.
29. Treatment of any sexual problem including impotence (irrespective of the cause) or erectile dysfunction.
30. Treatment for any sexually transmitted disease, including Genital Warts, Syphilis, Gonorrhoea, Genital Herpes, Chlamydia, Pubic
Lice and Trichomoniasis.
31. Treatment for sleep apnea, snoring, or any other sleep-related breathing problem.
32. Any treatment received outside India.
33. 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
34. Treatment provided by a Medical Practitioner who is not recognized by the Medical Council of India.
35. Excluded Providers (Code-Excl11)
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.
List of these have been provided on Our website.
36. Treatment provided by anyone with the same residence as the Insured Person or who is a member of the Insured Person's
immediate family.

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37. 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.
38. X-Ray or laboratory examinations or other diagnostic studies, not consistent with or incidental to the diagnosis and treatment of
the positive existence or presence of any Illness or Injury, whether or not requiring Hospitalization.
39. 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:
i. 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.
ii. Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.
40. 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.
41. 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
Claim Procedure
Provided that due adherence/observance and fulfilment of the terms and conditions of this Policy (conditions and all endorsements,
Annexures hereon are to be read as part of this Policy) shall so far as they relate to anything to be done or not to be done by You and /
or any Insured Person be a Condition Precedent to admission of Our liability under this Policy.
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:
1. For Availing Cashless Facility (Procedure for Domestic Claims )
Cashless facility can be availed only at Our Network Providers. The complete list of Network Providers is available on Our website
and and can also be obtained by contacting Us over the telephone. The updated list of TPA containing complete details is
available on Our website www.magmahdi.com.
Cashless facility will be availed through the TPA. The TPA will be contacted on its helpline and must be provided with the
membership number, Policy Number and the name of the Insured Person at least 72 hours before admission to the Hospital for
planned Hospitalization and within 24 hours of admission to the Hospital in case of Emergency Hospitalization. The TPA will also,
by fax or e-mail, be provided with details of Hospitalization like diagnosis, name of the Hospital, duration of stay in the Hospital,
estimated expenses of Hospitalization etc. in the prescribed form available with the insurance help desk at the Hospital. Any
additional information as may be required by the medical panel of the TPA must also be furnished. After establishing the
admissibility of the claim under the Policy, the TPA shall provide a pre-authorisation to the Hospital guaranteeing payment of the
Hospitalization expenses subject to the Sum Insured, terms conditions and limitations of the Policy. The authorization shall be
issued to the Network Provider within 24 hours of receiving the complete information.
2. For admission in Non-Network Provider or into Network Provider if Cashless facility is not availed (Re-
imbursement Claims)
a. Intimation of claim: Preliminary intimation of claim with particulars relating to Policy Number, name of the Insured Person in
respect of whom claim is made, nature of Illness/Injury and name and address of the attending Hospital, must be provided to
Us at least 72 hours before admission to the Hospital in case of planned Hospitalization, and within 24 hours of admission in
the Hospital, in case of Emergency Hospitalization.

Group Health
Insurance
3. Submission of claim: The claim form along with the attending Medical Practitioner's certificate duly filled and signed in all
respects with the following claim documents will be submitted to Us not later than 30 days from the date of discharge from the
Hospital.
Mandatory documents:
a) Duly completed claim form
b) Test reports and prescriptions relating to first / previous consultations for the same or related illness.
c) Case history / admission-discharge summary describing the nature of the complaints and its duration, treatment given,
advice on discharge etc. issued by the Hospital.
d) Death summary in case of death of the Insured Person at the Hospital.
e) Post Mortem Report, if applicable & if conducted
f) Hospital receipts / bills / cash memos in original (including advance and final Hospital settlement receipts).
g) All test reports for X-rays, ECG, Scan, MRI, Pathology etc., including the Medical Practitioner's prescription advising such
tests/investigations (CDs of angiogram, surgery etc. need not be sent unless specifically sought).
h) Medical Practitioner's prescriptions with cash bills for medicines purchased from outside the Hospital.
I) F.I.R/MLC. in the case of Accidental Injury and English translation of the same, if in any other language.
j) Legal heir certificate in the absence of nomination under the Policy, in case of death of the Insured Person. In the absence of
legal heir certificate, evidence establishing legal heirship may be provided as required by Us.
k) For a) maternity claims, discharge summary mentioning LMP, EDD & Gravida b) Cataract claims - IOL sticker c) PTCA claims
- Stent sticker.
l) Copies of health insurance policies held with any other insurer covering the Insured Person(s).
m) If a claim is partially settled by any other insurer, a certificate from the other insurer confirming the final claim amount settled
by them and that original claim documents are retained at their end.
Documents to be submitted if specifically sought:

a. Copy of indoor case records (including Qualified Nurse's notes, OT notes and anaesthetists' notes, vitals chart).
b. Copy of extract of inpatient register.
c. Attendance records of employer/educational institution.
d. Complete medical records (including indoor case records and OP records) of past Hospitalization/treatment, if any.
e. Attending Medical Practitioner's certificate clarifying.
i. reason for Hospitalization and duration of Hospitalization
ii. history of any self-inflicted Injury
iii. history of alcoholism, smoking
iv. history of associated medical conditions, if any
f. Previous master health check-up records/pre-employment medical records, if any.
g. Any other document necessary in support of the claim on case to case basis.
The claim documents should be sent to:
Magma HDI General Insurance Co. Ltd.

516 & 517, 5th Floor, Neelkanth Corporate Park,
Plot No.: 240, 2401/1-8, Kirol Road,
Vidyavihar (West) Mumbai,
Maharashtra - 400086.
Payment of Claim
• No liability under the Policy will be admitted, if the claim is fraudulent or supported by fraudulent means.
• The Insured Person or any person acting on behalf of the Insured Person, as the case may be, must provide at his/her expense, all
the information asked by Us in relation to the claim and he/she must provide all reasonable cooperation and assistance to Us as
may be required.
• If required, the Insured Person or any person acting on behalf of the Insured Person, as the case may be, must give consent to
obtain medical reports from the Medical Practitioner at Our expense.
• If requested by Us, the Insured Person must agree to be examined by a Medical Practitioner of Our choice and at Our expense.
• All claims under this Policy shall be payable in Indian Currency.
• Claims under this Policy shall be settled or rejected, as the case may be, within 30 days of the receipt of the last necessary
document.

Group Health
Insurance
Section 5. Standard Terms and Conditions
1. Disclosure to 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)
2. 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
3. Claim Settlement (Provision for penal interest)
(I) The Company shall settle or reject a claim, as may be the case, within 30 days from the date of receipt of last necessary
document.
(ii) In 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. In such cases, the Company shall settle or reject the claim within 45 days from the date of receipt of last
necessary document.
(iv) In 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 India (RBI) at the beginning of the financial year in
which claim has fallen due.)
4. Material change
It is a Condition Precedent to the Our liability under the Policy that the Policyholder/ Insured Person shall immediately notify Us in
writing of any material change in the risk on account of change in the nature of occupation or business at his/her own expense.
We may, in Our discretion, adjust the scope of cover and/or the premium payable, accordingly, in line with our board approved
underwriting policy. The Policyholder/Insured Person must exercise the same duty to disclose those matters to Us before the
Renewal, extension, variation, endorsement or reinstatement of the Policy. The Policy terms and conditions may be altered
accordingly.
5. Multiple Policies
1. In 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.
In 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.
2. Insured 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.
3. If the amount to be claimed exceeds the sum insured under a single policy, the Insured Person shall have the right to choose
insurers from whom he/she wants to claim the balance amount.
4. 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. Alteration to the Policy
This Policy constitutes the complete contract of insurance. Subject to the provisions of applicable law, no change or alteration will
be effective or valid unless approved in writing which will be evidenced by a written endorsement signed and stamped by Us. No
one except Us can change or vary this Policy.

Group Health
Insurance
7. No Constructive Notice
Any knowledge or information of any circumstances or condition in relation to the Policyholder/Insured Person which is in Our
possession and not specifically informed by the Policyholder/ Insured Person shall not be held to bind or prejudicially affect Us
notwithstanding subsequent acceptance of any premium.
8. Free Look Provision
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 shall be allowed a free look provision of fifteen days 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.
If the insured has not made any claim during the Free Look Period, the insured shall be entitled to
i. 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; or
ii. where the risk has already commenced and the option of return of the Policy is exercised by the insured person, a deduction
towards the proportionate risk premium for period of cover or
Where only a part of the insurance coverage has commenced, such proportionate premium commensurate with the insurance
coverage during such period;
9. Cancellation/ Termination (other than Free Look cancellation)
a. The Policyholder may cancel this Policy by giving 15 days' written notice and in such an event, the Company shall refund
premium for the unexpired policy period as detailed below.:
We shall cancel the Policy and refund the premium for the balance of the Policy Period in accordance with the table below, after
deducting the amount spent on pre-policy medical check up by Us, provided that no claim has been made under the Policy by
or on behalf of any Insured Person.
We may cancel the Policy and refund the premium for the balance of the Policy Period on pro-rata basis, if specified so in Policy
Schedule/Certificate of Insurance.
Cancellation refund grid for non-credit linked Policy:
Covered up to Days Refund of Premium
7 Up to 90.00%
30 Up to 75.00%
60 Up to 65.00%
90 Up to 50.00%
120 Up to 40.00%
180 Up to 25.00%
240 Up to 15.00%
Exceeding 240 Nil

Group Health
Insurance
Cancellation refund grid for credit linked Policy: If policy is taken as linked to loan, following grid will be applicable
Policy Tenure 1 Yr Policy Tenure 2 Yr Policy Tenure 3 Yr Policy Tenure 4 Yr Policy Tenure 5 Yr
Time of Refund Time of Refund Time of Refund Time of Refund Time of Refund
cancellation % cancellation % cancellation % cancellation % cancellation %
Up to Up to Up to Up to
Up to 1 month 75% 75% 75% 75% 80%
3 months 6 months 1 Year 1 Year
> 1 month to > 3 months > 6 months > 1 year > 1 year
50% 50% 50% 50% to 2 years 60%
3 months to 6 months to 1 year to 2 years
>3 months to > 6 months > 1 year > 2 years > 2 years
25% 25% to 2 years 25% to 3 years 25% 40%
6 months to 1 year to 3 years
> 3 years
>6 months Nil > 1 year Nil > 2 years Nil > 3 years Nil Nil
to 4 years
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.
(ii) 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.
10. Fraud
If 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 mis-statement of or suppression of material fact are within the knowledge of the insurer.
11. Limitation of Liability
If a claim is rejected or partially settled and is not the subject of any pending suit or other proceeding or arbitration, as the case
may be, within twelve months from the date of such rejection or settlement the claim shall be deemed to have been abandoned
and Our liability shall be extinguished and shall not be recoverable thereafter.
12. Records to be maintained
The Policyholder or the Insured Person, as the case may be shall keep an accurate record containing all relevant and accurate
medical records like in-patient records, Discharge summary, medical certificates, medical prescriptions, diagnostic reports and

Group Health
Insurance
reports confirming the need for treatment (if any) and shall allow Us or our representative(s) to inspect such records. The
Policyholder or the Insured Person as the case may be, shall furnish such information as may be required by Us under this Policy at
any time during the Policy Period or until final adjustment (if any) and resolution of all claims under this Policy.
13. Geographical Scope
The geographical scope of this Policy applies to events within India unless specified otherwise for any of the Base and/or Extension
Covers.
14. Policy Disputes
Any and all disputes or differences under or in relation to this Policy herein shall be determined by Indian law and shall be subject
to the jurisdiction of the Indian Courts.
15. Assignment
The payment due under any Benefit under this Policy can be assigned in accordance with provisions of applicable law.
16. Renewal of Policy
The policy shall ordinarily be renewable except on grounds of fraud, misrepresentation by the insured person.
a) The Company shall endeavour to give notice for renewal. However, the Company is not under obligation to give any notice
for renewal.
b) Renewal shall not be denied on the ground that the insured had made a claim or claims in the preceding policy years
c) Request for renewal along with requisite premium shall be received by the Company before the end of the Policy Period.
d) 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 with Break in Policy. Coverage is not available during the grace period.
e) No loading shall apply on renewals based on individual claim experience.
17. Withdrawal of Policy;
i. In 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. Insured 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.
18. Endorsements:
Insured Person/the Policyholder should request for any endorsement in writing. Any endorsement that is accepted by Us shall be
effective from the date of the request as received from Insured Person /the Policyholder, or the date of receipt of premium,
whichever is later.
We reserve the rights to do underwriting in case of any such endorsement requests which has a bearing on the premium and/or
material risk.
19. Communications & Notices
Any communication or notice or instruction under this Policy shall be in writing and will be sent to:
a. To Us, at the address as specified in Policy Schedule and Certificate of Insurance
b. The Policyholder's, at the address as specified in Policy Schedule OR to the Insured Person , at the address as specified in
Certificate of Insurance
c. No insurance agents, brokers, other person or entity is authorized to receive any notice on behalf of Us unless explicitly stated in
writing by Us
d. Notice and instructions will be deemed served 10 days after posting or immediately upon receipt in the case of hand delivery,
facsimile or e-mail.
20. Redressal of Grievance

Group Health
Insurance
In case of any grievance, the insured person may contact the Company through
Website: www.magmahdi.com
Toll free: 1800 266 3202
E –mail: Gro@magma-hdi.co.in
Fax: 91 033 4401 7471
Courier: Any of Our branch offices or corporate office during business hours Insured person may also approach the grievance
cell at any of the company's branches with the details of grievance.
If Insured Person is not satisfied with the redressal of grievance through one of the above methods, insured person may contact the
grievance officer at:
Magma HDI General Insurance Co. Ltd.

516 & 517, 5th Floor, Neelkanth Corporate Park,
Plot No.: 240, 2401/1-8, Kirol Road,
Vidyavihar (West) Mumbai,
Maharashtra - 400086.
For updated details of grievance officer, kindly refer the link https://www.magmahdi.com/grievance-redressal.
If Insured Person is not satisfied with the redressal of grievance through above methods, insured person may may also approach
the office of Insurance Ombudsman of the respective area/region for redressal of grievance as per Insurance Ombudsman
Rules, 2017. The contact details of the Insurance Ombudsman offices have been provided as Annexure-I
Grievance may also be lodged at IRDAI Integrated Grievance management System: https://igms.irda.gov.in/.
21. Complete Discharge
Any payment to the Insured Person or his/ her nominees or his/ her legal representative or assignee or to the Hospital, as the case
may be, for any benefit under the Policy shall be a valid discharge towards payment of claim by the Company to the extent of that
amount for the particular claim.
Annexure I
Office of the
Contact Details Jurisdiction
Ombudsman
AHMEDABAD Ofce of the Insurance Ombudsman, 2nd Gujarat and Union Territories of Dadra &
oor, Ambica House, Near C.U. Shah Nagar Haveli, Daman and Diu.
College, 5, Navyug Colony, Ashram Road,
Ahmedabad – 380 014 Tel.:- 079-
27546150/139 Fax:- 079-27546142
Email:-
bimalokpal.ahmedabad@gbic.co.in
BENGALURU Ofce of the Insurance Ombudsman, Karnataka

Jeevan Soudha Building,PID No. 57-27-
N-19, Ground Floor, 19/19, 24th Main
Road, JP Nagar, Ist Phase, Bengaluru –
560 078. Tel.:- 080 - 26652048 /
26652049 Email:-
bimalokpal.bengalurul@gbic.co.in

Group Health
Insurance
Annexure I
Office of the
Ombudsman
BHOPAL Ofce of the Insurance Ombudsman, Madhya Pradesh and Chattisgarh.

Janak Vihar Complex, 2nd Floor, 6,
Malviya Nagar, Opp. Airtel Ofce, Near
New Market Bhopal – 462 003. Tel.:-
0755-27692001/2769202 Fax:- 0755-
2769203 Email:-
bimalokpalbhopal@gbic.co.in
BHUBANESHWAR Ofce of the Insurance Ombudsman, 62, Orissa

Forest park, Bhubneshwar – 751 009.
Tel.:- 0674-2596461/2596455
Fax:- 0674-2596429 Email:-
bimalokpal.bhubaneswar@gbic.co.in
CHANDIGARH Ofce of the Insurance Ombudsman, Punjab, Haryana, Himachal Pradesh,

S.C.O. No. 101, 102 & 103, 2nd Floor, Jammu & Kashmir and Union territory of
Batra Building, Sector 17 – D, Chandigarh Chandigarh.
– 160 017. Tel.:- 0172-
2706196/2706468 Fax:- 0172-2708274
Email:-
bimalokpal.chandigarh@gbic.co.in
CHENNAI Ofce of the Insurance Ombudsman, Tamil Nadu and Union Territories -
Fatima Akhtar Court, 4th Floor, 453 (old Pondicherry Town and Karaikal (which
312), Anna Salai, Teynampet, CHENNAI – are part of Union Territory of
600 018. Tel.:- 044- Pondicherry).
24333668/24335284 Fax:- 044-
24333664 Email:-
bimalokpal.chennai@gbic.co.in
DELHI Ofce of the Insurance Ombudsman, 2/2 Delhi

A, Universal Insurance Building, Asaf Ali
Road, New Delhi – 110 002. Tel.:- 011-
23239633 / 23237532 Fax:- 011-
23230858 Email:-
bimalokpal.delhi@gbic.co.in
GUWAHATI Ofce of the Insurance Ombudsman, Assam, Meghalaya, Manipur, Mizoram,

Jeevan Nivesh, 5th Floor, Nr. Panbazar Arunachal Pradesh, Nagaland and
over bridge, S.S. Road, Guwahati – Tripura.
781001(ASSAM). Tel.:- 0361-2132204 /
2132205 Fax:- 0361-2732937 Email:-
bimalokpal.guwahati@gbic.co.in
HYDERABAD Ofce of the Insurance Ombudsman, 6-2- Andhra Pradesh, Telangana, Yanam and
46, 1st oor, "Moin Court" Lane Opp. part of Territory of Pondicherry
Saleem Function Palace, A. C. Guards,
Lakdi-Ka-Pool, Hyderabad - 500 004.
Tel.:- 040-65504123 / 23312122 Fax:-
040-23376599 Email:-
bimalokpal.hyderabad@gbic.co.in

Group Health
Insurance
Annexure I
Office of the
Ombudsman
JAIPUR Ofce of the Insurance Ombudsman, Rajasthan

Jeevan Nidhi – II Bldg., Gr. Floor, Bhawani
Singh Marg, Jaipur - 302 005. Tel.: 0141
– 2740363 Email:
Bimalokpal.jaipur@gbic.co.in
ERNAKULAM Ofce of the Insurance Ombudsman, 2nd Kerala and Union Territory of (a)
Floor, Pulinat Bldg., Opp. Cochin Lakshadweep (b) Mahe-a part of Union
Shipyard, M. G. Road, Ernakulam - 682 Territory of Pondicherry.
015. Tel.:- 0484-2358759 / 2359338
Fax:- 0484-2359336 Email:-
bimalokpal.ernakulam@gbic.co.in
KOLKATA Ofce of the Insurance Ombudsman, West Bengal, Sikkim and Union Territories
Hindustan Bldg. Annexe, 4th Floor, 4, C.R. of Andaman and Nicobar Islands.
Avenue, KOLKATA - 700 072. TEL : 033-
22124339 / 22124340 Fax : 033-
22124341 Email:-
bimalokpal.kolkata@gbic.co.in
LUCKNOW Ofce of the Insurance Ombudsman, 6th Districts of Uttar Pradesh : Laitpur, Jhansi,
Floor, Jeevan Bhawan, Phase-II, Nawal Mahoba, Hamirpur, Banda, Chitrakoot,
Kishore Road, Hazratganj, Lucknow-226 Allahabad, Mirzapur, Sonbhabdra,
001. Tel.:- 0522-2231330 / 2231331 Fatehpur, Pratapgarh, Jaunpur, Varanasi,
Fax:- 0522-2231310 Email:- Gazipur, Jalaun, Kanpur, Lucknow,
bimalokpal.lucknow@gbic.co.in Unnao, Sitapur, Lakhimpur, Bahraich,
Barabanki, Raebareli, Sravasti, Gonda,
Faizabad, Amethi, Kaushambi,
Balrampur, Basti, Ambedkarnagar,
Sultanpur, Maharajgang, Santkabirnagar,
Azamgarh, Kushinagar, Gorkhpur,
Deoria, Mau, Ghazipur, Chandauli,
Ballia, Sidharathnagar.
MUMBAI Ofce of the Insurance Ombudsman, 3rd Goa, Mumbai Metropolitan Region
Floor, Jeevan Seva Annexe, S. V. Road, excluding Navi Mumbai & Thane.
Santacruz (W), Mumbai - 400 054. Tel.:-
022-26106552 / 26106960
Fax:- 022-26106052 Email:-
bimalokpal.mumbai@gbic.co.in

Group Health
Insurance
Annexure I
Office of the
Ombudsman
NOIDA Ofce of the Insurance Ombudsman, State of Uttaranchal and the following
Bhagwan Sahai Palace 4th Floor, Main Districts of Uttar Pradesh: Agra, Aligarh,
Road, Naya Bans, Sector 15, Distt: Bagpat, Bareilly, Bijnor, Budaun,
Gautam Buddh Nagar, U.P-201301. Tel.: Bulandshehar, Etah, Kanooj, Mainpuri,
0120-2514250 / 2514252 / 2514253 Mathura, Meerut, Moradabad,
Email: bimalokpal.noida@gbic.co.in Muzaffarnagar, Oraiyya, Pilibhit, Etawah,
Farrukhabad, Firozbad,
Gautambodhanagar, Ghaziabad,
Hardoi, Shahjahanpur, Hapur, Shamli,
Rampur, Kashganj, Sambhal, Amroha,
Hathras, Kanshiramnagar, Saharanpur
PATNA Ofce of the Insurance Ombudsman, 1st Bihar, Jharkhand

Floor,Kalpana Arcade Building,, Bazar
Samiti Road, Bahadurpur, Patna 800 006.
Tel.: 0612-2680952 Email:
bimalokpal.patna@gbic.co.in
PUNE Ofce of the Insurance Ombudsman, Maharashtra, Area of Navi Mumbai and
Jeevan Darshan Bldg., 3rd Floor, C.T.S. Thane excluding Mumbai Metropolitan
No.s. 195 to 198, N.C. Kelkar Road, Region
Narayan Peth, Pune – 411 030.
Tel.: 020-41312555
Email: bimalokpal.pune@gbic.co.in

Group Health
Insurance
Annexure II
List I – Items for which coverage is not available in the policy
Sl No Items Sl No Items
1 BABY FOOD 27. CERTIFICATE CHARGES
2. BABY UTILITIES CHARGES 28. COURIER CHARGES
3. BEAUTY SERVICES 29. CONVEYANCE CHARGES
4. BELTS/ BRACES 30. MEDICAL CERTIFICATE
5. BUDS 31. MEDICAL RECORDS
6. COLD PACK/HOT PACK 32. PHOTOCOPIES CHARGES
7. CARRY BAGS 33. MORTUARY CHARGES
8. EMAIL / INTERNET CHARGES 34. WALKING AIDS CHARGES
9. FOOD CHARGES (OTHER THAN PATIENT's 35. OXYGEN CYLINDER (FOR USAGE OUTSIDE
DIET PROVIDED BY HOSPITAL) THE HOSPITAL)
10. LEGGINGS 36. SPACER
11. LAUNDRY CHARGES 37. SPIROMETRE
12. MINERAL WATER 38. NEBULIZER KIT
13. SANITARY PAD 39. STEAM INHALER
14. TELEPHONE CHARGES 40. ARMSLING
15. GUEST SERVICES 41. THERMOMETER
16. CREPE BANDAGE 42. CERVICAL COLLAR
17. DIAPER OF ANY TYPE 43. SPLINT
18. EYELET COLLAR 44. DIABETIC FOOT WEAR
19. SLINGS 45. KNEE BRACES (LONG/ SHORT/ HINGED)
20. BLOOD GROUPING AND CROSS 46. NIMBUS BED OR WATER OR AIR BED
MATCHING OF DONORS SAMPLES CHARGES
21. SERVICE CHARGES WHERE NURSING 47. PRIVATE NURSES CHARGES- SPECIAL
CHARGE ALSO CHARGED NURSING CHARGES
22. TELEVISION CHARGES 48. KNEE IMMOBILIZER/SHOULDER IMMOBILIZER
23. SURCHARGES 49. LUMBO SACRAL BELT
24. ATTENDANT CHARGES 50. AMBULANCE COLLAR
25. EXTRA DIET OF PATIENT (OTHER THAN 51. CREAMS POWDERS LOTIONS (Toiletries are not
THAT WHICH FORMS PART OF BED payable, only prescribed medical
CHARGE) pharmaceuticals payable)
26. BIRTH CERTIFICATE 52. AMBULANCE EQUIPMENT

Group Health
Insurance
Annexure II
List I – Items for which coverage is not available in the policy
53. SUGAR FREE Tablets 61. OXYGEN MASK
54. ABDOMINAL BINDER 62. PELVIC TRACTION BELT
55. ECG ELECTRODES 63. PAN CAN
56. GLOVES 64. TROLLY COVER
57. NEBULISATION KIT 65. UROMETER, URINE JUG
58. KIDNEY TRAY 66. AMBULANCE
59. MASK 67. VASOFIX SAFETY
60. OUNCE GLASS 68. ANY KIT WITH NO DETAILS MENTIONED

[DELIVERY KIT, ORTHOKIT, RECOVERY KIT, ETC]
List II – Items that are to be subsumed into Room Charges
1 BABY CHARGES (UNLESS SPECIFIED/INDICATED) 18. SPUTUM CUP
2. HAND WASH 19. DISINFECTANT LOTIONS
3. SHOE COVER 20. LUXURY TAX
4. CAPS 21. HVAC
5. CRADLE CHARGES 22. HOUSE KEEPING CHARGES
6. COMB 23. AIR CONDITIONER CHARGES
7. EAU-DE-COLOGNE / ROOM FRESHNERS 24. IM IV INJECTION CHARGES
8. FOOT COVER 25. CLEAN SHEET
9. GOWN 26. BLANKET/WARMER BLANKET
10. SLIPPERS 27. ADMISSION KIT
11. TISSUE PAPER 28. DIABETIC CHART CHARGES
12. TOOTH PASTE 29. DISCHARGE PROCEDURE CHARGES
13. TOOTH BRUSH 30. DAILY CHART CHARGES
14. BED PAN 31. ENTRANCE PASS / VISITORS PASS CHARGES
15. FACE MASK 32. FILE OPENING CHARGES
16. FLEXI MASK 33. HAND HOLDER
17. DOCUMENTATION CHARGES / 34. EXPENSES RELATED TO PRESCRIPTION

ADMINISTRATIVE EXPENSES ON DISCHARGE

Group Health
Insurance
List II – Items that are to be subsumed into Room Charges
35. INCIDENTAL EXPENSES / MISC. CHARGES 36. PATIENT IDENTIFICATION BAND / NAME TAG
(NOT EXPLAINED)
37. PULSEOXYMETER CHARGES
Annexure II
List III – Items that are to be subsumed into Procedure Charges
Sl No Item
1 HAIR REMOVAL CREAM
2. DISPOSABLES RAZORS CHARGES (for site preparations)
3. EYE PAD
4. EYE SHEILD
5. CAMERA COVER
6. DVD, CD CHARGES
7. GAUSE SOFT
8. GAUZE
9. WARD AND THEATRE BOOKING CHARGES
10. ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS
11. MICROSCOPE COVER
12. SURGICAL BLADES, HARMONICSCALPEL,SHAVER
13. SURGICAL DRILL
14. EYE KIT
15. EYE DRAPE
16. X-RAY FILM
17. BOYLES APPARATUS CHARGES
18. COTTON
19. COTTON BANDAGE
20. SURGICAL TAPE
21. APRON
22. TORNIQUET
23. ORTHOBUNDLE, GYNAEC BUNDLE

Group Health
Insurance
Annexure II
List IV – Items that are to be subsumed into costs of treatment
Sl No Item
1 ADMISSION/REGISTRATION CHARGES
2. HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC PURPOSE
3. URINE CONTAINER
4. BLOOD RESERVATION CHARGES AND ANTE NATAL BOOKING CHARGES
5. BIPAP MACHINE
6. CPAP/ CAPD EQUIPMENTS
7. INFUSION PUMP– COST
8. HYDROGEN PEROXIDE\SPIRIT\ DISINFECTANTS ETC
9. NUTRITION PLANNING CHARGES - DIETICIAN CHARGES- DIET CHARGES
10. HIV KIT
11. ANTISEPTIC MOUTHWASH
12. LOZENGES
13. MOUTH PAINT
14. VACCINATION CHARGES
15. ALCOHOL SWABES
16. SCRUB SOLUTION/STERILLIUM
17. GLUCOMETER& STRIPS
18. URINE BAG
Magma HDI General Insurance Co. Ltd. | www.magmahdi.com | E-mail: customercare@magma-hdi.co.in | Toll Free: 1800 266 3202
| Registered Office: Development House, 24 Park Street, Kolkata – 700016. CIN: U66000WB2009PLC136327 | IRDAI Reg. No. 149
Group Health Insurance - MAGHLGP21234V022021 | Trade logos displayed above belong to Magma Fincorp Ltd. and HDI Global SE
respectively, and are being used by Magma HDI General Insurance Company Limited, under license. (PW-01-07-21)

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TRUTH MUST BE TOLD

GROUP HEALTH INSURANCE

Section I. Interpretations & Definitions

Age or Aged means age as on last birthday.

a. Central or State Governemnt AYUSH Hospital or

Group Health Insurance - MAGHLGP21234V022021 1

i. Having qualified registered AYUSH Medical Practitioner(s) in charge;

a) Internal Congenital Anomaly

i) has qualified nursing staff under its employment;

Group Health Insurance - MAGHLGP21234V022021 2

Group Health Insurance - MAGHLGP21234V022021 3

Maternity expenses: Maternity expenses means:

Group Health Insurance - MAGHLGP21234V022021 5

Sum Insured means:

We/Our/Us means MAGMA HDI General Insurance Company Ltd.

Section II. Coverage under the Policy:

a) Medical Practitioners' fees

- medically necessary consultations with a Medical Practitioner

4. Critical Illness Cover

For the purpose of this Benefit, covered Critical Illness means:

Sr. Option Option Option Option Option Option

4 Major Organ Transplant Yes Yes Yes Yes Yes Yes

5 Heart Valve Replacement Yes Yes Yes Yes Yes Yes

8 Permanent Paralysis of Limbs Yes Yes Yes Yes Yes Yes

10 Coma of specified severity - Yes Yes Yes Yes Yes

11 Parkinson's Disease - Yes Yes Yes Yes Yes

12 Benign Brain Tumor - Yes Yes Yes Yes Yes

Group Health Insurance - MAGHLGP21234V022021 8

14 End Stage Liver failure - - Yes Yes Yes Yes

15 Surgery of Aorta - - Yes Yes Yes Yes

16 Deafness - - - Yes Yes Yes

17 Loss of Speech - - - Yes Yes Yes

18 Third Degree Burns - - - Yes Yes Yes

19 Motor Neuron Disease with Permanent Symptoms - - - - Yes Yes

20 Primary Pulmonary Hypertension - - - - Yes Yes

21 Pulmonary Artery Graft Surgery - - - - Yes Yes

22 Muscular Dystrophy - - - - Yes Yes

23 Systemic Lupus Erythematosis with Lupus Nephritis - - - - Yes Yes

24 Pneumonectomy - - - - Yes Yes

25 Medullary Cystic Disease - - - - Yes Yes

26 Angioplasty - - - - Yes Yes

27 Blindness - - - - Yes Yes

28 End Stage lung failure - - - - Yes Yes

29 Major Head Trauma - - - - Yes Yes

30 Cardiomyopathies - - - - Yes Yes

31 Terminal illness - - - - Yes Yes

32 Fulminant Hepatitis - - - - Yes Yes

33 Coronary Artery disease - - - - Yes Yes

34 Bacterial Meningitis - - - - Yes Yes

35 Multiple system Atrophy - - - - Yes Yes

Group Health Insurance - MAGHLGP21234V022021 9

1. Cancer of Specified Severity

The following are excluded –

2. Kidney Failure requiring regular dialysis

3. Multiple Sclerosis with persisting symptoms

4. Major Organ/ Bone Marrow Transplant

The actual undergoing of a transplant of:

The following are excluded:

5. Open Heart Replacement or Repair of Heart Valves