Policy Wording

Heartbeat
Policy Document
1. Preamble
This 'Heartbeat' policy is a contract of insurance between You and Us which is subject to payment of full premium in advance
and the terms, conditions and exclusions of this Policy. This Policy has been issued on the basis of the Disclosure to
Information Norm, including the information provided by You in the Proposal Form and / or the Information Summary
Sheet.
Please inform Us immediately of any change in the address or any other changes affecting You or any Insured Person which
would impact the benefits, terms and conditions under this Policy.
In addition, please note the list of exclusions is set out in Section 7 of this Policy.
2. Definitions & Interpretation

For the purposes of interpretation and understanding of this Policy, We have defined, in this Section, some of the important
words used in the Policy which will have the special meaning accorded to these terms for the purposes of this Policy. For the
remaining language and words used, the usual meaning as described in standard English language dictionaries shall apply.
The words and expressions defined in the Insurance Act 1938, IRDA Act 1999, regulations notified by the IRDAI and circulars
and guidelines issued by the IRDAI, together with their amendment shall carry the meanings given therein.
Note: Where the context permits, the singular will be deemed to include the plural, one gender shall be deemed to include
the other genders and references to any statute shall be deemed to refer to any replacement or amendment of that statute.
Defined Terms
The terms listed below in this Section and used elsewhere in the Policy in Initial Capitals shall have the meaning set out
against them in this Section.
Standard definitions
2.1 Accident or Accidental means a sudden, unforeseen and involuntary event caused by external, visible and violent
means.
2.2 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.
2.3 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.
2.4 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 claim amount. A Co-payment does not reduce
the Sum Insured.
2.5 Cumulative Bonus means any increase or addition in the Sum Insured granted by the insurer without an associated
increase in premium.
2.6 Day Care Center means any institution established for Day Care Treatment of Illness and/or Injuries or a medical set-
up with a Hospital and which has been registered with the local authorities, wherever applicable, and is under the
supervision of a registered and qualified Medical Practitioner AND must comply with all minimum criterion as under:
a. has Qualified Nursing staff under its employment;
b. has qualified Medical Practitioner(s) in charge;
c. has a fully equipped operation theatre of its own where Surgical Procedures are carried out;
d. maintains daily records of patients and will make these accessible to the insurance company's authorized
personnel.
2.7 Day Care Treatment refers to medical treatment, and/or Surgical Procedure which is:
a. undertaken under General or Local Anaesthesia in a Hospital/Day Care Center in less than 24 hrs because of
technological advancement, and
b. which would have otherwise required a Hospitalization of more than 24 hours.
Treatment normally taken on an OPD basis is not included in the scope of this definition.
Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

2.8 Deductible means a cost-sharing requirement under a health insurance policy that provides that the Insurer will not
be liable for a specified rupee amount in case of indemnity policies and for a specified number of days/hours in case
of hospital cash policies which will apply before any benefits are payable by the insurer. A deductible does not reduce
the Sum Insured.
2.9 Dental Treatment means a treatment related to teeth or structures supporting teeth including examinations, fillings
(where appropriate), crowns, extractions and Surgery.
2.10 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:
a. the condition of the patient is such that he/she is not in a condition to be removed to a Hospital, or
b. the patient takes treatment at home on account of non availability of room in a Hospital.
2.11 Hospital (within India) means any institution established for Inpatient Care and Day Care Treatment of Illness and /
or Injuries and which has been registered as a Hospital with the local authorities under the Clinical Establishments
(Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the
said Act OR complies with all minimum criteria as under:
a. has Qualified Nursing staff under its employment round the clock;
b. has at least 10 Inpatient beds in towns having a population of less than 10,00,000 and at least 15 Inpatient beds in
all other places;
c. has qualified Medical Practitioner(s) in charge round the clock;
d. has a fully equipped operation theatre of its own where Surgical Procedures are carried out;
e. maintains daily records of patients and makes these accessible to the Insurance company's authorized personnel.
2.12 Hospitalization or Hospitalized means the admission in a Hospital for a minimum period of 24 consecutive Inpatient
Care hours except for specified procedures/treatments, where such admission could be for a period of less than 24
consecutive hours.
2.13 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.
2.14 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:
i. it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /or tests
ii. it needs ongoing or long-term control or relief of symptoms
iii. it requires rehabilitation for the patient or for the patient to be specially trained to cope with it
iv. it continues indefinitely
v. it recurs or is likely to recur
2.15 Injury means Accidental physical bodily harm excluding Illness or disease solely and directly caused by external,
violent and visible and evident means which is verified and certified by a Medical Practitioner.
2.16 Inpatient Care means treatment for which the Insured Person has to stay in a Hospital for more than 24 hours for a
covered event.
2.17 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.
2.18 Maternity Expense shall include:

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.
2.19 Medical Advice means any consultation or advice from a Medical Practitioner including the issuance of any
prescription or follow-up prescription.
2.20 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.
2.21 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 set up by the Government of India or a State
Government and is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and
jurisdiction of his licence.
Only for the purposes of any claim or treatment permitted to be made or taken outside India, Medical Practitioner
shall mean a general practitioner, surgeon, anaesthetist or physician who:
a. holds a degree of a recognized institute; and
b. is registered with a Medical Council or equivalent body of the country where the treatment has taken place; and
c. is legally qualified to practice medicine or Surgery in the jurisdiction where he practices.
2.22 Medically Necessary Treatment means any treatment, tests, medication, or stay in Hospital or part of a stay in
Hospital which:
a. is required for the medical management of the Illness or Injury suffered by the insured;
b. must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope,
duration, or intensity;
c. must have been prescribed by a Medical Practitioner;
d. must conform to the professional standards widely accepted in international medical practice or by the medical
community in India.
2.23 Network Provider means Hospital enlisted by an insurer, TPA or jointly by an insurer and TPA to provide medical
services to an insured by a Cashless Facility.
Only for the purposes of any claim or treatment permitted to be made or taken outside India, Network Provider shall
mean the Hospitals that are a part of the Service Provider's network, a list of which is available with the Service
Provider.
2.24 New Born Baby means baby born during the Policy Period and is aged between 1 day and 90 days, both days
inclusive.
2.25 Non-Network means any Hospital, Day Care Center or other provider that is not part of the network.
2.26 Notification of Claim means the process of intimating a claim to the insurer or TPA through any of the recognized
modes of communication.
2.27 OPD Treatment means the one in which the Insured visits a clinic / Hospital or associated facility like a consultation
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.
2.28 Pre-existing Disease 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.
2.29 Pre-hospitalization Medical Expenses means medical expenses incurred during pre-defined number of days
preceding the hospitalization of the Insured Person, provided that:
a. Such Medical Expenses are incurred for the same condition for which the Insured Person's Hospitalization was
required, and

b. The Inpatient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.
2.30 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:
a. Such Medical Expenses are for the same condition for which the Insured Person's Hospitalization was required,
and
b. The Inpatient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.
2.31 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.
2.32 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.
2.33 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.
2.34 Room Rent means the amount charged by a Hospital towards Room and Boarding expenses and shall include the
Associated Medical Expenses.
2.35 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 or prolongation of
life, performed in a Hospital or Day Care Center by a Medical Practitioner.
2.36
Specific Definitions
2.37 Age means age as on last birthday.
2.38 AYUSH Treatment refers to the medical and / or hospitalization treatments given under Ayurveda, Yoga and
Naturopathy, Unani, Sidha and Homeopathy systems.
2.39 AYUSH Hospital:
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 Government AYUSH Hospital; or
b. Teaching Hospital attached to AYUSH College recognized by the Central Government/Central Council of Indian
Medicine/Central Council of 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 all 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
2.40 Associated Medical Expenses shall include Room Rent, nursing charges, Medical Practitioners' fees and operation
theatre charges
2.41 Base Sum Insured means the amount stated in the Policy Schedule.
2.42 Bone Marrow Transplant is the actual undergoing of a transplant of human bone marrow using haematopoietic stem
cells. The undergoing of a transplant has to be confirmed by a specialist medical practitioner. The following will be
excluded:
i. Other stem-cell transplants
ii. Where only islets of langerhans are transplanted

2.43 Break in Policy means the period of gap that occurs at the end of the existing policy term, when the premium due for
renewal on a given policy is not paid on or before the premium renewal date or within 30 days thereof.
2.44 Critical Illness, an Illness, medical event or Surgical Procedure specifically defined in Section 4.2.
2.45 Diagnostic Services means those diagnostic tests and exploratory or therapeutic procedures required for the
detection, identification and treatment of a medical condition.
2.46 Emergency means a medical condition or symptom resulting from Illness or Injury which arises suddenly and
unexpectedly and requires immediate care and treatment by a Medical Practitioner to prevent death or serious long
term impairment of the Insured Person's health.
2.47 Emergency Assistance Service Provider means the licensed entity which will provide identified emergency medical
assistance and personal services to people travelling more than 150(one hundred and fifty) kilometers from their
declared place of residence in India.
2.48 Evidence Based Clinical Practice means process of making clinical decisions for Inpatient Care using current best
evidence in conjugation with clinical expertise.
2.49 e-Consultation means opinion from a Medical Practitioner 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 set up by the Government of
India or a state government and is thereby entitled to practice medicine within its jurisdiction; and is acting within the
scope and jurisdiction of his license.
2.50 Family Floater Policy means a Policy described as such in the Policy Schedule where the family members (two or
more) named in the Policy Schedule are Insured Persons under this Policy. Only the following family members can be
covered under a Family Floater Policy:
a. Insured Person; and/or
b. Insured Person's legally married spouse (for as long as she/he continues to be married to the Insured Person);
and/or
c. Insured Person's children who are less than 21 years of Age on the commencement of the Policy Period (a
maximum 4 children can be covered under the Policy as Insured Persons).
2.51 Family First Policy means a Policy described as such in the Policy Schedule where You and Your family members
named in the Policy Schedule are insured under this Policy. Only the following family members can be covered under
a Family First Policy:
a. Your legally married spouse for as long as Your spouse continues to be married to You;
b. Son;
c. Daughter-in-law as long as Your son continues to be married to Your Daughter-in-law;
d. Daughter;
e. Son-in-law as long as Your daughter continues to be married to Your Son-in-law;
f. Father;
g. Mother;
h. Father-in-law as long as Your spouse continues to be married to You;
i. Mother-in-law as long as Your spouse continues to be married to You;
j. Grandfather;
k. Grandmother;
l. Grandson;
m. Granddaughter;
n. Brother;
o. Sister;
p. Sister-in-law;
q. Brother-in-law;
r. Nephew;
s. Niece.
2.52 First Policy means for the purposes of this Policy the Policy Schedule issued to the Policyholder at the time of

inception of the first Policy mentioned in the Policy Schedule with Us.
2.53 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.
2.54 Hospital (outside India) means an institution (including nursing homes) established outside India for Inpatient
medical care and treatment of sickness and 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, old age home.
2.55 Individual Policy means a Policy described as such in the Policy Schedule where the individual named in the Policy
Schedule is the Insured Person under this Policy.
2.56 Information Summary Sheet means the information and details provided to Us or Our representatives over the
telephone for the purposes of applying for this Policy which has been recorded by Us and confirmed by You.
2.57 Inpatient means admission for treatment in a Hospital for more than 24 hours for an Insured Event.
2.58 IRDAI means the Insurance Regulatory and Development Authority of India.
2.59 Insured Event means any event specifically mentioned as covered under this Policy.
2.60 Insured Person means person(s) named as insured persons in the Policy Schedule.
2.61 Medical Record means the collection of information as submitted in claim documentation concerning a Insured
Person's Illness or Injury that is created and maintained in the regular course of management, made by Medical
Practitioners who have knowledge of the acts, events, opinions or diagnoses relating to the Insured Person's Illness or
Injury, and made at or around the time indicated in the documentation.
2.62 Mental Illness means a substantial disorder of thinking, mood, perception, orientation or memory that grossly
impairs judgment, behaviour, capacity to recognise reality or ability to meet the ordinary demands of life, mental
conditions associated with the abuse of alcohol and drugs, but does not include mental retardation which is a
condition of arrested or incomplete development of mind of a person, specially characterised by subnormality of
intelligence.
2.63 Migration: "Migration" means, the right accorded to health insurance policyholders (including all members under
family cover and members of group health insurance policy), to transfer the credit gained for pre-existing conditions
and time bound exclusions, with the same insurer.
2.64 Policy means these terms and conditions, the Policy Schedule (as amended from time to time), Your statements in
the Proposal and the Information Summary Sheet and any endorsements attached by Us to the Policy from time to
time.
2.65 Policy Period is the period between the inception date and the expiry date of the Policy as specified in the Policy
Schedule or the date of cancellation of this Policy, whichever is earlier.
2.66 Policy Year means the period of one year commencing on the date of commencement specified in the Policy
Schedule or any anniversary thereof.
2.67 Policy Schedule means a certificate issued by Us, and, if more than one, then the latest in time. The Policy Schedule
contains details of the Policyholder, Insured Persons, the Sum Insured and other relevant details related to the
coverage.
2.68 Portability: Portability means the right accorded to individual health insurance policyholders (including all members
under family cover), to transfer the credit gained for pre-existing conditions and time bound exclusions, from one
insurer to another insurer.
2.69 Reimbursement means settlement of claims paid directly by Us to the Policyholder/Insured Person.
2.70 Second Medical Opinion means an alternate evaluation of diagnosis or treatment modalities arranged by Us from a
Medical Practitioner related to Specified Illnesses or planned Surgery or Surgical Procedure which the Insured Person
has been diagnosed or advised to undergo during the Policy Year. The Second Medical Opinion will be arranged by Us
solely on the Insured Person's request.

2.71 Service Provider means any person, organization, institution that has been empanelled with Us to provide services
specified under the benefits to the Insured Person.
2.72 Shared accommodation means a Hospital room with two or more patient beds.
2.73 Single Private Room means an air conditioned room in a Hospital where a single patient is accommodated and which
has an attached toilet (lavatory and bath). Such room type shall be the most basic and the most economical of all
accommodations available as a single occupancy room in that Hospital.
2.74 Specified Illness means the following Illnesses or procedures:
a. Cancer:
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.
Specific Exclusion: All tumors in the presence of HIV infection are excluded.
b. Myocardial Infarction (First Heart Attack of specific severity):
I. 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 for Myocardial Infarction
should be evidenced by all of the following criteria:
i. A history of typical clinical symptoms consistent with the diagnosis of acute myocardial infarction (For e.g.
typical chest pain)
ii. New characteristic electrocardiogram changes
iii. Elevation of infarction specific enzymes, Troponins or other specific biochemical markers.
II. The following are excluded:
i. Other acute Coronary Syndromes
ii. Any type of angina pectoris
iii. A rise in cardiac biomarkers or Troponin T or I in absence of overt ischemic heart disease OR following an
intra-arterial cardiac procedure.
c. Open Chest CABG:
I. 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.
i. Angioplasty and/or any other intra-arterial procedures
d. Major Organ/Bone Marrow Transplant:
I. The actual undergoing of a transplant of:
i. One of the following human organs: heart, lung, liver, kidney, pancreas, that resulted from irreversible end-
stage failure of the relevant organ, or
ii. Human bone marrow using haematopoietic stem cells. The undergoing of a transplant has to be confirmed
by a specialist medical practitioner.
e. Stroke Resulting in Permanent Symptoms:
Any cerebrovascular incident producing permanent neurological sequelae. This includes infarction of brain tissue,
thrombosis in an intracranial vessel, haemorrhage and embolisation from an extracranial 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 atleast 3 months has to be produced.
The following are excluded:

i. Transient ischemic attacks (TIA)
ii. Traumatic Injury of the brain
iii. Vascular disease affecting only the eye or optic nerve or vestibular functions
f. Surgery of Aorta:
Surgery of aorta including graft, insertion of stents or endovascular repair.
Specific Exclusion: Surgery for correction of an underlying Congenital Anomaly.
g. Angioplasty:
I. 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).
II. Coronary arteries herein refer to left main stem, left anterior descending, circumflex and right coronary artery.
III. Diagnostic angiography or investigation procedures without angioplasty/stent insertion are excluded.
h. Primary (Idiopathic) Pulmonary Hypertension:
I. 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.
II. The NYHA Classification of Cardiac Impairment are as follows:
i. Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes
symptoms.
ii. Class IV: Unable to engage in any physical activity without discomfort. Symptoms may be present even at
rest.
III. 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.
i. Brain Surgery:
Any brain (intracranial) Surgery required to treat traumatic or non-traumatic conditions.
Specific Exclusion: Surgery for treating Neurocysticercosis.
2.75 Standby Services are services of another Medical Practitioner requested by treating Medical Practitioner and
involving prolonged attendance without direct (face-to-face) patient contact or involvement.
2.76 Suite Room means
a. a space available for boarding in a Hospital which contains two or more rooms; Or
b. a space available for boarding in a Hospital which contains an extended living/dining/kitchen area
2.77 Sum Insured
In case of Individual Policy, Sum Insured means the total of the Base Sum Insured, Loyalty Additions and re-fill
amount, which is Our maximum, total and cumulative liability for any and all claims during the Policy Year in respect
of the Insured Person.
In case of Family Floater Policy, Sum Insured means the total of the Base Sum Insured, Loyalty Additions and re-fill
amount, which is Our maximum, total and cumulative liability for any and all claims during the Policy Year in respect
of all Insured Persons.
In case of Family First Policy, Sum Insured means the total of the Base Sum Insured for each Insured Person, the
Loyalty Additions for each Insured Person and the Floater Sum Insured specified in the Policy Schedule which is Our
maximum, total and cumulative liability for any and all claims during the Policy Year in respect of each Insured
Person. For aforesaid purposes:
a. The Base Sum Insured stated in the Policy Schedule for each Insured Person is available for claims in respect of
that Insured Person only, during the Policy Year.
b. If the Base Sum Insured for an Insured Person is exhausted due to payment of claims, then that Insured Person

may utilise the Floater Sum Insured stated in the Policy Schedule for any claims arising in that Policy Year. In the
event of a claim being admitted from the Floater Sum Insured, the Floater Sum Insured shall stand
correspondingly reduced by the amount of claim paid (including 'taxes') or admitted and only the remaining
amount of the Floater Sum Insured shall be available for claims arising in that Policy Year in respect of the Insured
Persons who have exhausted their Base Sum Insured during that Policy Year.
c. The total of the Base Sum Insured for all Insured Persons, the Loyalty Additions for all Insured Persons and the
Floater Sum Insured specified in the Policy Schedule is Our maximum, total and cumulative liability for all claims
during a Policy Year in respect of all Insured Persons.
If the Policy Period is 2 years, then the Sum Insured shall be applied separately for each Policy Year in the Policy
Period.
2.78 Survival Period means the period, if any, specified under the Policy after the occurrence of an Insured Event that the
Insured Person has to survive before a claim becomes admissible under the Policy.
2.79 Waiting Period means a time-bound exclusion period related to condition(s) specified in the Policy Schedule or the
Policy which shall be served before a claim related to such condition(s) becomes admissible.
2.80 We/Our/Us means Niva Bupa Health Insurance Company Limited.
2.81 You/Your/Policyholder means the person named in the Policy Schedule who has concluded this Policy with Us.
3. Benefits available under the Policy

The benefits available under this Policy are described below.
a. The Policy covers Reasonable and Customary Charges incurred towards medical treatment taken by the Insured Person
during the Policy Period for an Illness, Injury or condition as described in the sections below and contracted or sustained
during the Policy Period. The benefits listed in the sections below will be payable subject to the terms, conditions and
exclusions of this Policy and the availability of the Sum Insured and any sub-limits for the benefit as maybe specified in
the Policy Schedule.
b. All the benefits (including optional benefits) which are available under the Policy along with the respective limits /
amounts applicable based on the Sum Insured have been summarized in the Product Benefit Table in Annexure II
c. The expenses that are not covered or subsumed into room charges/ procedure charges/ costs of treatment are
mentioned in Annexure VI
d. All claims under the Policy must be made in accordance with the process defined under Section 6.2.16 (Claim Process &
Requirements).
e. All claims paid under any benefit except for those admitted under Section 3.11 (Health Check-up), Section 3.13 (Pharmacy
and diagnostic services), Section 3.16 (Emergency Assistance Services except Medical Evacuation), Section 3.18 (Second
Medical Opinion), Section 4.1 (Personal Accident Cover), Section 4.2 (Critical Illness Cover), Section 4.3 (e-Consultation),
Section 4.4 (Premium Waiver) and Section 4.5 (Hospital Cash) shall reduce the Sum Insured for the Policy Year in which
the Insured Event in relation to which the claim is made has been occurred, unless otherwise specified in the respective
section. Thereafter only the balance Sum Insured after payment of claim amounts admitted shall be available for future
claims arising in that Policy Year.
3.1 Inpatient Care
What is covered:
We will indemnify the Medical Expenses incurred for one or more of the following due to the Insured Person's
Hospitalization during the Policy Period following an Illness or Injury:
a. Room Rent: Room boarding and nursing charges during Hospitalization as charged by the Hospital where the
Insured Person availed medical treatment;
b. Medical Practitioners' fees, excluding any charges or fees for Standby Services;
c. Investigative tests or diagnostic procedures directly related to the Insured Event which led to the current
Hospitalization;
d. Medicines, drugs as prescribed by the treating Medical Practitioner related to the Insured Event that led to the
current Hospitalization;

e. Intravenous fluids, blood transfusion, injection administration charges, allowable consumables, and/or enteral
feedings;
f. Operation theatre charges;
g. The cost of prosthetics and other devices or equipment, if implanted internally during Surgery;
h. Intensive Care Unit Charges.
Conditions - The above coverage is subject to fulfillment of following conditions:
a. The Hospitalization is for Medically Necessary Treatment and advised in writing by a Medical Practitioner.
b. If the Insured Person is admitted in a Hospital room where the room category opted or Room Rent incurred is
higher than the eligibility as specified in the Policy Schedule, then We shall be liable to pay only a pro-rated
portion of the total Associated Medical Expenses (including surcharge or taxes thereon) as per the following
formula:
(Eligible Room Rent limit / Room Rent actually incurred) * total Associated Medical Expenses
Associated Medical Expenses shall include Room Rent, nursing charges, Medical Practitioners' fees and operation
theatre charges
c. We will pay the visiting fees or consultation charges for any Medical Practitioner visiting the Insured Person only
if:
i. The Medical Practitioner's treatment or advice has been specifically sought by the Hospital; and
ii. The visiting fees or consultation charges are included in the Hospital's bill
3.2 Pre-hospitalization Medical Expenses
What is covered:
We will indemnify on Reimbursement basis only, the Insured Person's Pre-hospitalization Medical Expenses incurred
in respect of an Illness or Injury.
Conditions - The above coverage is subject to fulfilment of following conditions:
a. We have accepted a claim under Section 3.1 (Inpatient Care) or Section 3.4 (Day Care Treatment) or Section 3.5
(Domiciliary Hospitalization) or Section 3.6 (Alternative Treatments) or Section 3.24 (Modern Treatments)
b. Pre-hospitalization Medical Expenses are incurred for the same condition for which We have accepted the
Inpatient Care or Day Care Treatment or Domiciliary Hospitalization or Alternative Treatments or Modern
Treatments claim.
c. The expenses are incurred after the inception of the First Policy with Us. If any portion of these expenses is
incurred before the inception of the First Policy with Us, then We shall be liable only for those expenses incurred
after the commencement date of the First Policy, irrespective of the initial waiting period.
d. Pre-hospitalization Medical Expenses incurred on physiotherapy will also be payable provided that such
physiotherapy is prescribed in writing by the treating Medical Practitioner as Medically Necessary Treatment and is
directly related to the same condition that led to Hospitalization.
e. Any claim admitted under this Section 3.2 shall reduce the Sum Insured for the Policy Year in which In-patient
Care or Day Care Treatment or Domiciliary Hospitalization or Alternative Treatments or Modern Treatments claim
has been incurred.
Sub-limit:
a. We will pay above mentioned Pre-hospitalization Medical Expenses only for period up to 60 days immediately
preceding the Insured Person's admission for Inpatient Care or Day Care Treatment or Domiciliary Hospitalization
or Alternative Treatments or Modern Treatments.
3.3 Post-hospitalization Medical Expenses
What is covered:
We will indemnify on Reimbursement basis only, the Insured Person's Post-hospitalization Medical Expenses incurred
following an Illness or Injury.
a. We have accepted a claim under Section 3.1 (Inpatient Care) or Section 3.4 (Day Care Treatment) or Section 3.5
(Domiciliary Hospitalization) or Section 3.6 (Alternative Treatments) or Section 3.24 (Modern Treatments)

b. Post-hospitalization Medical Expenses are incurred for the same condition for which We have accepted the
Inpatient Care or Day Care Treatment or Domiciliary Hospitalization or Alternative Treatments or Modern
Treatments claim.
c. The expenses incurred shall be as advised in writing by the treating Medical Practitioner.
d. Post-hospitalization Medical Expenses incurred on physiotherapy will also be payable provided that such
physiotherapy is prescribed in writing by the treating Medical Practitioner as Medically Necessary Treatment and is
directly related to the same condition that led to Hospitalization.
e. Any claim admitted under this Section 3.3 shall reduce the Sum Insured for the Policy Year in which In-patient
Care or Day Care Treatment or Domiciliary Hospitalization or Alternative Treatments or Modern Treatments claim
has been incurred.
Sub-limit:
a. We will pay Post-hospitalization Medical Expenses only for up to 90 days immediately following the Insured
Person's discharge from Hospital or Day Care Treatment or Domiciliary Hospitalization or Alternative Treatments
or Modern Treatments.
3.4 Day Care Treatment
What is covered:
We will indemnify the Medical Expenses incurred on the Insured Person's Day Care Treatment during the Policy
Period following an Illness or Injury. List of Day Care Treatments which are covered under the Policy are provided in
Annexure III.
a. The Day Care Treatment is advised in writing by a Medical Practitioner as Medically Necessary Treatment.
b. Only those Day Care Treatments are covered that are mentioned under list of Day Care Treatments under
Annexure III.
c. If We have accepted a claim under this benefit, We will also indemnify the Insured Person's Pre-hospitalization
Medical Expenses and Post-hospitalization Medical Expenses in accordance with Sections 3.2 and 3.3 above.
What is not covered:
OPD Treatment and Diagnostic Services costs are not covered under this benefit.
3.5 Domiciliary Hospitalization
What is covered:
We will indemnify on Reimbursement basis only, the Medical Expenses incurred for the Insured Person's Domiciliary
Hospitalization during the Policy Period following an Illness or Injury.
a. The Domiciliary Hospitalization continues for at least 3 consecutive days in which case We will make payment
under this benefit in respect of Medical Expenses incurred from the first day of Domiciliary Hospitalization;
b. The treating Medical Practitioner confirms in writing that the Insured Person's condition was such that the Insured
Person could not be transferred to a Hospital OR the Insured Person satisfies Us that a Hospital bed was
unavailable.
c. If We have accepted a claim under this benefit, We will also indemnify the Insured Person's Pre-hospitalization
Medical Expenses and Post-hospitalization Medical Expenses in accordance with Sections 3.2 and 3.3 above.
3.6 Alternative Treatments
What is covered:
We will indemnify the Medical Expenses incurred on the Insured Person's Hospitalization for Inpatient Care during the
Policy Period on treatment taken under Ayurveda, Unani, Siddha and Homeopathy.
The treatment should be taken in AYUSH Hospital.
a. Pre-hospitalization Medical Expenses incurred for up to 60 days immediately preceding the Insured Person's
admission and Post-hospitalization Medical Expenses incurred for up to 90 days immediately following the
Insured Person's discharge will also be indemnified under this benefit in accordance with Sections 3.2 and 3.3

above, provided that these Medical Expenses relate only to Alternative Treatments and not Allopathy.
b. Section 5.2.12 of the Permanent Exclusions (other than for Yoga) shall not apply to the extent this benefit is
applicable.
3.7 Living Organ Donor Transplant
What is covered:
We will indemnify the Medical Expenses incurred for a living organ donor's treatment as an Inpatient for the
harvesting of the organ donated.
a. The donation conforms to the Transplantation of Human Organs Act 1994 and any amendments thereafter and the
organ is for the use of the Insured Person.
b. The organ transplant is certified in writing by a Medical Practitioner as Medically Necessary Treatment for the
Insured Person.
c. We have accepted the recipient Insured Person's claim under Section 3.1 (Inpatient Care).
a. Stem cell donation whether or not it is Medically Necessary Treatment except for Bone Marrow Transplant.
b. Pre-hospitalization Medical Expenses or Post-hospitalization Medical Expenses of the organ donor.
c. Screening or any other Medical Expenses related to the organ donor, which are not incurred during the duration of
Insured Person's Hospitalization for organ transplant.
d. Transplant of any organ/tissue where the transplant is Unproven/Experimental Treatment or investigational in
nature.
e. Expenses related to organ transportation or preservation.
f. Any other medical treatment or complication in respect of the donor, which is directly or indirectly consequence to
harvesting.
3.8 Emergency Ambulance
What is covered:
We will indemnify the costs incurred, on transportation of the Insured Person by road Ambulance to a Hospital for
treatment in an Emergency following an Illness or Injury.
a. The medical condition of the Insured Person requires immediate ambulance services from the place where the
Insured Person is injured or is ill to a Hospital where appropriate medical treatment can be obtained or;
b. The medical condition of the Insured Person requires immediate ambulance services from the existing Hospital to
another Hospital with advanced facilities as advised by the treating Medical Practitioner for management of the
current Hospitalization.
c. This benefit is available for only one transfer per Hospitalization.
d. The ambulance service shall be offered by a healthcare or ambulance Service Provider.
e. We have accepted a claim under Section 3.1 (Inpatient Care) above.
f. We will cover expenses up to the amount specified in Your Policy Schedule.
The Insured Person's transfer to any Hospital or diagnostic centre for evaluation purposes only.
3.9 Maternity Benefit
What is covered:
We will indemnify the Maternity Expenses incurred during the Policy Period.
a. This benefit is available only if:
i. The female Insured Person of Age 18 years or above is covered under a Family First Policy; or
ii. Both the Insured Person and his / her legally married spouse are covered under a Family Floater Policy.
b. This Benefit cannot be availed under an Individual Policy.
c. The female Insured Person in respect of whom a claim for Maternity Benefits is made must have been covered as

an Insured Person for a period of 24 months of continuous coverage since the inception of the First Policy, with
maternity as a benefit, with Us.
d. For the purposes of this benefit, We shall consider any eligibility period for maternity benefits served by the
Insured Person under any previous policy with Us.
e. The Maternity Expenses incurred are Reasonable and Customary Charges.
f. The Maternity Benefit may be claimed under the Policy in respect of eligible Insured Person(s) only twice during
the lifetime of the Policy including any Renewal thereafter for the delivery of a child or Medically Necessary and
lawful termination of pregnancy up to maximum 2 pregnancies or terminations.
g. Any treatment related to the complication of pregnancy or termination will be treated within the maternity sub
limits.
h. On Renewal or incase of internal Portability, if an enhanced sub-limit is applicable under this benefit, 24 months of
continuous coverage (as per Section 3.9.c) would apply afresh to the extent of the increased benefit amount.
i. Clause 5.1.2.14, 5.1.2.15 under Permanent Exclusions is superseded to the extent covered under this Benefit.
a. Expenses incurred in respect of the harvesting and storage of stem cells for any purposes whatsoever;
b. Medical Expenses for ectopic pregnancy will be covered under the Section 3.1 (Inpatient Care) and shall not fall
under the Maternity Benefit.
c. Sections 3.2 (Pre-hospitalization Medical Expenses) and Section 3.3 (Post- hospitalization Medical Expenses) are
not payable under this benefit.
d. Any expenses to manage complications arising from or relating to pregnancy or termination of pregnancy within
24 months from the inception of the First Policy with Us.
e. Pre-natal and post-natal Medical Expenses.
3.10 New Born Baby
What is covered:
We will cover the Medical Expenses incurred towards the medical treatment of the Insured Person's New Born Baby
from the date of delivery until the expiry of the Policy Year, subject to continuous coverage of 24 months of that
Insured Person since the inception of the First Policy which offers Maternity Benefit with Us, without the requirement
of payment of any additional premiu
a. All the terms and conditions mentioned in Section 3.9 (Maternity Benefit) shall apply to this benefit as well.
b. The New Born Baby should be added as an endorsement within 90 days from date of delivery
c. We will indemnify the Reasonable and Customary Charges for Medical Expenses incurred for the below
vaccination of the New Born Baby till the New Born Baby completes one year from his/her birth.
Time interval Vaccination to be done (Age) Frequency

BCG (From birth to 1 weeks) 1
OPV (1 week) + IPV1 (6 week,10 weeks) 3
DPT (6& 10 week) 2
0-3 months
Hepatitis-B (0 & 6 week,) 2
Haemophilus influenzae type B (Hib) (6 & 10 Week) 2
Rota (6 & 10 Week) 2
OPV (6 month) + IPV (14 week) 2
DPT (14 week) 1
3-6 months Hepatitis-B (6 month) 1
Haemophilus influenzae type B (Hib) (14 week) 1
Rota (14 week) 1
MMR ( 9 Months) 1
9 months
OPV (9 Months) 1
Typhoid(12 Months) 1
12 months
Hepatitis A (12 Months) 1

d. If the Policy expires before the New Born Baby has completed one year, then Medical Expenses for balance
vaccination shall not be covered and will be covered only if the Policy is Renewed with the New Born Baby as an
Insured Person and not otherwise.
e. On the expiry of the Policy Year We will cover the baby as an Insured Person under the Policy on request of the
Proposer, subject to Our underwriting policy and payment of the applicable additional premium.
3.11 Health Check-up
What is covered:
The Insured Person may avail a health check-up, only for Diagnostic Tests, up to a sub-limit as per the Plan applicable
to the Insured Person as specified in the Product Benefits Table.
Note - In case of silver plan, a pre-defined set of tests can be availed by the Insured Person. A list of eligible tests is
attached in Annexure - IV.
a. Health check-up will be available on Cashless Facility basis only and will be arranged at Our empanelled Service
Providers.
Any unutilized test or amount cannot be carried forward to the next Policy Year.
3.12 Re-fill Benefit
What is covered:
If the Base Sum Insured and increased Sum Insured under Loyalty Additions (Section 3.14) (if any) has been partially
or completely exhausted due to claims paid or accepted as payable for any Illness / Injury during the Policy Year
under Section 3.1 or Section 3.4 or Section 3.5 or Section 3.6 or Section 3.7 or Section 3.24, then We will provide an
additional re-fill amount of maximum up to 100% of the Base Sum Insured.
a. The re-fill amount shall be utilized only for subsequent claims under Section 3.1 (In-patient Care) or Section 3.4
(Day Care Treatment) or Section 3.5 (Domiciliary Hospitalization) or Section 3.6 (Alternative Treatments) or
Section 3.7 (Living Organ Donor Transplant) or Section 3.24 (Modern Treatments) arising in that Policy Year for
any or all Insured Person(s).
b. We will provide a re-fill amount only once in a Policy Year.
c. For Family Floater Policies, the re-fill amount will be available on a floater basis to all Insured Persons in that
Policy Year.
a. If the re-fill amount is not utilized in whole or in part in a Policy Year, it cannot be carried forward to any extent in
any subsequent Policy Year.
b. This benefit is not available under Family First Policy.
3.13 Pharmacy and Diagnostic Services
What is covered:
You may purchase medicines or avail diagnostic services from Our Service Provider through Our website or mobile
application.
a. The cost for the purchase of the medicines or for availing diagnostic services shall be borne by You.
b. Further it is made clear that purchase of medicines from Our Service Provider is Your absolute discretion and
choice.
3.14 Loyalty Additions
What is covered:
a. For an Individual Policy or Family Floater Policy, if the Policy is Renewed with Us without a break or if the Policy
continues to be in force for the 2nd Policy Year in the 2 year Policy Period respectively (if applicable), We will
provide Loyalty Additions in the form of Cumulative Bonus by increasing the Sum Insured applicable under the
Policy by 10% of the Base Sum Insured of the immediately preceding Policy Year subject to a maximum of a

percentage as specified in the Policy Schedule. There will be no change in the sub-limits applicable to various
benefits due to increase in Sum Insured under this benefit.
b. For a Family First Policy, if the Policy is Renewed with Us without a break or if the Policy continues to be in force
for the 2nd Policy Year in the 2 year Policy Period respectively (if applicable), We will provide Loyalty Additions in
the form of Cumulative Bonus by increasing the Sum Insured applicable under the Policy by 10% of the Base Sum
Insured of the immediately preceding Policy Year of each individual Insured Person only subject to a maximum of
a percentage as specified in the Policy Schedule. The increase shall not apply to the Floater Sum Insured stated in
the Policy Schedule as applicable under the Policy. There will be no change in the sub-limits applicable to any
benefit due to increase in Sum Insured under this benefit.
a. If the Insured Person in the expiring Policy is covered under an Individual Policy and has an accumulated
Cumulative Bonus in the expiring Policy under this benefit, and such expiring Policy is Renewed with Us on a
Family Floater Policy, then We will provide the credit for the accumulated Cumulative Bonus to the Family Floater
Policy.
b. If the Insured Person in the expiring Policy is covered under an Individual Policy and has an accumulated
Cumulative Bonus in the expiring Policy under this benefit, and such expiring Policy is Renewed with Us on a
Family First Policy, then the accumulated Cumulative Bonus to be carried forward for credit in the Renewing
Policy would be the accumulated Cumulative Bonus for that Insured Person only.
c. If the Insured Persons in the expiring Policy are covered under a Family First Policy and have an accumulated
Cumulative Bonus for each Insured Person in the expiring Policy under this benefit, and such expiring Policy is
Renewed with Us on a Family Floater Policy with same or higher Base Sum Insured, then the accumulated
Cumulative Bonus to be carried forward for credit in the Renewing Policy would be the least of the accumulated
Cumulative Bonus amongst all the Insured Persons.
d. If the Insured Persons in the expiring Policy are covered under a Family First Policy and have an accumulated
Cumulative Bonus for each Insured Person in the expiring Policy under this benefit, and such expiring Policy is
Renewed with Us on an Individual Policy with same or higher Base Sum Insured, then the accumulated
Cumulative Bonus to be carried forward for credit in the Renewing Policy would be the accumulated Cumulative
Bonus for that Insured Person.
e. If the Insured Persons in the expiring Policy are covered on a Family Floater Policy and such Insured Persons
Renew their expiring Policy with Us by splitting the Floater Sum Insured stated in the Policy Schedule in to two or
more floater / individual / Family First Policy, then We will provide the credit of the accumulated Cumulative
Bonus to the split Policy reduced proportionately.
f. If the Insured Persons covered on a Family Floater Policy are reduced at the time of Renewal, the applicable
accumulated Cumulative Bonus shall also be reduced proportionately.
g. In case the Base Sum Insured under the Policy is reduced at the time of Renewal, the applicable accumulated
Cumulative Bonus shall also be reduced in proportion to the Base Sum Insured. The maximum reduction in the
accumulated Cumulative Bonus shall be limited to 50% of the accumulated Cumulative Bonus. Post reduction in
the Base Sum Insured and the accumulated Cumulative Bonus, if the accumulated Cumulative Bonus is equal to or
more than 100% of the revised Base Sum Insured, then there will be no further increase in the accumulated
Cumulative Bonus upon Renewal of such Policy.
h. In case the Base Sum Insured under the Policy is increased at the time of Renewal, the applicable accumulated
Cumulative Bonus shall also be increased in proportion to the Base Sum Insured. The maximum increase in the
accumulated Cumulative Bonus shall be limited to 50% of the accumulated Cumulative Bonus. Post increase in the
Base Sum Insured and the accumulated Cumulative Bonus, if the accumulated Cumulative Bonus is equal to or
more than 100% of the revised Base Sum Insured, then there will be no further increase in the accumulated
Cumulative Bonus upon Renewal of such Policy.
i. This benefit is not applicable for Health Check-up, Pharmacy & diagnostic services, Emergency assistance services,

Second Medical Opinion, Child care benefits and any of the optional benefits (if opted for). Enhancement of Sum
Insured due to Loyalty Additions benefit cannot be utilized for the aforementioned benefits.
3.15 HIV / AIDS
What is covered:
We will indemnify the expenses incurred by the Insured Person for Hospitalization (including Day Care Treatment)
due to condition caused by or associated with HIV / AIDS up to the limit as specified in Your Policy Schedule.
a. The Hospitalization or Day Care Treatment is Medically Necessary and the Illness is the outcome of HIV / AIDS.
This needs to be prescribed in writing by a registered Medical Practitioner.
b. The coverage under this benefit is provided for opportunistic infections which are caused due to low immunity
status in HIV / AIDS resulting in acute infections which may be bacterial, viral, fungal or parasitic.
c. The patient should be a declared HIV positive.
d. This benefit is provided subject to a Waiting Period of 48 months from inception of the cover with Us, with HIV /
AIDS covered as a benefit, for the respective Insured Person.
e. Pre-hospitalization Medical Expenses incurred for up to 60 days, if falling within the Policy Period, immediately
preceding the Insured Person's admission and Post-hospitalization Medical Expenses incurred for up to 90 days, if
falling within the Policy Period, immediately following the Insured Person's discharge will also be indemnified
under this benefit as per Section 3.2 & Section 3.3 respectively.
a. Chronic health conditions including ischemic heart disease, chronic liver disease, chronic kidney disease, cerebro-
vascular disease/ stroke, bronchial asthma and neoplasms which are not directly related to the patient's immunity
status would not be covered under this benefit.
b. Lifestyle diseases like diabetes, hypertension, heart diseases and dyslipidemia which are not related to HIV / AIDS
would not be covered under this benefit.
Sub-limit:
a. This benefit is covered up to a limit of Rs. 50,000.
b. Pre-hospitalization and Post-hospitalization Medical Expenses are also covered within the overall benefit sub-limit
as specified above in point (a).
3.16 Emergency Assistance Services
What is covered:
This Policy provides a host of value added Emergency Medical Assistance and Emergency personal services as
described below, on Cashless Facility basis.
a. Medical referral: Insured Person(s) will have tele-access to an operations center of Our Service Provider, who with
their multilingual staff on duty 24(twenty-four) hours a day, 365(three hundred and sixty-five) days a year will
provide reference of doctors in the vicinity where the Insured Person is located for medical consultations. This
medical consultation is only facilitated by Us / Our Service Provider and is independent judgment of medical
consultant. We do not assume any liability and shall not be deemed to assume any liability towards any loss or
damage arising out of or in relation to any opinion, advice, prescription, actual or alleged errors, omissions and
representations made by the professional giving medical consultant.
b. Emergency medical evacuation: When an adequate medical facility is not available proximate to the Insured
Person, as determined by the Insured Person's attending physician and agreed by Us / Our Service Provider,
We/Our Service Provider will arrange and pay for ambulance services under appropriate medical supervision, by
an appropriate mode of transport as decided by Us / Our Service Provider's consulting physician and patient's
attending physician to the nearest medical facility capable of providing the required care.
c. Medical repatriation: We / Our Service Provider will arrange and pay for transportation under medical supervision
to the Insured Person's residence or to a medical or rehabilitation facility near the Insured Person's residence (as
mentioned in the Policy Schedule) when the Insured Person's attending physician determines that transportation
is medically necessary and is agreed by Us / Our Service Provider, at such time as the Insured Person is medically

cleared for travel by Us / Our Service Provider's consulting physician and Insured Person's attending physician.
d. Compassionate visit: When an Insured Person will be hospitalized for more than seven (7) consecutive days and
has travelled without a companion or doesn't have a companion by his / her side, We / Our Service Provider will
arrange and pay for travel of a family member or personal friend to visit such Insured Person by providing an
appropriate means of transportation via economy carrier transportation as determined by Us / Our Service
Provider. The family member or the personal friend is responsible to meet all travel document requirements, as
may be applicable.
e. Care and/or transportation of minor children: One-way economy common carrier transportation, with attendants
if required, will be provided to the place of residence of minor child(ren) when they are left unattended as a result
of medical emergency or death of an Insured person.
f. Return of mortal remains: In the event of death of Insured Person, We/Our Service Provider will arrange and pay
for the return of mortal remains to an authorized funeral home proximate to the Insured Person's legal residence.
Conditions - Any coverage under this section 3.16 is subject to fulfilment of following conditions:
a. The services are provided when Insured Person(s) is/are traveling within India to a place which is at a minimum
distance of 150(one hundred and fifty) kilometers or more away from the residential address as mentioned in the
Policy Schedule, and the travel is for less than 90(ninety) days period.
a. No claims for Reimbursement of expenses incurred for services arranged by Insured/Insured Person(s) will be
entertained as the coverage under this section 3.16 are on Cashless Facility basis only.
b. Emergency assistance service will not be provided in the following instances:
i. Travel undertaken specifically for securing medical treatment
ii. Services sought outside India.
iii. If Emergency is a result of injuries resulting from participation in acts of war or insurrection
iv. Commission of unlawful act(s).
v. Attempt at suicide /self-inflicted injuries.
vi. Incidents involving the use of drugs, unless prescribed by a physician
vii. Transfer of the insured person from one medical facility to another medical facility of similar capabilities and
providing a similar level of care
c. We / Our Service Provider will not evacuate or repatriate an insured person in the following instances:
i. Without medical authorization from attending physician
ii. With mild lesions, simple injuries such as sprains, simple fractures, or mild sickness or similar such conditions
which can be treated by local doctors and do not prevent Insured Person(s) from continuing your trip or
returning home as determined by Us / Our Service Provider's consulting physician and the Insured Person's
attending physician
iii. If the Insured Person is pregnant and beyond the end of the 28th week and with respect to the child born from
the pregnancy, We / Our Service Provider shall not evacuate or repatriate the Insured Person and the child who
was born while the Insured Person was traveling beyond the 28th week
iv. With mental or nervous disorders unless hospitalized
d. Specific exclusions:
i. Trips exceeding 90(ninety) days from declared residence.
While assistance services are available all over India, transportation response time is directly related to the
location / jurisdiction where an event occurs. We / Our Service Provider is not responsible for failing to provide
services or for delays in the delivery of services caused by reasons beyond Our reasonable control, including
without any limitation, strike, road traffic, the weather conditions, availability and accessibility of airports, flight
conditions, availability of hyperbaric chambers, pandemics and endemics, communications systems, absence of
proper travel documents or where rendering of service is limited or prohibited by local law, edict or regulation.
Our / Our Service Provider's performance of any obligation here in this section 3.16 shall be waived / excused if
such failure to perform is caused by an event, contingency, or circumstance beyond its reasonable control that

prevents, hinders or makes impractical the performance of services. Legal actions arising hereunder shall be
barred unless written notice thereof is received by Us / Our Service Provider within one (1) year from the date of
event giving rise to such legal action. All consulting physicians and Our Service Provider are independent
contractors and not under the control of the Company. We / Our Service Provider are not responsible or liable for
any service rendered herein through professionals to You.
3.17 Mental Disorders Treatment
What is covered:
We will indemnify the expenses incurred by the Insured Person for Inpatient treatment for Mental Illness up to the
limit as specified in Your Policy Schedule.
a. Mental Disorders Treatment is only covered where patient is diagnosed by a qualified psychiatrist or a professional
registered with the concerned State Authority or a professional having a post-graduate degree (Ayurveda) in
Mano Vigyan Avum Manas Roga or a post-graduate degree (Homoeopathy) in Psychiatry or a post-graduate
degree (Unani) in Moalijat (Nafasiyatt) or a post-graduate degree (Siddha) in Sirappu Maruthuvam.
b. The Hospitalization is for Medically Necessary Treatment.
c. The treatment should be taken in Mental Health Establishment, including Ayurveda, Yoga and Naturopathy, Unani,
Siddha and Homoeopathy establishment, by whatever name called, either wholly or partly, meant for the care of
persons with mental illness, established, owned, controlled or maintained by the appropriate Government, local
authority, trust, whether private or public, corporation, co-operative society, organization or any other entity or
person, where persons with mental illness are admitted and reside at, or kept in, for care, treatment,
convalescence and rehabilitation, either temporarily or otherwise; and includes any general hospital or general
nursing home established or maintained by the appropriate Government, local authority, trust, whether private or
public, corporation, co-operative society, organization or any other entity or person; but does not include a family
residential place where a person with mental illness resides with his relatives or friend.
d. The Insured Person in respect of whom a claim for any expenses or complications arising from Mental Illness is
made must have been covered as an Insured Person for a period of 36 months of continuous coverage since the
inception of the First Policy, with Mental Illness as a benefit, with Us.
e. Pre-hospitalization Medical Expenses incurred for up to 60 days, if falling within the Policy Period, immediately
preceding the Insured Person's admission and Post-hospitalization Medical Expenses incurred for up to 90 days, if
falling within the Policy Period, immediately following the Insured Person's discharge will also be indemnified
under this benefit as per Section 3.2 & Section 3.3 respectively.
a. The condition which is not clinically significant or is related to anxiety, bereavement, relationship or academic
problems, acculturation difficulties or work pressure.
b. Treatment related to intentional self inflicted Injury or attempted suicide by any means.
c. Mental retardation which is a condition of arrested or incomplete development of mind of a person, specially
characterized by subnormality of intelligence.
Sub-limit:
a. The following disorders / conditions shall be covered only up to the limit specified in the Policy Schedule. This
sub-limit shall apply for all the following disorders / conditions on cumulative basis.
Disorder / Condition Description
Severe Depression Severe depression is characterized by a persistent feeling of sadness or a lack of

interest in outside stimuli. It affects the way one feels, thinks and behaves.
Schizophrenia is mental disorder, that distorts the way a person thinks, acts,
Schizophrenia expresses emotions, perceives reality, and relates to others. Schizophrenia result in
combination of hallucinations, delusions, and extremely disordered thinking and
behavior that impairs daily functioning,

Bipolar disorder is a mental illness that brings severe high and low moods and
Bipolar Disorder changes in sleep, energy, thinking, and behavior. It includes periods of extreme
mood swings with emotional highs and lows.
Post-traumatic stress disorder is an anxiety disorder caused by very stressful,
Post traumatic stress disorder frightening or distressing events. It includes flashbacks, nightmares, severe anxiety
and uncontrollable thoughts about the event.
Eating disorder Eating disorder is a mental condition where people experience severe disturbances
in their eating behaviors and related thoughts and emotions.
Generalized anxiety disorder Generalized Anxiety Disorder is a mental health disorder characterized by a
perpetual state of worry, fear, apprehension, inability to relax.
Obsessive-compulsive disorder is an anxiety disorder in which people have
Obsessive compulsive disorders recurring, unwanted thoughts, ideas or sensations (obsessions) that make them
feel driven to do something repetitively (compulsions).
Panic disorder is an anxiety disorder characterized by reoccurring unexpected panic
attacks with sudden periods of intense fear. It may include palpitations, sweating,
Panic disorders shaking, shortness of breath, numbness, or a feeling that something terrible is
going to happen.
Personality disorder is a type of mental disorder in which people have a rigid and
Personality disorders unhealthy pattern of thinking, functioning and behaving. It includes trouble in
perceiving and relating to situations and people.
Conversion disorder is a type of mental disorder where mental or emotional distress
Conversion disorders causes physical symptoms without the existence of an actual physical condition.
Dissociative disorders are mental disorders that involve experiencing a disconnection
Dissociative disorders and lack of continuity between thoughts, memories, surroundings, actions and
identity.
ICD codes for the above disorders / conditions are provided in Annexure V.
b. Pre-hospitalization and Post-hospitalization Medical Expenses are also covered within the overall benefit sub-limit
as specified above in point (a).
3.18 Second Medical Opinion
What is covered:
If the Insured Person is diagnosed with a Specified Illness as defined under Section 2.74 or is planning to undergo a
planned Surgery or a Surgical Procedure for any Illness or Injury, the Insured Person can, at the Insured Person's
choice, obtain a Second Medical Opinion during the Policy Period.
a. Our Service Provider is contacted seeking the Second Medical Opinion.
b. The Second Medical Opinion will be arranged by Our Service Provider and will be based only on the information
and documentation provided by the Insured Person that will be shared with the Medical Practitioner.
c. This benefit can be availed only once by an Insured Person during a Policy Year for the same Specified Illness or
planned Surgery.
d. By seeking the Second Medical Opinion under this Benefit the Insured Person is not prohibited or advised against
visiting or consulting with any other independent Medical Practitioner or commencing or continuing any
treatment advised by such Medical Practitioner.
e. The Insured Person is free to choose whether or not to obtain the Second Medical Opinion, and if obtained then
whether or not to act on it in whole or in part.
f. The Second Medical Opinion under this Benefit shall be limited to defined criteria and not be valid for any medico
legal purposes.

We do not assume any liability and shall not be deemed to assume any liability towards any loss or damage arising
out of or in relation to any opinion, advice, prescription, actual or alleged errors, omissions and representations made
by the Medical Practitioner.
3.19 Child care Benefits
What is covered:
a. We will indemnify the Reasonable and Customary Charges, once during a Policy Period, incurred for the
vaccination of the Insured Persons less than 12 years of Age.
b. We will also cover expenses towards one consultation for nutrition and growth provided to the child during a visit
for vaccination.
a. The following vaccinations will be covered under this benefit:
Time interval Vaccination to be done (Age) Frequency

OPV (15 &18 months) 2
DPT (15-18 months) 1
1-2 years
Haemophilus influenzae type B (Hib) (15-18 months) 1
Meningococcal vaccine (24 months) 1
After 10 years Tetanus Toxoide 1
3.20 Specified Illness Cover (outside the geographical boundaries of India)

What is covered:
If an Insured Person suffers a Specified Illness as defined under Section 12.72 during the Policy Period, We will
indemnify the Reasonable and Customary Charges for Medical Expenses of the Insured Person incurred towards
treatment of that Specified Illness that would otherwise have been payable under Section 3.1 (Inpatient Care), on
Cashless Facility basis only.
a. The symptoms of the Specified Illness first occur or manifest itself during the Policy Period and after completion
of the 90 day from the inception of the First Policy with Us.
b. The Specified Illness is diagnosed by a Medical Practitioner within India during the Policy Period and after
completion of the 90 day from the inception of the First Policy with Us.
c. Medical treatment for the Specified Illness is taken outside India within the Policy Period but only within those
regions specified in the Policy Schedule.
d. Clause 5.2.9 under Permanent Exclusions is superseded to the extent covered under this Benefit.
a. Any claims for Reimbursement of the costs incurred in relation to the treatment of the Specified Illness or any
claims which are not pre-authorized by Us.
b. Any costs or expenses incurred in relation to any persons accompanying the Insured Person during any period of
treatment, even if such persons are also Insured Persons.
c. Any costs or expenses incurred on things that are not in direct relation to the Medical Expenses for treatment
under this benefit like travel expenses, etc shall not be covered.
d. Any costs or expenses incurred in relation to personal stay or transportation in the overseas location where
treatment is being taken.
e. Sections 3.2 (Pre-hospitalization Medical Expenses) and Section 3.3 (Post- hospitalization Medical Expenses) are
not payable under this benefit.
f. Any costs or expenses incurred by any organ donor in relation to harvesting of organs.
g. Any OPD Treatment taken outside India.
3.21 OPD Treatment and Diagnostic Services

What is covered:
We will indemnify the Reasonable and Customary Charges incurred for OPD Treatment and/or Diagnostic Services
and/or prescribed medicines for the OPD Treatment taken during the Policy Period.
a. Expenses under this benefit are covered for ayurvedic or homeopathic or unani or sidha or allopathic services
only.
b. For treatment taken under ayurveda, homeopathy, unani or sidha (AYUSH), expenses are covered only if taken in
a government Hospital or in any institute recognized by government and/or accredited by Quality Council of
India/National Accreditation Board on Health.
c. The OPD Treatment and/or Diagnostic Services are Medically Necessary and follow the written advice of a Medical
Practitioner.
d. Diagnostic Services are performed on an outpatient basis with or without local anesthetics for topical, infiltration,
nerve block anesthesia and require Hospitalization for less than 24 hours.
e. If the Policy is Renewed with Us without any break and there is a unutilized amount (not used by the Insured
Person) under the applicable sub-limit (as specified in the Product Benefits Table) in a Policy Year, then We will
carry forward 80% of this unutilized amount to the immediately succeeding Policy Year, provided that the total
amount (including the unutilized amount available under this Benefit) shall at no time exceed 2.5 times the
amount of the entitlement in respect of this Benefit under the Plan applicable to the Insured Person.
3.22 Emergency Medical Evacuation (outside the geographical boundaries of India)
What is covered:
We will indemnify the Reasonable and Customary Charges for the Insured Person's Medical Evacuation in an
Emergency and for which medical facilities are not available locally, but within the regions specified in the Policy
Schedule during the Policy Period on Cashless Facility basis only.
a. We will provide this benefit from the Hospital where the Insured Person is admitted (required for stabilization) to
a Hospital where adequate treatment is available, if necessary treatment is not available locally or Medical
Evacuation is Medically Necessary for saving the life of the Insured Person.
b. The treating Medical Practitioner has advised that Medical Evacuation is Medically Necessary.
c. We or Our Service Provider has approved the request for Medical Evacuation.
d. We or Our Service Provider, will arrange for the evacuation utilizing the means best suited to do so, based on the
medical severity of Insured Person(s) condition.
e. We will also cover the costs of transportation of an attending Medical Practitioner if the treating Medical
Practitioner has advised that it is Medically Necessary.
f. Under this benefit We will cover expenses for services provided and/or arranged by Us for the transportation of
the Insured Person and shall include medical services and cost for medical supplies necessarily incurred as a result
of the Emergency Medical Evacuation.
g. We shall be liable only if the treating Medical Practitioner confirms that necessary medical treatment can't be
provided at the Hospital where the Insured Person is situated at the time of Emergency.
a. Any costs or expenses incurred in relation to any persons accompanying the Insured Person to be evacuated, even
if such persons are also Insured Person(s).
b. Any expenses (other than necessary Medical Expenses) already included in the cost of a scheduled trip, including
but not limited to the unutilized portion of the return air ticket for the scheduled trip.
c. Any expenses for a service not approved and arranged by Us or Our authorized representative.
3.23 Emergency Hospitalization (outside the geographical boundaries of India)
What is covered:
If the Insured Person is required to be admitted in a Hospital in an Emergency condition, We will indemnify the
Medical Expenses incurred on Hospitalization of that Insured Person untill the Insured Person reaches a Medically

Stable Condition during the Policy Period on Cashless Facility basis only.
a. The treating Medical Practitioner has advised that Hospitalization is Medically Necessary.
b. The Insured Person is required to be admitted in a Hospital in an Emergency when the Insured Person is outside
India, but within those regions specified in the Policy Schedule.
c. The Medical Expenses incurred are for one or more of the following:
i. Room Rent: Room boarding and nursing charges during Hospitalization as charged by the Hospital where the
Insured Person availed medical treatment;
ii. Medical Practitioners' fees, excluding any charges or fees for Standby Services;
iii. Investigative tests or diagnostic procedures directly related to the Insured Event which led to the current
Hospitalization;
iv. Medicines, drugs as prescribed by the treating Medical Practitioner related to the Insured Event that led to the
current Hospitalization;
v. Intravenous fluids, blood transfusion, injection administration charges and /or allowable consumables;
vi. Operation theatre charges;
vii. The cost of prosthetics and other devices or equipment, if implanted internally during Surgery;
viii.Intensive Care Unit Charges.
3.24 Modern Treatments
What is covered:
a. The following procedures / treatments will be covered either as Inpatient Care or as part of Day Care Treatment as
per Section 3.1 and Section 3.4 respectively, in a Hospital :
i. Uterine Artery Embolization and HIFU (High intensity focused ultrasound)
ii. Balloon Sinuplasty
iii. Deep Brain stimulation
iv. Oral chemotherapy
v. Immunotherapy- Monoclonal Antibody to be given as injection
vi. Intra vitreal injections
vii. Robotic surgeries
viii.Stereotactic radio surgeries
ix. BronchicalThermoplasty
x. Vaporisation of the prostrate (Green laser treatment or holmium laser treatment)
xi. IONM - (Intra Operative Neuro Monitoring)
xii. Stem cell therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be
covered.
b. If We have accepted a claim under this benefit, We will also indemnify the Insured Person's Pre-hospitalization
Medical Expenses and Post-hospitalization Medical Expenses in accordance with Sections 3.2 and 3.3 within the
overall benefit sub-limit.
Special condition applicable for robotic surgeries:
A limit of maximum INR 1 Lac will apply to all robotic surgeries, except the following:
i. Robotic total radical prostatectomy
ii. Robotic cardiac surgeries
iii. Robotic partial nephrectomy
iv. Robotic surgeries for malignancies
4. Optional Benefits
The following optional benefits shall apply under the Policy only if it is specified in the Policy Schedule. Optional benefits
can be selected by You only at the time of issuance of the First Policy or at Renewal on payment of the corresponding
additional premium.
The optional benefits 'Personal Accident Cover', 'Critical Illness Cover' and 'Hospital Cash' will be payable (only on

Reimbursement basis) if the conditions mentioned in the below sections are contracted or sustained by the Insured Person
covered under these optional benefits during the Policy Period.
The applicable optional benefits will be payable subject to the terms, conditions and exclusions of this Policy and subject
always to any sub-limits for the optional benefit as specified in the Policy Schedule.
All claims for any applicable optional benefits under the Policy must be made in accordance with the process defined under
Section 6.2.16 (Claim Process & Requirements).
4.1 Personal Accident Cover
What is covered:
If the Insured Person covered under this optional benefit dies or sustains any Injury resulting solely and directly from
an Accident occurring during the Policy Period at any location worldwide, and while the Policy is in force, We will
provide the benefits described below.
a. Accident Death (AD)
What is covered:
If the Injury due to Accident solely and directly results in the Insured Person's death within 365 days from the
occurrence of the Accident, We will make payment of Personal Accident Cover Sum Insured specified in the Policy
Schedule. If a claim is made under this optional benefit, the coverage for that Insured Person under the Policy
shall immediately and automatically cease. Any claim incurred before death of such Insured person shall be
admissible subject to terms and conditions under this Policy.
b. Accident Permanent Total Disability (APTD)
What is covered:
If the Injury due to Accident solely and directly results in the Permanent Total Disability of the Insured Person
which means that the Injury results in one or more of the following conditions within 365 days from the
occurrence of an Accident, We will make payment of 125% of the Personal Accident Cover Sum Insured as
specified in the Policy Schedule.
i. Loss of use of limbs or sight
The Insured Person suffers from total and irrecoverable loss of:
1. The use of two limbs (including paraplegia and hemiplegia) OR
2. The sight in both eyes OR
3. The use of one limb and the sight in one eye
ii. Loss of independent living
The Insured Person is permanently unable to perform independently three or more of the following six
activities of daily living.
1. Washing: the ability to maintain an adequate level of cleanliness and personal hygiene.
2. Dressing: the ability to put on and take off all necessary garments, artificial limbs or other surgical
appliances that are medically necessary.
3. Feeding: the ability to transfer food from a plate or bowl to the mouth once food has been prepared and
made available.
4. Toileting: the ability to manage bowel and bladder function, maintaining an adequate and socially
acceptable level of hygiene.
5. Mobility: the ability to move indoors from room to room on level surfaces at the normal place of residence.
6. 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.
i. The Permanent Total Disability is proved through a disability certificate issued by a Medical Board duly
constituted by the Central and/or the State Government; and
ii. We will admit a claim under this optional benefit only if the Permanent Total Disability continues for a period
of at least 6 continuous calendar months from the commencement of the Permanent Total Disability unless it is
irreversible, such as in case of amputation/loss of limbs etc; and

iii. If the Insured Person dies before a claim has been admitted under this optional benefit, no amount will be
payable under this optional benefit, however We will consider the claim under Section 4.1.a (Accident Death)
subject to terms and conditions mentioned therein; and
iv. We will not make payment under Accident Permanent Total Disability more than once in the Insured Person's
lifetime for any and all Policy Periods.
v. If a claim under this optional benefit is admitted, then coverage for the Insured Person will immediately and
automatically cease under Section 4.1(Personal Accident Cover) and this optional benefit shall not be applied
in respect of that Insured Person on any Renewal thereafter. However, other applicable benefits can be
Renewed in respect of the Insured Person.
c. Accident Permanent Partial Disability (APPD)
What is covered:
If the Injury due to Accident solely and directly results in the Permanent Partial Disability of the Insured Person
which is of the nature specified in the table below within 365 days from the occurrence of such Accident, We will
make payment under this optional benefit in accordance with the table below:
i. The Permanent Partial Disability is proved through a disability certificate issued by a Medical Board duly
constituted by the Central and/or the State Government; and
ii. We will admit a claim under this optional benefit only if the Permanent Partial Disability continues for a period
of at least 6 continuous calendar months from the commencement of the Permanent Partial Disability, unless it
is irreversible; and
iii. If the Insured Person dies before a claim has been admitted under this optional benefit, no amount will be
payable under this optional benefit, however We will consider the claim under Section 4.1.a (Accident Death)
subject to the terms and conditions mentioned therein.
iv. If a claim under this optional benefit has been admitted, then no further claim in respect of the same condition
will be admitted under this optional benefit.
v. If a claim under this optional benefit is paid and the entire Personal Accident Sum Insured specified in the
Policy Schedule does not get utilized, then the balance Personal Accident Cover Sum Insured shall be available
for further claims under Section 4.1 (Personal Accident Cover) until the entire Personal Accident Cover Sum
Insured is consumed. The Personal Accident Cover Sum Insured specified in the first Policy Schedule shall be a
lifetime limit for the Insured Person and once this limit is exhausted, coverage for the Insured Person will
immediately and automatically cease under Section 4.1 (Personal Accident Cover) and this optional benefit
shall not be applied in respect of that Insured Person on any Renewal thereafter. However, other applicable
benefits can be Renewed in respect of the Insured Person
Permanent Partial Disability Grid

% of Personal
S. No. Nature of Disability Accident Cover
Sum Insured
Loss or total and permanent loss of use of both the hands from
1 100%
the wrist joint
Loss or total and permanent loss of use of both feet from the
2 100%
ankle joint
Loss or total and permanent loss of use of one hand from the
3 100%
wrist joint and of one foot from the ankle joint
Loss or total and permanent loss of use of one hand from the
4 100%
wrist joint and total and permanent loss of sight in one eye
Loss or total and permanent loss of use of one foot from the ankle
5 100%
joint and total and permanent loss of sight in one eye

6 Total and permanent loss of speech and hearing in both ears 100%
7 Total and permanent loss of hearing in both ears 50%
8 Loss or total and permanent loss of use of one hand from wrist joint 50%
9 Loss or total and permanent loss of use of one foot from ankle joint 50%
10 Total and permanent loss of sight in one eye 50%
11 Total and permanent loss of speech 50%
12 Permanent total loss of use of four fingers and thumb of either hand 40%
13 Permanent total loss of use of four fingers of either hand 35%
14 Uniplegia 25%
15 Permanent total loss of use of one thumb of either hand
a. Both joints 25%
b. One joint 10%
16 Permanent total loss of use of fingers of either hand
a. Three joints 10%
b. Two joints 8%
c. One joint 5%
17 Permanent total loss of use of toes of either foot
a. All toes- one foot 20%
b. Great toe- both joints 5%
c. Great toe- one joint 2%
d. Other than great toe, one toe 1%
4.2 Critical Illness Cover

What is covered:
If the Insured Person covered under this optional benefit is diagnosed for the first time with any of the following
listed Critical Illnesses or if any of the following Critical Illnesses occurs or manifests itself in the Insured Person during
the Policy Period for the first time, We will pay the Critical Illness Sum Insured specified in the Policy Schedule
provided that the Insured Person survives the Survival Period of 30 days from the diagnosis of the Critical Illness
during the Policy Period.
a. Cancer of Specified Severity
I. 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.
II. The following are excluded -
i. All tumors which are histologically described as carcinoma in situ, benign, pre-malignant, borderline
malignant, low malignant potential, neoplasm of unknown behaviour, or non-invasive, including but not
limited to: Carcinoma in situ of breasts, Cervical dysplasia CIN-1, CIN -2 and CIN-3.
ii. Any non-melanoma skin carcinoma unless there is evidence of metastases to lymph nodes or beyond;
iii. Malignant melanoma that has not caused invasion beyond the epidermis;
iv. 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
v. All Thyroid cancers histologically classified as T1N0M0 (TNM Classification) or below;
vi. Chronic lymphocytic leukaemia less than RAI stage 3
vii. Non-invasive papillary cancer of the bladder histologically described as TaN0M0 or of a lesser classification,
viii.All Gastro-Intestinal Stromal Tumors histologically classified as T1N0M0 (TNM Classification) or be low and
with mitotic count of less than or equal to 5/50 HPFs;
ix. All tumors in the presence of HIV infection.
b. Myocardial Infarction

(First Heart Attack of specific severity)
III. 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 for Myocardial Infarction
should be evidenced by all of the following criteria:
I. A history of typical clinical symptoms consistent with the diagnosis of acute myocardial infarction (For e.g.
typical chest pain)
ii. New characteristic electrocardiogram changes
iii. Elevation of infarction specific enzymes, Troponins or other specific biochemical markers.
IV. The following are excluded:
I. Other acute Coronary Syndromes
ii. Any type of angina pectoris
iii. A rise in cardiac biomarkers or Troponin T or I in absence of overt ischemic heart disease OR following an
intra-arterial cardiac procedure.
c. Open Chest CABG
I. 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.
i. Angioplasty and/or any other intra-arterial procedures
d. Open Heart Replacement or Repair of Heart Valves
I. The actual undergoing of open-heart valve surgery is 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.
e. Coma of Specified Severity
I. 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:
i. no response to external stimuli continuously for at least 96 hours;
ii. life support measures are necessary to sustain life; and
iii. Permanent neurological deficit which must be assessed at least 30 days after the onset of the coma.
II. The condition has to be confirmed by a specialist medical practitioner. Coma resulting directly from alcohol or
drug abuse is excluded
f. Kidney Failure requiring Regular Dialysis
I. End stage renal disease presenting as chronic irreversible failure of both kidneys to function, as a result of
which either regular renal dialysis (haemodialysis or peritoneal dialysis) is instituted or renal transplantation is
carried out. Diagnosis has to be confirmed by a specialist medical practitioner
g. Stroke resulting in Permanent Symptoms
I. Any cerebrovascular incident producing permanent neurological sequelae. This includes infarction of brain
tissue, thrombosis in an intracranial vessel, haemorrhage and embolisation from an extracranial 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.
h. Major Organ /Bone Marrow Transplant
I. The actual undergoing of a transplant of:
i. One of the following human organs: heart, lung, liver, kidney, pancreas, that resulted from irreversible end-
stage failure of the relevant organ, or
ii. Human bone marrow using haematopoietic stem cells. The undergoing of a transplant has to be confirmed
by a specialist medical practitioner.
i. Permanent Paralysis of Limbs
I. 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.
j. Motor Neuron Disease with Permanent Symptoms
I. 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.
k. Multiple Sclerosis with Persisting Symptoms
I. The unequivocal diagnosis of Definite Multiple Sclerosis confirmed and evidenced by all of the following:
i. investigations including typical MRI findings which unequivocally confirm the diagnosis to be multiple
sclerosis and
ii. there must be current clinical impairment of motor or sensory function, which must have persisted for a
continuous period of at least 6 months.
II. Other causes of neurological damage such as SLE and HIV are excluded.
l. Deafness
I. Total and irreversible loss of hearing in both ears as a result of illness or accident. This diagnosis must be
supported by pure tone audiogram test and certified by an Ear, Nose and Throat (ENT) specialist. Total means
"the loss of hearing to the extent that the loss is greater than 90decibels across all frequencies of hearing" in
both ears.
m. End Stage Lung Failure
I. 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.
n. End Stage Liver Failure
I. Permanent and irreversible failure of liver function that has resulted in all three of the following:
i. Permanent jaundice; and
ii. Ascites; and
iii. Hepatic encephalopathy.
II. Liver failure secondary to drug or alcohol abuse is excluded.
o. Loss of Speech
I. Total and irrecoverable loss of the ability to speak as a result of injury or disease to the vocal cords. The
inability to speak must be established for a continuous period of 12 months. This diagnosis must be supported

by medical evidence furnished by an Ear, Nose, Throat (ENT) specialist.
II. All psychiatric related causes are excluded
p. Third Degree Burns
I. There must be third-degree burns with scarring that cover at least 20% of the body's surface area. The
diagnosis must confirm the total area involved using standardized, clinically accepted, body surface area charts
covering 20% of the body surface area.
q. Fulminant Viral Hepatitis
I. A sub-massive to massive necrosis of the liver by any virus, leading precipitously to liver failure.
This diagnosis must be supported by all of the following:
i. rapid decreasing of liver size; and
ii. necrosis involving entire lobules, leaving only a collapsed reticular framework; and
iii. rapid deterioration of liver function tests; and
iv. deepening jaundice; and
v. hepatic encephalopathy.
Acute Hepatitis infection or carrier status alone does not meet the diagnostic criteria
r. Aplastic Anemia
I. Aplastic Anemia is chronic persistent bone marrow failure. A certified hematologist must make the diagnosis
of severe irreversible aplastic anemia. There must be permanent bone marrow failure resulting in bone marrow
cellularity of less than 25% and there must be two of the following:
i. Absolute neutrophil count of less than 500/mm³
ii. Platelets count less than 20,000/mm³
iii. Reticulocyte count of less than 20,000/mm³
The Insured Person must be receiving treatment for more than 3 consecutive months with frequent blood
product transfusions, bone marrow stimulating agents, or immunosuppressive agents or the Insured Person
has received a bone marrow or cord blood stem cell transplant. Temporary or reversible Aplastic Anemia is
excluded and not covered under this Policy
s. Muscular Dystrophy
I. Muscular Dystrophy is a disease of the muscle causing progressive and permanent weakening of certain
muscle groups. The diagnosis of Muscular Dystrophy must be made by a consultant neurologist, and confirmed
with the appropriate laboratory, biochemical, histological, and electromyography evidence. The disease must
result in the permanent inability of the Insured Person to perform (whether aided or unaided) at least three (3)
of the six (6)"Activities of Daily Living".
Activities of Daily Living are defined as:
a. Washing: the ability to maintain an adequate level of cleanliness and personal hygiene
b. Dressing: the ability to put on and take off all necessary garments, artificial limbs or other surgical
appliances that are Medically Necessary
c. Feeding: the ability to transfer food from a plate or bowl to the mouth once food has been prepared and
made available
d. Toileting: the ability to manage bowel and bladder function, maintaining an adequate and socially
acceptable level of hygiene
e. Mobility: the ability to move indoors from room to room on level surfaces at the normal place of residence
f. 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
t. Bacterial Meningitis
I. Bacterial meningitis is a bacterial infection of the meninges of the brain causing brain dysfunction. There must
be an unequivocal diagnosis by a consultant physician of bacterial meningitis that must be proven on analysis
and culture of the cerebrospinal fluid. There must also be permanent objective neurological deficit that is

present on physical examination at least 3 months after the diagnosis of the meningitis infection.
Conditions applicable to 'Critical Illness cover':
a. We will not make payment under Section 4.2 (Critical Illness Cover) more than once in the Insured Person's
lifetime for any and all Policy Periods
b. The diagnosis of a Critical Illness must be verified in writing by a Medical Practitioner.
c. The Waiting Periods specified below shall be applicable to the Insured Person and claims shall be assessed
accordingly. On Renewal, if the Critical Illness Cover Sum Insured specified in the Policy Schedule is enhanced,
the Waiting Periods would apply afresh to the extent of the increase in benefit amount limit, subject to
Underwriting Guidelines and in accordance with the existing guidelines of the IRDAI.
We shall not be liable to make any payment under this Policy for covered listed Critical Illnesses directly or
indirectly caused by, based on, arising out of or howsoever attributable to any of the following:
i. Pre-existing Diseases (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 48 months for any Pre-existing Disease is subject to the
same being declared at the time of application and accepted by Us.
ii. 90 day Waiting Period:
a. Expenses related to the treatment of any Illness within 90 days from the first Policy commencement
date shall be excluded except claims arising due to an Accident, provided the same are covered.
b. This exclusion shall not, however, apply if the Insured Person has continuous coverage for more than
twelve months
c. The within referred waiting period is made applicable to the enhanced Sum Insured in the event of
granting higher Sum Insured subsequently.
d. If the Insured Person is diagnosed / undergoes a Surgical Procedure or any medical condition occurs
falling under the definition of Critical Illness as specified above that may result in a claim, then We shall
be given written notice immediately and in any event within 7 days of the aforesaid Illness/ condition/
Surgical Procedure.
e. We shall not be liable to make any payment under this optional benefit if the Insured Person does not
survive the Survival Period.
f. If diagnosis of the Critical Illness takes place on or before the Policy expiry date specified in the Policy
Schedule, but the Survival Period expires after the Policy expiry date, such claims would be admissible if
the Insured Person survives the Survival Period.
g. In the event of death of the Insured Person post the Survival Period, the immediate family
member/relative of the Insured Person claiming on Insured Person's behalf must inform Us in writing
immediately and send a copy of all the required documents to prove the cause of death within 30 days
of the death. We upon acceptance of the admission of claim under the Policy shall make payment to the
Nominee/legal heirs of the Insured Person.
h. If We have admitted a claim under this optional benefit for an Insured Person in any Policy Year, this
optional benefit shall not be renewed in respect of that Insured Person for any subsequent Policy Year,
but the cover for this optional benefit will be renewable for other Insured Persons.
4.3 e-Consultation

What is covered:
If the Insured Person is diagnosed with an Illness or is planning to undergo a planned Surgery or a Surgical Procedure,
the Insured Person can, at the Insured Person's sole direction, obtain an e-Consultation during the Policy Period.
a. e-Consultation shall be requested through Our call centre or website chat.
b. e-Consultation will be arranged by Us (without any liabilities) and will be based solely on the information
provided by the Insured Person.
c. e-Consultation must not be considered a substitute to medical opinion or advise nor shall be same pursued over a
medical advice or opinion given by treating physician or doctor
d. By seeking e-Consultation under this benefit, the Insured Person is not prohibited or advised against visiting or
consulting with any other independent Medical Practitioner or commencing or continuing any treatment advised
by such Medical Practitioner.
e. The Insured Person is free to choose whether or not to obtain the e-Consultation, and if obtained then whether or
not to act on it in whole or in part.
f. e-Consultation under this benefit shall not be valid for any medico-legal purposes.
g. We do not represent correctness of e-Consultation and shall not assume or deem to assume any liability towards
any loss or damage arising out of or in relation to any opinion, advice, prescription, actual or alleged errors,
omissions and representations made by the Medical Practitioner.
4.4 Premium Waiver
What is covered:
If the Policyholder (who should also be an Insured Person) dies or is diagnosed or undergoes treatment for the first
time, with any of the Specified Illness as mentioned under Section 2.74 during the Policy Period, the cover under the
Policy shall be automatically extended for a tenure of 1 Policy Year starting from the end of that Policy Period.
a. This optional benefit is provided once in the lifetime in the Policy regardless of the number of years the Policy has
served with Us.
b. The symptoms of the Specified Illness first occur or manifest itself during the Policy Period and after completion
of the 90 day from the inception of the First Policy with Us.
c. The Specified Illness is diagnosed by a Medical Practitioner during the Policy Period and after completion of the
90 day from the inception of the First Policy with Us.
d. If We have admitted a claim under this optional benefit during the Policy Period, this optional benefit shall not be
renewed for any subsequent Policy Period.
a. This benefit is not available under Individual Policy.
4.5 Hospital Cash
What is covered:
If We have accepted an Inpatient Care Hospitalization claim under Section 3.1 (Inpatient Care), We will pay the
Hospital Cash amount specified in the Policy Schedule up to a maximum 30 days of Hospitalization during the Policy
Year for the Insured Person for each continuous period of 24 hours of Hospitalization from the first day of
Hospitalization.
a. The Insured Person has been admitted in a Hospital for a minimum period of 48 hours continuously.
4.6 Enhanced Geographical Scope for International Coverage
What is covered:
This optional benefit shall be subject to all guidelines and conditions mentioned under Section 3.20 (Specified Illness
cover), Section 3.22 (Emergency Medical Evacuation - outside the geographical boundaries of India) and Section 3.23
(Emergency Hospitalization - outside the geographical boundaries of India), without limitation to the geographical

coverage in USA & Canada unlike specified under Section 3.20, Section 3.22 and Section 3.23.
a. Waiting Periods as specified under Section 5.1.1 shall apply afresh to the geographical coverage in USA & Canada
when this Optional Cover is opted.
5. Exclusions
5.1 Standard exclusions
5.1.1 Waiting Periods
All the Waiting Periods shall be applicable individually for each Insured Person and claims shall be assessed
accordingly. On Renewal, if the Sum Insured or the benefit amount is enhanced, the Waiting Periods would apply
afresh to the extent of the increased amount only. The Waiting Periods set out below shall not apply to Section 3.11
(Health Check-up), Section 3.13 (Pharmacy and diagnostic services), Section 4.1 (Personal Accident Cover), Section
4.2 (Critical Illness Cover), Section 4.3 (e-Consultation) and Section 4.4 (Premium Waiver). The Waiting Periods
for Critical Illness Cover have already been specified under Section 4.2 respectively.
We shall not be liable to make any payment under this Policy directly or indirectly caused by, based on, arising out
of or howsoever attributable to any of the following:
5.1.1.1 Pre-existing Diseases (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 24 months (under gold & platinum Plans)/ 48 months (under Silver
Plans) of continuous coverage after the date of inception of the first Policy with Us.
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 24 months (under gold & platinum Plans)/ 48 months
(under Silver Plans) for any Pre-existing Disease is subject to the same being declared at the time of
application and accepted by Us.
5.1.1.2 30-day Waiting Period (Code-Excl03)
a. 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.
b. This exclusion shall not, however, apply if the Insured Person has continuous coverage for more than
twelve months
c. The within referred waiting period is made applicable to the enhanced Sum Insured in the event of
granting higher Sum Insured subsequently.
5.1.1.3 Specified disease/procedure waiting period (Code- Excl02)
For all Insured Persons who are above 45 years of Age as on the date of inception of the First Policy
with Us, the following specifies disease/procedure waiting period will be applicable.
a. Expenses related to the treatment of the listed conditions, surgeries/treatments shall be excluded
until the expiry of 24 months of continuous coverage after the date of inception of the first Policy
with us. This exclusion shall not be applicable for claims arising due to an Accident (covered from
day 1 or Cancer (covered after 30-day waiting period).
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.
f. List of specific diseases/procedures:
a. Pancreatitis and Stones in Biliary and Urinary System,
b. Cataract, Glaucoma and other disorders of lens, disorders of Retina,
c. Hyperplasia of Prostate, Hydrocele and spermatocele,
d. Abnormal Utero-vaginal bleeding, female genital Prolapse, Endometriosis/Adenomyosis,
Fibroids, PCOD, or any condition requiring dilation and curettage or Hysterectomy,
e. Hemorrhoids, Fissure or Fistula or Abscess of anal and rectal region,
f. Hernia of all sites,
g. Osteoarthritis, Systemic Connective Tissue disorders, Dorsopathies, Spondylopathies,
inflammatory Polyarthropathies, Arthrosis such as RA, Gout, Intervertebral Disc disorders,
h. Chronic kidney disease and failure,
i. Varicose veins of lower extremities,
j. Disease of middle ear and mastoid including Otitis Media, Cholesteatoma, Perforation of
Tympanic Membrane,
k. All internal or external benign or In Situ Neoplasms/Tumours, Cyst, Sinus, Polyp, Nodules,
Swelling, Mass or Lump,
l. Ulcer, Erosion and Varices of Upper Gastro Intestinal Tract,
m. Tonsils and Adenoids, Nasal Septum and Nasal Sinuses,
n. Internal Congenital Anomaly.
5.1.2 Permanent Exclusions
We shall not be liable to make any payment under this Policy directly or indirectly caused by, based on, arising out
of or howsoever attributable to any of the following unless specifically mentioned elsewhere in the Policy.
Sections 5.1.2.1 to 5.1.2.27 are not applicable to Section 4.1 (Personal Accident Cover) and Section 4.2 (Critical
Illness Cover)
The permanent exclusions applicable to Section 4.1 (Personal Accident Cover) and Section 4.2 (Critical Illness
Cover) have been specified separately under Section 5.1.2.28 and Section 5.1.2.29 respectively.
5.1.2.1 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.
5.1.2.2 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:
a. 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.
b. Any services for people who are terminally ill to address physical, social, emotional and spiritual
needs.
5.1.2.3 Obesity/ Weight Control (Code-Excl06)
Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:
a. Surgery to be conducted is upon the advice of the Doctor.
b. The surgery/Procedure conducted should be supported by clinical protocols.
c. The member has to be 18 years of age or older and;

d. Body Mass Index (BMI);
i. greater than or equal to 40 or
ii. 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:
1. Obesity-related cardiomyopathy
2. Coronary heart disease
3. Severe Sleep Apnea
4. Uncontrolled Type2 Diabetes
5.1.2.4 Change-of-Gender treatments (Code-Excl07)
Expenses related to any treatment, including surgical management, to change characteristics of the
body to those of the opposite sex.
5.1.2.5 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.
5.1.2.6 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.
5.1.2.7 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.
5.1.2.8 Excluded Providers (Code-Excl11)
Expenses incurred towards treatment in any Hospital or by any Medical Practitioner or any other
provider specifically excluded by Us and disclosed in Our 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.
The complete list of excluded providers can be referred to on our website.
5.1.2.9 Treatment for, alcoholism, drug or substance abuse or any addictive condition and consequences
thereof. (Code-Excl12)
5.1.2.10 Treatments 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)
5.1.2.11 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)
5.1.2.12 Refractive Error (Code-Excl15)
Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5
dioptres.
5.1.2.13 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.
5.1.2.14 Sterility and Infertility (Code-Excl17)
Expenses related to sterility and infertility. This includes:
a. Any type of contraception, sterilization

b. Assisted Reproduction services including artificial insemination and advanced reproductive
technologies such as IVF, ZIFT, GIFT, ICSI
c. Gestational Surrogacy
d. Reversal of sterilization
5.1.2.15 Maternity (Code-Excl18)
a. Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean
sections incurred during Hospitalization) except ectopic pregnancy;
b. Expenses towards miscarriage (unless due to an Accident) and lawful medical termination of
pregnancy during the Policy Period.
5.2 Specific exclusions
5.2.1 Ancillary Hospital Charges
Charges related to a Hospital stay not expressly mentioned as being covered. This will include charges for
admission, discharge, administration, RMO charges, night charges, registration, documentation and filing,
surcharges and service charges levied by the Hospital.
5.2.2 Circumcision:
Circumcision unless necessary for the treatment of a disease or necessitated by an Accident.
5.2.3 Conflict & Disaster:
Treatment for any Injury or Illness resulting directly or indirectly from nuclear, radiological emissions, war or war
like situations (whether war is declared or not), rebellion (act of armed resistance to an established government
or leader), acts of terrorism.
5.2.4 External Congenital Anomaly:
Screening, counseling or treatment related to external Congenital Anomaly.
5.2.5 Dental/oral treatment:
Treatment, procedures and preventive, diagnostic, restorative, cosmetic services related to disease, disorder and
conditions related to natural teeth and gingiva except if required by an Insured Person while Hospitalized due to
an Accident.
5.2.6 Hormone Replacement Therapy:
Treatment for any condition / illness which requires hormone replacement therapy.
5.2.7 Sexually transmitted Infections & diseases (other than HIV / AIDS):
Screening, prevention and treatment for sexually related infection or disease (other than HIV / AIDS).
5.2.8 Sleep disorders:
Treatment for any conditions related to disturbance of normal sleep patterns or behaviors.
5.2.9 Any treatment or medical services received outside the geographical limits of India.
5.2.10 Unrecognized Physician or Hospital:
a. Treatment or Medical Advice provided by a Medical Practitioner not recognized by the Medical Council of India
or by Central Council of Indian Medicine or by Central council of Homeopathy.
b. Treatment provided by anyone with the same residence as an Insured Person or who is a member of the
Insured Person's immediate family or relatives.
c. Treatment provided by Hospital or health facility that is not recognized by the relevant authorities in India.
5.2.11 Artificial life maintenance for the Insured Person who has been declared brain dead or in vegetative state as
demonstrated by:
a. Deep coma and unresponsiveness to all forms of stimulation; or
b. Absent pupillary light reaction; or
c. Absent oculovestibular and corneal reflexes; or
d. Complete apnea.
5.2.12 AYUSH Treatment
Any form of AYUSH Treatments, except as mentioned under Section 3.6

5.2.13 Permanent Exclusions for Personal Accident Cover
We shall not be liable to make any payment under any benefits under Section 4.1 (Personal Accident Cover) if the
claim is attributable to, or based on, or arises out of, or is directly or indirectly connected to any of the following:
a. Suicide or self inflicted Injury, whether the Insured Person is medically sane or insane.
b. Treatment for any Injury or Illness resulting directly or indirectly from nuclear, radiological emissions, war or
war like situations (whether war is declared or not), rebellion (act of armed resistance to an established
government or leader), acts of terrorism.
c. Service in the armed forces, or any police organization, of any country at war or at peace or service in any force
of an international body or participation in any of the naval, military or air force operation during peace time.
d. Any change of profession after inception of the Policy or any Renewal which results in the enhancement of Our
risk, if not accepted and endorsed by Us on the Policy Schedule.
e. Committing an assault, a criminal offence or any breach of law with criminal intent.
f. Taking or absorbing, accidentally or otherwise, any intoxicating liquor, drug, narcotic, medicine, sedative or
poison, except as prescribed by a Medical Practitioner other than the Policyholder or an Insured Person.
g. Participation in aviation/marine activities (including crew) other than as a passenger in an aircraft/water craft
that is authorized by the relevant regulations to carry such passengers between established airports or ports.
h. Engaging in or taking part in professional/adventure sports or any hazardous pursuits, speed contest or racing
of any kind (other than on foot), bungee jumping, parasailing, ballooning, parachuting, skydiving, paragliding,
hang gliding, mountain or rock climbing necessitating the use of guides or ropes, potholing, abseiling, deep
sea diving, polo, snow and ice sports, hunting.
i. Body or mental infirmity or any Illness except where such condition arises directly as a result of an Accident
during the Policy Period. However this exclusion is not applicable to claims made under Section 4.1.c
(Permanent Partial Disability).
5.2.14 Permanent Exclusions for Critical Illness Cover
We shall not be liable to make any payment under Section 4.2 (Critical Illness Cover) directly or indirectly caused
by, based on, arising out of or howsoever attributable to any of the following unless specifically mentioned
elsewhere in the Policy.
1. AYUSH Treatment:
Any covered Critical Illnesses diagnosed and/or treated by a Medical Practitioner who practices AYUSH
Treatment.
2. Conflict & Disaster:
Treatment for any Injury or Illness resulting directly or indirectly from nuclear, radiological emissions, war or
war like situations (whether war is declared or not), rebellion (act of armed resistance to an established
government or leader), acts of terrorism.
3. External Congenital Anomaly:
Screening, counseling or treatment related to External Congenital Anomaly.
4. 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.
5. 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.
6. 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.
7. Sterility and Infertility (Code-Excl17)
Expenses related to sterility and infertility. This includes:
e. Any type of contraception, sterilization
f. Assisted Reproduction services including artificial insemination and advanced reproductive technologies
such as IVF, ZIFT, GIFT, ICSI
g. Gestational Surrogacy
h. Reversal of sterilization
8. Maternity (Code-Excl18)
c. Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean
sections incurred during Hospitalization) except ectopic pregnancy;
d. Expenses towards miscarriage (unless due to an Accident) and lawful medical termination of pregnancy
during the Policy Period.
9. Sexually transmitted Infections & Diseases:
Screening, prevention and treatment for sexually related infection or disease.
10. Treatment for, alcoholism, drug or substance abuse or any addictive condition and consequences thereof.
(Code-Excl12)
11. 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.
12. Treatments 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)
13. Unrecognized Physician or Hospital:
a. Treatment or Medical Advice provided by a Medical Practitioner not recognized by the Medical Council of
India or by Central Council of Indian Medicine or by Central council of Homeopathy.
b. Treatment provided by anyone with the same residence as an Insured Person or who is a member of the
Insured Person's immediate family or relatives.
c. Treatment provided by Hospital or health facility that is not recognized by the relevant authorities in India.
5.2.15 Personal Waiting Periods:
Conditions specified for an Insured Person under Personal Waiting Period in the Policy Schedule will be subject to
a Waiting Period of 24 months from the inception of the First Policy with Us for that Insured Person and will be
covered from the commencement of the third Policy Year for that Insured Person as long as the Insured Person
has been insured continuously under the Policy without any break.
6. General Terms and Clauses
6.1 Standard General Terms and Clauses

6.1.1 Free Look Period
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 person shall be allowed free look period of fifteen days (thirty days for policies with a term of 3 years,
if sold through distance marketing) 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.
lf the insured has not made any claim during the Free Look Period, the insured shall be entitled to
a. 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
6.1.2 Cancellation
I. The policyholder may cancel this policy by giving 30 days' written notice and in such an event, the Company
shall refund premium for the unexpired policy period as detailed below.
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.
1 year 2 years
Policy in-force up to Refund Premium (%) Policy in-force up to Refund Premium (%)
Up to 30 days 75% Up to 30 days 87.5%
31 to 90 days 50% 31 to 90 days 75%
91 to 180 days 25% 91 to 180 days 62.5%
exceeding 180 days 0% 181 to 365 days 50%
366 to 455 days 25%
456 to 545 days 12%
Exceeding 545 days 0%
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.
6.1.3 Renewal of Policy
The policy shall ordinarily be renewable except on grounds of fraud, misrepresentation by the insured person.
I. The Company shall endeavor to give notice for renewal. However, the Company is not under obligation to give
any notice for renewal.
II. Renewal shall not be denied on the ground that the insured person had made a claim or claims in the
preceding policy years.
III. Request for renewal along with requisite premium shall be received by the Company before the end of the
policy period.
IV. 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 without break in policy. Coverage is not available during the grace
period.
V. No loading shall apply on renewals based on individual claims experience.
6.1.4 Nomination
The policyholder is required at the inception of the policy to make a nomination for the purpose of payment of
claims under the policy in the event of death of the policyholder. Any change of nomination shall be
communicated to the company in writing and such change shall be effective only when an endorsement on the
policy is made. ln the event of death of the policyholder, the Company will pay the nominee {as named in the
Policy Schedule/Policy Certificate/Endorsement (if any)} and in case there is no subsisting nominee, to the legal
heirs or legal representatives of the policyholder whose discharge shall be treated as full and final discharge of its
liability under the policy.
6.1.5 Fraud
lf 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 misstatement of or suppression of material fact are within
the knowledge of the insurer.
6.1.6 Possibility of Revision of Terms of the Policy Including the Premium Rates
The Company, with prior approval of lRDAl, may revise or modify the terms of the policy including the premium
rates. The insured person shall be notified three months before the changes are effected.
6.1.7 Withdrawal of Policy
I. ln 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. lnsured 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.
6.1.8 Redressal of Grievances:
In case of any grievance the insured person may contact the company through:
Website: www.nivabupa.com
Toll free: 1860-500-8888
E-mail: customercare@nivabupa.com (Senior citizens may write to us at: seniorcitizensupport@nivabupa.com)
Fax : 011-3090-2010
Courier: Customer Services Department
Niva Bupa Health Insurance Company Limited
D-5, 2nd Floor, Logix Infotech Park
opp. Metro Station, Sector 59, Noida, Uttar Pradesh, 201301
lnsured person may also approach the grievance cell at any of the company's branches with the details of
grievance. lf lnsured person is not satisfied with the redressal of grievance through one of the above methods,
insured person may contact the grievance officer at Head - Customer Services
opp. Metro Station, Sector 59, Noida, Uttar Pradesh, 201301
Customer Helpline No: 1860-500-8888
Fax No.: 011-3090-2010
Email ID: customercare@nivabupa.com
For updated details of grievance officer, kindly refer the link https://www.nivabupa.com/customer-care/health-
services/grievance-redressal.aspx
If the Insured person is not satisfied with the above, they can escalate to GRO@nivabupa.com.

lf lnsured person is not satisfied with the redressal of grievance through above methods, the insured person may
also approach the office of lnsurance Ombudsman of the respective area/region for redressal of grievance as per
lnsurance Ombudsman Rules 2017 ( at the addresses given in Annexure I).
Grievance may also be lodged at IRDAI lntegrated Grievance Management System - https:/igms. irda.qov. in/
6.1.9 Claim settlement (Provision for Penal interest)
I. The Company shall settle or reject a claim, as the case may be, within 30 days from the date of receipt of last
necessary document.
II. ln 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- ln such cases, the Company shall settle or reject the claim within 45 days
from the date of receipt of last necessary document.
IV. ln 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 lndia (RBl) at the beginning of the
financial year in which claim has fallen due)
6.1.10 Moratorium Period
After completion of eight continuous years under the Policy no look back to be applied. This period of eight years
is called as moratorium period. The moratorium would be applicable for the sums insured of the first Policy and
subsequently completion of 8 continuous years would be applicable from date of enhancement of sums insured
only on the enhanced limits. After the expiry of Moratorium Period no health insurance claim shall be contestable
except for proven fraud and permanent exclusions specified in the Policy contract. The policies would however be
subject to all limits, sub limits, co-payments, deductibles as per the Policy contract.
6.1.11 Multiple Policies
I. ln 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. ln 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.
II. lnsured 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.
III. lf the amount to be claimed exceeds the sum insured under a single policy, the insured person shall have the
right to choose insurer from whom he/she wants to claim the balance amount.
IV. 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
6.1.12 Disclosure of 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)
6.1.13 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.
6.1.14 Portability
The insured person will have the option to port the policy to other insurers by applying to such insurer to port the
entire policy along with all the members of the family, if any, at least 45 days before, but not earlier than 60 days
from the policy renewal date as per IRDAI guidelines related to portability. lf such person is presently covered and
has been continuously covered without any lapses under any health insurance policy with an lndian
General/Health insurer, the proposed insured person will get the accrued continuity benefits in waiting periods as
per IRDAI guidelines on portability
For Detailed Guidelines on portability, kindly refer the link
https://www.irdai.gov.in/ADMINCMS/cms/whatsNew_Layout.aspx?page=PageNo3987&flag=1
6.1.15 Migration
The insured person will have the option to migrate the policy to other health insurance products/plans offered by
the company by applying for migration of the policy atleast 30 days before the policy renewal date as per IRDAI
guidelines on Migration. lf such person is presently covered and has been continuously covered without any lapses
under any health insurance product/plan offered by the company, the insured person will get the accrued
continuity benefits in waiting periods as per IRDAI guidelines on migration.
For Detailed Guidelines on migration, kindly refer the link
https://www.irdai.gov.in/ADMINCMS/cms/whatsNew_Layout.aspx?page=PageNo3987&flag=1
6.2 Specific Terms and Clauses
6.2.1 Automatic Cancellation
Individual Policy:
The Policy shall automatically terminate in the event of death of the Insured Person.
For Family Floater Policies:
The Policy shall automatically terminate in the event of the death of all the Insured Persons. .
Refund:
A refund in accordance with the table in Section 6.1.2 (I) shall be payable if there is an automatic cancellation of
the Policy provided that no claim has been made and e-consultation, Health Check-up, Emergency Assistance
Services or Second Medical Opinion have not been availed under the Policy by or on behalf of any Insured Person.
We will pay the refund of premium to the Nominee named in the Policy Schedule or Your legal heirs or legal
representatives holding a valid succession certificate.
6.2.2 Loading on Premium
a. Based upon the disclosure of the health status of the persons proposed for insurance and declarations made in
the Proposal or Insurance Summary Sheet, We may apply a risk loading on the premium payable (excluding
statutory levies and taxes) under the Policy. The maximum risk loading applicable shall not exceed more than
250% of the premium.
b. These loadings will be applied from inception date of the First Policy and subsequent Renewal(s) with Us.
c. If a loading applies to the premium for the main Policy, such loading will also apply to the premium for the
optional benefits selected except under Section 4.1 (Personal Accident Cover) and Section 4.3 (e-consultation).
6.2.3 Other Renewal Conditions:
b. Continuity of benefits on Timely Renewal:
i. The Renewal premium is payable on or before the due date and in any circumstances before the expiry of
Grace Period
ii. Renewal premium rates for this Policy may be further altered by Us including in the following
circumstances:
A. You proposed to add an Insured Person to the Policy
B. You change any coverage provision
iii. Renewal premium will alter based on individual Age. The reference of Age for calculating the premium for

Family Floater Policies shall be the Age of the eldest Insured Person, and for Family First Policies it shall be
the individual Age of each Insured Person of the family.
c. Reinstatement:
i. The Policy shall lapse after the expiration of the Grace Period. If the Policy is not Renewed within the Grace
Period then We may agree to issue a fresh Policy subject to Our underwriting criteria, as per Our Board
approved underwriting policy and no continuing benefits shall be available from the expired Policy.
ii. We will not pay for any Medical Expenses which are incurred between the date the Policy expires and the
date immediately before the reinstatement date of Your Policy.
iii. If there is any change in the Insured Person's medical or physical condition, We may add exclusions or
charge an extra premium from the reinstatement date.
d. Disclosures on Renewal:
You shall make a full disclosure to Us in writing of any material change in the health condition or geographical
location of any Insured Person at the time of seeking Renewal of this Policy, irrespective of any claim arising or
made. The terms and condition of the existing Policy will not be altered.
e. Renewal for Insured Persons who have achieved Age 22:
If any Insured Person who is a child and has completed Age 22 years at the time of Renewal, then such Insured
Person will have to take a separate policy based on Our underwriting guidelines, as per Our Board approved
underwriting policy as he/she will no longer be eligible to be covered under a Family Floater Policy. In such
cases, the credit of the Waiting Periods served under the Policy will be passed on to the separate policy taken
by such Insured Person.
f. Addition of Insured Persons on Renewal:
Where an individual is added to this Policy, either by way of endorsement or at the time of Renewal, the Pre-
existing Disease clause, exclusions, loading (if any) and Waiting Periods will be applicable considering such
Policy Year as the first year of the Policy with Us for that Insured Person.
g. Changes to Sum Insured on Renewal:
You may opt for enhancement of Sum Insured at the time of Renewal, subject to underwriting. All Waiting
Periods as defined in the Policy under Section 5.1.1 shall apply afresh for this enhanced limit from the effective
date of such enhancement.
6.2.4 Change of Policyholder
a. The Policyholder may be changed only at the time of Renewal. The new Policyholder must be a member of the
Insured Person's immediate family. Such change would be solely subject to Our discretion and payment of
premium by You. The Renewed Policy shall be treated as having been Renewed without break. The
Policyholder may be changed upon request in case of Your death, Your emigration from India or in case of Your
divorce during the Policy Period.
b. Any alteration in the Policy due to unavoidable circumstances as in case of the Policyholder's death,
emigration or divorce during the Policy Period should be reported to Us immediately.
c. Renewal of such Policies will be according to terms and conditions of existing Policy.
6.2.5 Obligations in case of a minor
If an Insured Person is less than 18 years of Age, You or another adult Insured Person or legal guardian (in case of
Your and all other adult Insured Person's demise) shall be completely responsible for ensuring compliance with all
the terms and conditions of this Policy on behalf of that minor Insured Person.
6.2.6 Authorization to obtain all pertinent records or information:
As a Condition Precedent to the payment of benefits, We and/or Our Service Provider shall have the authority to
obtain all pertinent records or information from any Medical Practitioner, Hospital, clinic, insurer, individual or
institution to assess the validity of a claim submitted by or on behalf of any Insured Person.
6.2.7 Policy Disputes
Any dispute concerning the interpretation of the terms, conditions, limitations and/or exclusions contained herein

shall be governed by Indian law and shall be subject to the jurisdiction of the Indian Courts.
6.2.8 Territorial Jurisdiction
All benefits are available in India only and all claims shall be payable in India in Indian Rupees only except for
benefits and claims under Section 3.20 (Specified Illness cover), Section 3.22 (Emergency Medical Evacuation -
outside the geographical boundaries of India) and Section 3.23 (Emergency Hospitalization - outside the
geographical boundaries of India).
6.2.9 Notices
Any notice, direction or instruction given under this Policy shall be in writing and delivered by hand, post, or
facsimile to:
a. You/the Insured Person at the address specified in the Policy Schedule or at the changed address of which We
must receive written notice.
b. Us at the following address:
opp. Metro Station, Sector 59, Noida,
Uttar Pradesh, 201301
Fax No.: 011-3090-2010
c. No insurance agents, brokers or other person/entity is authorized to receive any notice on Our behalf.
d. In addition, We may send You/the Insured Person other information through electronic and
telecommunications means with respect to Your Policy from time to time.
6.2.10 Alteration to the Policy
This Policy constitutes the complete contract of insurance. Any change in the Policy will only be evidenced by a
written endorsement signed and stamped by Us. No one except Us can within the permission of the IRDAI change
or vary this Policy.
6.2.11 Zonal pricing
For the purpose of calculating premium for silver and gold plan, following zones are available:
• Zone 1: All India coverage
• Zone 2: All India coverage (Co-payment applicable for Mumbai (including Navi Mumbai & Thane), Delhi NCR,
Kolkata & Gujarat State).
If You select Zone 2, then 20% Co-payment will apply for treatment in Mumbai (including Navi Mumbai &
Thane), Delhi NCR, Kolkata & Gujarat State. This Zone-wise Co-payment shall not be applicable to any claim
under Section 3.11 (Health Check-up), Section 3.13 (Pharmacy and diagnostic services), Section 3.16
(Emergency Assistance Services), Section 3.18 (Second Medical Opinion), Section 3.20 (Specified Illness cover),
Section 3.21 (OPD Treatment and Diagnostic Services), Section 4.1 (Personal Accident Cover), Section 4.2
(Critical Illness Cover), Section 4.3 (e-Consultation), Section 4.4 (Premium Waiver) and Section 4.5 (Hospital
Cash).
Note: Post choosing this option, zones can be changed only at the time of renewal on submission of proof of
change in address or any other valid reason.
For the purpose of calculating premium for platinum plan, the country has been divided into the following 3
zones based on the address provided by You:
• Zone 1: Delhi (NCR), Surat, Kolkata, Mumbai (including Navi Mumbai & Thane)
• Zone 2: Pune, Ludhiana, Jaipur
• Zone 3: Rest of India
Note: Zone based Co-payment is not applicable for platinum plan.
6.2.12 Assignment
The Policy can be assigned subject to applicable laws.
6.2.13 Claim Cost Sharing Option / Conditions

The following claim cost sharing options shall apply under the Policy as per the plan in the Product Benefits Table
and as specified in the Policy Schedule and shall apply to all Insured Persons only if such options are selected by
You in the Proposal Form and / or Information Summary Sheet. These claim cost sharing options can be selected
only at the time of issuance of the First Policy or at Renewal by You.
6.2.14 Co-payment
The Insured Person will bear a predetermined percentage of the admissible claim amounts subject to the Co-
payment option chosen by You in the Proposal Form and / or Information Summary Sheet irrespective of the Age
of the Insured Person and the number of claims made.
Co-payment will not apply to any claim under Section 3.11 (Health Check-up), Section 3.13 (Pharmacy and
diagnostic services), Section 3.16 (Emergency Assistance Services), Section 3.18 (Second Medical Opinion), Section
3.20 (Specified Illness cover), Section 3.21 (OPD Treatment and Diagnostic Services), Section 4.1 (Personal
Accident Cover), Section 4.2 (Critical Illness Cover), Section 4.3 (e-Consultation), Section 4.4 (Premium Waiver)
and Section 4.5 (Hospital Cash).
6.2.15 Annual Aggregate Deductible
The Insured Person shall bear on his/her own account an amount equal to the Deductible specified in the Policy
Schedule for any and all admissible claim amounts We assess to be payable by Us in respect of all claims made by
that Insured Person under the Policy for a Policy Year. It is agreed that Our liability to make payment under the
Policy in respect of any claim made in that Policy Year will only commence once the Deductible has been
exhausted.
It is further agreed that:
a. The provisions in Section 6.2.14 on Co-payment (if opted) will apply to any amounts payable by Us in respect
of a claim made by the Insured Person after the Deductible has been exhausted.
b. Deductible will not apply to any claim under Section 3.11 (Health Checkup), Section 3.13 (Pharmacy and
diagnostic services), Section 3.18 (Second Medical Opinion), Section 4.1 (Personal Accident Cover), Section 4.2
(Critical Illness Cover), Section 4.3 (e-Consultation), Section 4.4 (Premium Waiver) and Section 4.5 (Hospital
Cash).
6.2.16 Claim Process & Requirements
The fulfillment of the terms and conditions of this Policy (including payment of full premium in advance by the
due dates mentioned in the Policy Schedule) in so far as they relate to anything to be done or complied with by
You or any Insured Person, including complying with the following in relation to claims, shall be Condition
Precedent to admission of Our liability under this Policy.
6.2.16.1 Claims Administration:
On the occurrence or discovery of any Illness or Injury that may give rise to a claim under this Policy, the
Claims Procedure set out below shall be followed:
a. We advise You to submit all claims related document, including documents for claims within the
Deductible amount, once the Deductible limit has been exhausted.
b. The directions, advice and guidance of the treating Medical Practitioner shall be strictly followed.
c. We/Our Service Provider must be permitted to inspect the medical and Hospitalization records
pertaining to the Insured Person's treatment and to investigate the circumstances pertaining to the
claim.
d. We and Our Service Provider must be given all reasonable co-operation in investigating the claim in
order to assess Our liability and quantum in respect of the claim.
e. It is hereby agreed and understood that no change in the Medical Record provided under the Medical
Advice information, by the Hospital or the Insured Person to Us or Our Service Provider during the
period of Hospitalization or after discharge by any means of request will be accepted by Us. Any
decision on request for acceptance of such change will be considered on merits where the change
has been proven to be for reasons beyond the claimant's control.

6.2.16.2 Claims Procedure: 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:
a. For Availing Cashless Facility: Cashless Facility can be availed only at Our Network Providers or
Service Providers (as applicable). The complete list of Network Providers is available on Our website
and at Our branches and can also be obtained by contacting Us over the telephone. In order to avail
Cashless Facility, the following process must be followed:
i. Process for Obtaining Pre-Authorization
A. For Planned Treatment:
We must be contacted to pre-authorize Cashless Facility for planned treatment at least 72
hours prior to the proposed treatment. Once the request for pre-authorisation has been
granted, the treatment must take place within 15 days of the pre-authorization date at a
Network Provider.
B. In Emergencies:
If the Insured Person has been Hospitalized in an Emergency, We must be contacted to pre-
authorize Cashless Facility within 48 hours of the Insured Person's Hospitalization or before
discharge from the Hospital, whichever is earlier.
All final authorization requests, if required, shall be sent at least six hours prior to the Insured
Person's discharge from the Hospital.
Each request for pre-authorization must be accompanied with completely filled and duly
signed pre-authorization form including all of the following details:
I. The health card We have issued to the Insured Person at the time of inception of the Policy
(if available) supported with KYC document;
II. The Policy Number;
III. Name of the Policyholder;
IV. Name and address of Insured Person in respect of whom the request is being made;
V. Nature of the Illness/Injury and the treatment/Surgery required;
VI. Name and address of the attending Medical Practitioner;
VII. Hospital where treatment/Surgery is proposed to be taken;
VIII.Date of admission;
IX. First and any subsequent consultation paper / Medical Record since beginning of
diagnosis of that treatment/Surgery;
X. Admission note;
XI. Treating Medical Practitioner certificate for Illness / Insured Event history with justification
of Hospitalization.
If these details are not provided in full or are insufficient for Us to consider the request, We
will request additional information or documentation in respect of that request.
When We have obtained sufficient details to assess the request, We will issue the
authorization letter specifying the sanctioned amount, any specific limitation on the claim,
applicable Deductible / Co-payment and non-payable items, if applicable, or reject the
request for pre-authorisation specifying reasons for the rejection.
In case of preauthorization request where chronicity of condition is not established as per
clinical evidence based information, We may reject the request for preauthorization and ask
the claimant to claim as Reimbursement. Claim document submission for Reimbursement
shall not be deemed as an admission of Our liability.
Once the request for pre-authorisation has been granted, the treatment must take place
within 15 days of the pre-authorization date and pre-authorization shall be valid only if all the

details of the authorized treatment, including dates, Hospital, locations, indications and
disease details, match with the details of the actual treatment received. For Hospitalization on
a Cashless Facility basis, We will make the payment of the amount assessed to be due,
directly to the Network Provider / Service Provider.
We reserve the right to modify, add or restrict any Network Provider or Service Provider for
Cashless Facility at Our sole discretion.
ii. Reauthorization
Cashless Facility will be provided subject to re-authorization if requested for either change in the
line of treatment or in the diagnosis or for any procedure carried out on the incidental
diagnosis/finding prior to the discharge from the Hospital.
b. For Reimbursement Claims:
For all claims for which Cashless Facility has not been pre-authorized or for which treatment has not
been taken at a Network Provider/Service Provider or for which Cashless Facility is not available, We
shall be given written notice of the claim along with the following details within 48 hours of
admission to the Hospital or before discharge from the Hospital, whichever is earlier:
i. The Policy Number;
ii. Name of the Policyholder;
iii. Name and address of the Insured Person in respect of whom the request is being made;
iv. Nature of Illness or Injury and the treatment/Surgery taken;
v. Name and address of the attending Medical Practitioner;
vi. Hospital where treatment/Surgery was taken;
vii. Date of admission and date of discharge;
viii.Any other information that may be relevant to the Illness/ Injury/ Hospitalization.
6.2.16.3 Claims Documentation:
For medical claims - Reimbursement Facility:
We shall be provided with the following necessary information and documentation in respect of all
claims at Your/Insured Person's expense within 30 days of the Insured Event giving rise to a claim or
within 30 days from the date of occurrence of an Insured Event or completion of Survival Period (in case
of Critical Illness Cover).
For medical claims - Cashless Facility:
We will be provided these documents by the Network Provider immediately following the Insured
Person's discharge from Hospital.
Necessary information and documentation for medical claims
a. Claim form duly completed and signed by the claimant.
b. Details of past medical history record, first and subsequent consultation.
c. Age / Identity proof document of Insured Person in case of claim approved under Cashless Facility
(not required if submitted at the time of pre-authorization request) and Policyholder in case of
Reimbursement claim.
i. Self attested copy of valid age proof (passport / driving license / PAN card / class X certificate /
birth certificate);
ii. Self attested copy of identity proof (passport / driving license / PAN card / voter identity card);
iii. Recent passport size photograph
d. Cancelled cheque/ bank statement / copy of passbook mentioning account holder's name, IFSC code
and account number printed on it of Policyholder / nominee ( in case of death of Policyholder).
e. Original discharge summary.
f. Bar code sticker and invoice for implants and prosthesis (if used and only in case of Surgery/Surgical
Procedure).

g. Original final bill from Hospital with detailed break-up and paid receipt.
h. Room tariff of the entitled room category (in case of a Non-Network provider and if room tariff is not
a part of Hospital bill): duly signed and stamped by the Hospital in which treatment is taken.
(In case You are unable to submit such document, then We shall consider the Reasonable and
Customary Charges of the Insured Person's eligible room category of Our Network Provider within
the same geographical area for identical or similar services.)
i. Original bills of pharmacy/medicines purchased, or of any other investigation done outside Hospital
with reports and requisite prescriptions.
j. For Medico-legal cases (MLC) or in case of Accident
i. MLC/ Panchnama / First Information Report (FIR) copy attested by the concerned Hospital /
police station (if applicable);
ii. Original self-narration of incident in absence of MLC / FIR.
k. Original laboratory investigation, diagnostic, radiological & pathological reports with supporting
prescriptions.
In the event of the Insured Person's death during Hospitalization, written notice accompanied by a
copy of the post mortem report (if any) shall be given to Us regardless of whether any other notice
has been given to Us.
For Personal Accident claims
Additional claim documentation for Personal Accident Cover under Section 4.1:
a. Accident Death
i. Copy of death certificate (issued by the office of Registrar of Births and Deaths or any other
authorized legal institution)
ii. Copy of post mortem report wherever applicable
b. Accident Permanent Total Disability or Accident Permanent Partial Disability
i. Certificate of disability issued by a Medical Board duly constituted by the Central and/or the
State Government.
For Critical Illness claims
Additional claim documentation for Critical Illness Cover under Section 4.2:
a. Treating Medical Practitioner's certification for insured person's survival post survival period.
For claims outside India
Additional claim documentation for claims incurring outside India:
a. Passport copy with entry and exit stamps
b. Additional documents as specified under each benefit
6.2.16.4 Claims Assessment & Repudiation:
a. At Our discretion, We may investigate claims to determine the validity of a claim. All costs of
investigation will be borne by Us and all investigations will be carried out by those
individuals/entities that are authorized by Us in writing.
b. Payment for Reimbursement claims will be made to You. In the unfortunate event of Your death, We
will pay the Nominee named in the Policy Schedule or Your legal heirs or legal representatives
holding a valid succession certificate.
c. We are not obliged to make payment for any claim or that part of any claim that could have been
avoided or reduced if the Insured Person had taken reasonable care, or that is brought about or
contributed to by the Insured Person failing to follow the directions, advice or guidance provided by
a Medical Practitioner.
d. If a claim is made which extends in to two Policy Periods, then such claim shall be paid taking into
consideration the available Sum Insured in these Policy Periods. Such eligible claim amount will be
paid to the Policyholder/Insured Person after deducting the extent of premium to be received for the

Renewal/due date of premium of the Policy, if not received earlier.
e. All admissible claims under this Policy shall be assessed by Us in the following progressive order:-
i. If a room has been opted in a Hospital for which the room category is higher than the eligible
limit as applicable for that Insured Person as specified in the Policy Schedule, then the Associated
Medical Expenses payable shall be pro-rated as per the applicable limits in accordance with
Section 3.1.
ii. The Deductible (if applicable) shall be applied to claims that are either paid or payable under this
Policy. Our liability to make payment shall commence only once the amount of eligible claims as
per policy terms and conditions exceeds the Deductible limit within the same Policy Year.
iii. Co-payment (if applicable) as specified in the Policy Schedule shall be applicable on the amount
payable by Us.
f. The claim amount assessed in Section 6.2.16.4 f above would be deducted from the amount
mentioned against each benefit and Sum Insured as specified in the Policy Schedule.
6.2.16.5 Delay in Claim Intimation or Claim Documentation:
If the claim is not notified to Us or claim documents are not submitted within the stipulated time as
mentioned in the above sections, then We shall be provided the reasons for the delay, in writing. We
will condone such delay on merits where the delay has been proved to be for reasons beyond the
claimant's control.
6.2.16.6 Claims process for Section 4.3 (e-Consultation):
After validation of Insured Person and Policy details, We will evaluate the information of the Insured
Person from the perspective to check eligibility of cover only and if the request is approved, We will
facilitate arrangement as per the conditions specified under respective benefits admissible to the
Insured Person.
6.2.16.7 Claim process for Section 3.11 (Health Checkup)
a. The Insured Person shall seek appointment by contacting Our Service Provider.
b. Our Service Provider will facilitate Your appointment.
c. Reports of the medical tests can be collected directly from the Service Provider.
6.2.16.8 Claims process for Section 3.16.b and Section 3.22 (Emergency Medical Evacuation)
a. In the event of an Emergency, Our Service Provider shall be contacted immediately on the helpline
number specified in the Insured Person's health card.
b. Our Service Provider will evaluate the necessity for evacuation of the Insured Person and if the
request for Medical Evacuation is approved by Us, the Service Provider shall pre-authorise the type
of travel that can be utilized to transport the Insured Person and provide information on the Hospital
that may be approached for medical treatment of the Insured Person.
c. If the Service Provider pre-authorises the Medical Evacuation of the Insured Person by means of Air
Transportation through an air ambulance or commercial flight whichever is best suited, the Service
Provider shall also arrange for the same to be provided to the Insured Person unless there are any
logistical constraints or the medical condition of the Insured Person prevents Emergency Medical
Evacuation.
d. It is agreed and understood that We shall not cover any claims for Reimbursement of the costs
incurred in the evacuation or transportation of the Insured Person or which are not pre-authorized
by Our Service Provider.
6.2.16.9 Claim process for Section 3.18 (Second Medical Opinion)
a. In the event of submission of request for Second Medical Opinion, Our Service Provider shall be
contacted immediately on the helpline number specified in the Insured Person's health card.
b. Our Service Provider will evaluate the information of the Insured Person and if the request for
Second Medical Opinion is approved, the Service Provider will facilitate arrangement as per

conditions specified in the Section 3.18
6.2.16.10 Claim process for Section 3.20 (Specified Illness Cover)
a. In the event of the diagnosis of a Specified Illness, the Insured Person should call Us immediately
and in any event before the commencement of the travel for treatment overseas on the helpline
number specified on in the Insured Person's health card, requesting for a pre-authorization for the
treatment.
b. We will evaluate the request and the eligibility of the Insured Person's Policy and call for more
information or details, if required.
c. We will communicate directly to the Service Provider and the Insured Person whether the request for
pre-authorization has been approved or denied.
d. If the pre-authorization request is approved, Our Service Provider will directly settle the claim with
the Hospital. Any additional costs or expenses incurred by or on behalf of the Insured Person
beyond the limits pre-authorized by the Service Provider or at any Non-Network Hospital shall be
borne by the Insured Person.
e. This benefit is available only as Cashless Facility through pre-authorization by Us.
6.2.16.11 Claims process for Section 3.23 (Emergency Hospitalization - outside the geographical boundaries of
India)
a. The health card We provide will enable the Insured Person to access medical treatment at any
Network Provider outside India, but within those regions specified in the Policy Schedule, on a
cashless basis only by the production of the card to the Network Provider prior to admission, subject
to the following:
i. In the event of an Emergency, the Insured Person or Network Provider shall call Our Service
Provider immediately, on the helpline number specified in the Insured Person's health card,
requesting for a pre-authorization for the medical treatment required.
ii. Our Service Provider will evaluate the request and the eligibility of the Insured Person under the
Policy and call for more information or details, if required. Our Service Provider will communicate
directly to the Hospital whether the request for pre-authorization has been approved or denied.
iii. If the pre-authorization request is approved, Our Service Provider will directly settle the claim
with the Hospital. Any additional costs or expenses incurred by or on behalf of the Insured
Person beyond the limits pre-authorized by the Service Provider shall be borne by the Insured
Person.
iv. It is agreed and understood that We shall not cover any claims for Reimbursement of the costs
incurred in relation to the Hospitalization of the Insured Person while inside or outside India or
any claims which are not pre-authorized by Us.
Disclaimer: Insurance is a subject matter of solicitation. Niva Bupa Health Insurance Company Limited (formerly known as Max Bupa Health Insurance Company
Limited) (IRDAI Registration Number 145). 'Bupa' and 'HEARTBEAT' logo are registered trademarks of their respective owners and are being used by Niva Bupa
Health Insurance Company Limited under license. Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021. Registered office:- C-98, First Floor, Lajpat
Nagar, Part 1, New Delhi-110024, Customer Helpline: 1860-500-8888. Website: www.nivabupa.com. CIN: U66000DL2008PLC182918.

ANNEXURE - I
List of Insurance Ombudsmen
Office Details Jurisdiction of Office Union Territory, District
AHMEDABAD - Shri Kuldip Singh
Office of the Insurance Ombudsman, Jeevan Prakash Building, 6th floor,
Tilak Marg, Relief Road, Ahmedabad - 380 001. Gujarat, UT of Dadra & Nagar Haveli, Daman and Diu.
Tel.: 079 - 25501201/02/05/06
Email: bimalokpal.ahmedabad@cioins.co.in
BENGALURU - Smt. Neerja Shah

Office of the Insurance Ombudsman,
Jeevan Soudha Building, PID No. 57-27-N-19, Ground Floor, Karnataka.
19/19, 24th Main Road, JP Nagar, Ist Phase, Bengaluru - 560 078.
Tel.: 080 - 26652048 / 26652049
Email: bimalokpal.bengaluru@cioins.co.in
BHOPAL - Shri Guru Saran Shrivastava

Janak Vihar Complex, 2nd Floor, 6, Malviya Nagar, Madhya Pradesh, Chhattisgarh.
Opp. Airtel Office, Near New Market, Bhopal - 462 003.
Tel.: 0755 - 2769201 / 2769202
Fax: 0755 - 2769203
Email: bimalokpal.bhopal@cioins.co.in
BHUBANESHWAR - Shri Suresh Chandra Panda

62, Forest park, Bhubneshwar - 751 009.
Orissa.
Tel.: 0674 - 2596461 /2596455
Fax: 0674 - 2596429
Email: bimalokpal.bhubaneswar@cioins.co.in
CHANDIGARH - Dr. Dinesh Kumar Verma

S.C.O. No. 101, 102 & 103, 2nd Floor, Batra Building, Punjab, Haryana (excluding Gurugram, Faridabad,
Sector 17 - D, Chandigarh - 160 017. Sonepat and Bahadurgarh), Himachal Pradesh,
Tel.: 0172 - 2706196 / 2706468 UT of Jammu & Kashmir, Ladakh and Chandigarh.
Fax: 0172 - 2708274
Email: bimalokpal.chandigarh@cioins.co.in
CHENNAI - Shri M. Vasantha Krishna

Fatima Akhtar Court, 4th Floor, 453, Anna Salai,
Tamil Nadu, UT-Pondicherry Town and Karaikal
Teynampet, CHENNAI - 600 018.
(which are part of UT of Pondicherry).
Tel.: 044 - 24333668 / 24335284
Fax: 044 - 24333664
Email: bimalokpal.chennai@cioins.co.in
DELHI - Shri Sudhir Krishna

2/2 A, Universal Insurance Building, Delhi & Following Districts of
Asaf Ali Road, New Delhi - 110 002. Haryana - Gurugram, Faridabad, Sonepat & Bahadurgarh
Tel.: 011 - 23232481/23213504
Email: bimalokpal.delhi@cioins.co.in
GUWAHATI - Shri Kiriti .B. Saha

Jeevan Nivesh, 5th Floor, Nr. Panbazar over bridge, Assam, Meghalaya, Manipur, Mizoram,
S.S. Road, Guwahati - 781001(ASSAM). Arunachal Pradesh, Nagaland and Tripura.
Tel.: 0361 - 2632204 / 2602205
Email: bimalokpal.guwahati@cioins.co.in
HYDERABAD - Shri I. Suresh Babu

6-2-46, 1st floor, "Moin Court", Lane Opp. Saleem Function Palace,
Andhra Pradesh, Telangana, UT of Yanam
A. C. Guards, Lakdi-Ka-Pool, Hyderabad - 500 004.
and part of UT of Pondicherry.
Tel.: 040 - 23312122
Fax: 040 - 23376599
Email: bimalokpal.hyderabad@cioins.co.in

JAIPUR - Smt. Sandhya Baliga
Jeevan Nidhi - II Bldg., Gr. Floor, Rajasthan.
Bhawani Singh Marg, Jaipur - 302 005.
Tel.: 0141 - 2740363
Email: bimalokpal.jaipur@cioins.co.in
ERNAKULAM - Ms. Poonam Bodra

2nd Floor, Pulinat Bldg., Opp. Cochin Shipyard,
M. G. Road, Ernakulam - 682 015. Kerala, UT of Lakshadweep, Mahe-a part of UT of Pondicherry.
Tel.: 0484 - 2358759 / 2359338
Fax: 0484 - 2359336
Email: bimalokpal.ernakulam@cioins.co.in
KOLKATA - Shri P. K. Rath

Hindustan Bldg. Annexe, 4th Floor,
4, C.R. Avenue, KOLKATA - 700 072. West Bengal, Sikkim, UT of Andaman
Tel.: 033 - 22124339 / 22124340 & Nicobar Islands.
Fax : 033 - 22124341
Email: bimalokpal.kolkata@cioins.co.in
LUCKNOW -Shri Justice Anil Kumar Srivastava Districts of Uttar Pradesh : Lalitpur, Jhansi, Mahoba, Hamirpur, Banda,
Office of the Insurance Ombudsman, Chitrakoot, Allahabad, Mirzapur, Sonbhabdra, Fatehpur, Pratapgarh,
6th Floor, Jeevan Bhawan, Phase-II, Jaunpur,Varanasi, Gazipur, Jalaun, Kanpur, Lucknow, Unnao, Sitapur,
Nawal Kishore Road, Hazratganj, Lucknow - 226 001. Lakhimpur, Bahraich, Barabanki, Raebareli, Sravasti, Gonda, Faizabad,
Tel.: 0522 - 2231330 / 2231331 Amethi, Kaushambi, Balrampur, Basti, Ambedkarnagar, Sultanpur,
Fax: 0522 - 2231310 Maharajgang, Santkabirnagar, Azamgarh, Kushinagar, Gorkhpur, Deoria,
Email: bimalokpal.lucknow@cioins.co.in Mau, Ghazipur, Chandauli, Ballia, Sidharathnagar.
MUMBAI - Shri Milind A. Kharat

3rd Floor, Jeevan Seva Annexe, Goa,
S. V. Road, Santacruz (W), Mumbai - 400054. Mumbai Metropolitan Region
Tel.: 022 - 26106552 / 26106960 excluding Navi Mumbai & Thane.
Fax: 022 - 26106052
Email: bimalokpal.mumbai@cioins.co.in
NOIDA - Shri Chandra Shekhar Prasad

State of Uttaranchal and the following Districts of Uttar Pradesh:
Agra, Aligarh, Bagpat, Bareilly, Bijnor, Budaun, Bulandshehar, Etah,
Bhagwan Sahai Palace
Kanooj, Mainpuri, Mathura, Meerut, Moradabad, Muzaffarnagar,
4th Floor, Main Road, Naya Bans, Sector 15,
Oraiyya, Pilibhit, Etawah, Farrukhabad, Firozbad, Gautambodhanagar,
Distt: Gautam Buddh Nagar, U.P-201301.
Ghaziabad, Hardoi, Shahjahanpur, Hapur, Shamli, Rampur, Kashganj,
Tel.: 0120-2514252 / 2514253
Email: bimalokpal.noida@cioins.co.in Sambhal, Amroha, Hathras, Kanshiramnagar, Saharanpur.
PATNA - Shri N. K. Singh

1st Floor,Kalpana Arcade Building,
Bihar, Jharkhand.
Bazar Samiti Road, Bahadurpur, Patna - 800006.
Tel.: 0612-2680952
Email: bimalokpal.patna@cioins.co.in
PUNE - Shri Vinay Sah
Office of the Insurance Ombudsman, Maharashtra,
Jeevan Darshan Bldg., 3rd Floor, C.T.S. No.s. 195 to 198, Area of Navi Mumbai and Thane
N.C. Kelkar Road, Narayan Peth, Pune - 411030.
excluding Mumbai Metropolitan Region.
Tel.: 020-41312555
Email: bimalokpal.pune@cioins.co.in
EXECUTIVE COUNCIL OF INSURERS, 3rd Floor, Jeevan Seva Annexe, S. V. Road, Santacruz (W), Mumbai - 400 054.
Tel.: 022 - 69038801/03/04/05/06/07/08/09 | Email: inscoun@cioins.co.in
Shri B. C. Patnaik, Secretary General | Smt. Poornima Gaitonde, Secretary

ANNEXURE - II : Product Benefit Table (all limits in INR unless defined as percentage)
Individual and Family Floater - Silver Plan (Renewal only)

Base Sum Insured (in Rs) 2 Lacs 3 Lacs
Benefit
Inpatient care Covered up to Sum Insured
Room rent Shared Room or 1% of the Base Sum Insured per day
Pre-Hospitalization Medical Expenses (60 days) Covered up to Sum Insured
Post-Hospitalization Medical Expenses (90 days) Covered up to Sum Insured
Alternative Treatment Covered up to Sum Insured
Day Care Treatment Covered up to Sum Insured
Domiciliary Hospitalization Covered up to Sum Insured
Maternity Benefit (covered for up to
Covered up to Rs 20,000 Covered up to Rs 30,000
2 pregnancies or terminations) (1)
New Born Baby (covered uptill the end
Covered up to Sum Insured
of Policy Year) (1)
Vaccination of the new born baby Covered until new born baby completes one year, vaccinations as per annexure
Living Organ Donor Transplant Covered up to Sum Insured
Emergency Ambulance Network Hospital: Covered up to Sum Insured | Non-network Hospital: Covered up to Rs. 2,000 per event
Re-fill benefit Reinstate up to base Sum Insured. Applicable for same & different illness as well
Pharmacy and diagnostic services Available through our empanelled service provider
HIV / AIDS (waiting period of 4 years) covered up to Rs 50,000
Emergency assistance services covered up to Sum Insured
Mental disorder treatment (waiting
Covered up to Sum Insured (sub-limit of Rs 50,000 applicable on few conditions)
period of 3 years)
Loyalty Additions Increase of 10% of expiring Base Sum Insured in a Policy Year; maximum up to 50% of Base Sum Insured
Health Check-up (2) Once in two years, tests as per annexure
Modern Treatments Covered up to Sum Insured with sub-limit of Rs. 1Lac on few robotic surgeries
Optional Benefits
Hospital Cash (3) Rs 1,500/day
Personal Accident cover (for insured
Personal Accident cover will be equal to 5 times of base Sum Insured
aged 18 years & above on individual basis)
Critical illness cover (for insured 18 years
Critical illness cover will be equal to base Sum Insured
& above on individual basis)
e-consultation Unlimited tele / online consultations
Premium Waiver One time premium waiver if the Policyholder dies or suffers from specified illness
Claim cost sharing options
Co-payment Options of 10% and 20% co-payment
Annual aggregate Deductible 1 lac/ 2 lacs / 3 lacs
(1) subject to a continuous coverage of 24 months of that Insured Person since the inception of the first Policy which offers Maternity benefit with Us.
(2) If the Policy is Renewed with Us without a break or if the Policy continues to be in force for the 2nd Policy Year in the 2 year Policy Period (if applicable)
(3) Hospital Cash - Minimum 48 hrs of continuous hospitalization required. Maximum coverage offered for 30 days/policy year/insured person. Payment made from day
one subject to hospitalization claim being admissible.

Individual and Family Floater - Gold Plan
Base Sum Insured (in Rs) 5 lacs 7.5 lacs 10 lacs 15 lacs 20 lacs 30 lacs 50 lacs
Benefits
Room rent Covered up to Sum Insured (except for Suite or above room category)
Maternity Benefit (covered for up to 2 Covered up to Covered up to Covered up to Covered up to Covered up to Covered up to Covered up to
pregnancies or terminations) (1) Rs. 40,000 Rs. 60,000 Rs. 70,000 Rs. 75,000 Rs. 80,000 Rs. 1,00,000 Rs. 1,00,000
of Policy Year) (1) Covered up to Sum Insured
Mental disorder treatment (waiting
Covered up to Sum Insured (sub-limit of Rs 50,000 applicable on few conditions)
period of 3 years)
Annual, Annual, Annual, Annual, Annual, Annual, Annual,
Tests covered Tests covered Tests covered Tests covered Tests covered Tests covered Tests covered
Health Check-up (2) up to worth up to worth up to worth up to worth up to worth up to worth up to worth
Rs. 1,250 Rs. 1,875 Rs. 2,500 Rs. 2,500 Rs. 2,500 Rs. 2,500 Rs. 2,500
per Insured per Insured per Insured per Insured per Insured per Insured per Insured
Person Person Person Person Person Person Person
Optional Benefits
Personal Accident cover (for insured aged
Personal Accident cover will be equal to 5 times of base Sum Insured; subject to maximum of 50 lacs
18 years & above on individual basis)
Critical illness cover will be equal to base Sum Insured; subject to maximum of 10 lacs

Individual and Family Floater - Platinum Plan
Base Sum Insured (in Rs) 15 lacs 20 lacs 50 lacs 1 Cr
Benefits
Pre-Hospitalization Medical Expenses
(60 days)
Post-Hospitalization Medical Expenses
(90 days)
Maternity Benefit (covered for up to 2 Covered up to Covered up to Covered up to Covered up to
pregnancies or terminations) (1) Rs. 12,000 Rs. 160,000 Rs. 200,000 Rs. 200,000
of Policy Year) (1)
Mental disorder treatment (waiting Covered up to Sum Insured (sub-limit of Rs 50,000 applicable on few conditions)
period of 3 years)
Covered up to Covered up to Covered up to Covered up to
OPD Treatment and Diagnostic Services
Rs. 15,000 Rs. 20,000 Rs. 35,000 Rs. 50,000
Child Care Benefits (Vaccinations for
children up to 12 years including one
Covered up to Sum Insured (As per annexure)
consultation for nutrition and growth
during the visit for vaccination)
Emergency Medical Evacuation (outside
Covered up to Sum Insured ( for worldwide excluding USA & Canada)
the geographical boundaries of India)
Emergency Hospitalization (outside the
geographical boundaries of India)
Specified Illness Cover (outside the
geographical boundaries of India) (2)
Second Medical Opinion Covered, One opinion per Insured Person per Specified Illness / planned Surgery / Surgical Procedure
Annual, Tests covered Annual, Tests covered Annual, Tests covered Annual, Tests covered
Health Check-up (3)
up to worth Rs. 3,750 up to worth Rs. 5,000 up to worth Rs. 5,000 up to worth Rs. 5,000
per Insured Person per Insured Person per Insured Person per Insured Person
Optional Benefits
Enhanced Geographical Scope for USA & Canada included for 'Emergency Medical Evacuation', 'Emergency Hospitalization'
International coverage & 'Specified illness cover'

Personal Accident cover (for insured aged
Personal Accident cover will be equal to 50 lacs
18 years & above on individual basis)
Critical illness cover (for insured 18
Critical illness cover will be equal to 10 lacs
years & above on individual basis)
(1) Subject to a continuous coverage of 24 months of that Insured Person since the inception of the first Policy which offers Maternity benefit with Us.
(2) The symptoms of the Specified Illness first occur or manifest itself during the Policy Period and after completion of the 90 day from the inception of 1st Policy with Us.
Family First - Silver Plan

Base Sum Insured: 1Lacs, 2Lacs, 3Lacs, 4Lacs & 5Lacs per Insured Person
Floater Sum Insured - (available on a floating basis over Base Sum Insured):
3Lacs, 4Lacs, 5Lacs, 10Lacs &15Lacs.
Benefits
Room rent Rs 3,000 per day or Shared Room
Maternity Benefit (covered for up to 2 pregnancies
Covered up to Rs 35,000 per Policy Year
or terminations) (1)
New Born Baby (covered uptill the end of Policy Year) (1) Covered up to Sum Insured
Network Hospital: Covered up to Sum Insured
Emergency Ambulance
Non-network Hospital: Covered up to Rs. 2,000 per event
Mental disorder treatment (waiting period of 3 years) Covered up to Sum Insured (sub-limit of Rs 50,000 applicable on few conditions)
Increase of 10% of expiring Base Sum Insured in a Policy Year; maximum up to 50%
Loyalty Additions
of Base Sum Insured
Health Check-up (2) Once in two years, tests as per annexure
Optional Benefits

Personal Accident cover (for insured aged 18 years &
Personal Accident cover will be equal to 5 times of base Sum Insured
above on individual basis)
Critical illness cover will be equal to base Sum Insured
Family First - Gold Plan

Base Sum Insured: 1Lacs, 2Lacs, 3Lacs, 4Lacs, 5Lacs, 10Lacs & 15Lacs per Insured Person
3Lacs, 4Lacs, 5Lacs, 10Lacs, 15Lacs, 20Lacs, 30Lacs & 50Lacs
Benefits
Maternity Benefit (covered for up to 2 pregnancies or
Covered up to Rs 50,000 per Policy Year
terminations) (1)
Emergency Ambulance
Increase of 10% of expiring Base Sum Insured in a Policy Year; maximum up to
Loyalty Additions
100% of Base Sum Insured
Health Check-up (2) Annual, Tests covered up to worth Rs 2,500 per Insured Person
Optional Benefits
Personal Accident cover (for insured aged 18 years Personal Accident cover will be equal to 5 times of base Sum Insured;
& above on individual basis) subject to maximum of 50 lacs
Critical illness cover (for insured 18 years & above
on individual basis)

Family First - Platinum Plan

Base Sum Insured: 5Lacs, 10Lacs & 15Lacs per Insured Person
15Lacs, 20Lacs, 30Lacs & 50Lacs
Benefits
Room rent Covered up to Sum Insured
Maternity Benefit (covered for up to 2 pregnancies or
Covered up to Rs 100,000
terminations) (1)
Emergency Ambulance
OPD Treatment and Diagnostic Services Covered up to Rs 35,000
Child Care Benefits (Vaccinations for children up to
12 years including one consultation for nutrition and Covered up to Sum Insured (As per annexure)
growth during the visit for vaccination)
Emergency Medical Evacuation (outside the geographical
boundaries of India)
Emergency Hospitalization (outside the geographical
boundaries of India)
Specified Illness Cover (outside the geographical
boundaries of India) (2)
Covered, One opinion per Insured Person per Specified Illness / planned Surgery
Second Medical Opinion
/ Surgical Procedure
Increase of 10% of expiring Base Sum Insured in a Policy Year; maximum up to
Loyalty Additions
100% of Base Sum Insured
Health Check-up (3) Annual, tests covered up to worth Rs 5000 per Insured Person

Optional Benefits
USA & Canada included for 'Emergency Medical Evacuation',
Enhanced Geographical Scope for International coverage
'Emergency Hospitalization' & 'Specified illness cover'
Personal Accident cover (for insured aged 18 years Personal Accident cover will be equal to 5 times of base Sum Insured;
& above on individual basis) subject to maximum of 50 lacs
Critical illness cover (for insured 18 years &
above on individual basis)
(2) The symptoms of the Specified Illness first occur or manifest itself during the Policy Period and after completion of the 90 day from the inception of 1st Policy with Us.

Annexure - III
Day Care Treatments
Sr. No. Procedure Name Sr. No. Procedure Name Sr. No. Procedure Name
I - Cardiology Related: 29 Tonsillectomy with adenoidectomy Incision & drainage of retro
64 pharyngeal abscess
1 Coronary Angiography Excision and destruction of a
30 lingual tonsil
II - Critical Care Related: 65 UVULO palato pharyngo plasty
2 Insert Non- Tunnel CV cath 31 Revision of a tympanoplasty Adenoidectomy with grommet
66 insertion
Insert PICC cath (Peripherally Other microsurgical
3 Inserted Central Catheter) 32 Adenoidectomy without
operations on the middle ear 67 grommet insertion
Replace PICC cath (Peripherally
4 Incision of the mastoid process 68 Vocal cord lateralisation procedure
Inserted Central Catheter) 33 and middle ear
5 Insertion Catheter, Intra Anterior Incision & drainage of para
69 pharyngeal abscess
34 Mastoidectomy
6 Insertion of Portacath
35 Reconstruction of the middle ear 70 Tracheoplasty
III - Dental Related:
Other excisions of the middle V - Gastroenterology Related:
7 Splinting of avulsed teeth 36 and inner ear Cholecystectomy and
8 Suturing lacerated lip Choledocho - jejunostomy/
Incision (opening) and destruction 71 Duodenostomy /Gastrostomy/
9 Suturing oral mucosa 37 (elimination) of the inner ear Exploration common bile duct
Oral biopsy in case of abnormal
10 tissue presentation Other operations on the middle Esophagoscopy, Gastroscopy,
38 and inner ear Duodenoscopy with
11 FNAC 72 Polypectomy / Removal of
Excision and destruction of foreign body / Diathermy of
12 Smear from oral cavity 39 bleeding lesions
diseased tissue of the nose
IV - ENT Related: Pancreatic pseudocyst EUS &
40 Other operations on the nose 73 drainage
Myringotomy with grommet
13 insertion 41 Nasal sinus aspiration
RF ablation for barrett's
42 Foreign body removal from nose 74 oesophagus
Tympanoplasty (closure of an
eardrum perforation/ Other operations on the tonsils 75 ERCP and papillotomy
14 reconstruction of the auditory 43 and adenoids Esophagoscope and sclerosant
ossicles) 76 injection
44 Adenoidectomy
15 Removal of a tympanic drain 77 EUS + submucosal resection
45 Labyrinthectomy for severe vertigo
16 Keratosis removal under GA 78 Construction of gastrostomy tube
46 Stapedectomy under GA
Operations on the turbinates 79 EUS + aspiration pancreatic CYST
17 (nasal concha) 47 Stapedectomy under LA
48 Tympanoplasty (type - IV) Small bowel endoscopy
Tympanoplasty (closure of an
80 (therapeutic)
eardrum perforation / Endolymphatic sac surgery for
18 reconstruction of the auditory 49 meniere's disease 81 Colonoscopy ,lesion removal
ossicles) 82 ERCP
50 Turbinectomy
19 Removal of keratosis obturans 83 Colonscopy stenting of stricture
51 Endoscopic stapedectomy
Stapedotomy to treat various Percutaneous endoscopic
20 Incision and drainage of 84
lesions in middle ear 52 gastrostomy
perichondritis
21 Revision of a stapedectomy EUS and pancreatic pseudo
53 Septoplasty 85
Other operations on the CYST drainage
22 auditory ossicles 54 Vestibular nerve section
86 ERCP and choledochoscopy
55 Thyroplasty type - I
Myringoplasty (postaura/ Proctosigmoidoscopy volvulus
endaural approach as well as 56 Pseudocyst of the pinna - excision 87
23 detorsion
simple type -I tympanoplasty) Incision and drainage -
57 haematoma auricle 88 ERCP and sphincterotomy
24 Fenestration of the inner ear
89 Esophageal stent placement
Revision of a fenestration of 58 Tympanoplasty (type - II)
25 the inner ear 90 ERCP + placement of biliary stents
59 Reduction of fracture of nasal bone
26 Palatoplasty 60 Thyroplasty type - II 91 Sigmoidoscopy W / stent
Transoral incision and drainage 92 EUS + coeliac node biopsy
27 61 Tracheostomy
of a pharyngeal abscess UGI scopy and injection of
62 Excision of angioma septum
Tonsillectomy without 93 adrenaline, sclerosants bleeding
28 adenoidectomy 63 Turbinoplasty ulcers

VI - General Surgery Related: Ugi scopy and polypectomy Tips procedure for portal
133 oesophagus 166 hypertension
94 Incision of a pilonidal sinus/abscess
95 Fissure in ANO sphincterotomy 134 Breast abscess I & D 167 Esophageal growth stent
Surgical treatment of a varicocele 135 Feeding gastrostomy Pair procedure of hydatid CYST
96 and a hydrocele of the spermatic 168 liver
cord Oesophagoscopy and biopsy
136 of growth oesophagus 169 Tru cut liver biopsy
97 Orchidopexy
137 ERCP - bile duct stone removal
Abdominal exploration in Photodynamic therapy or
98 cryptorchidism 138 Ileostomy closure 170 esophageal tumour and lung
Colonoscopy tumour
139
Surgical treatment of
99 anal fistulas 140 Polypectomy colon 171 Excision of cervical RIB
Splenic abscesses laparoscopic Laparoscopic reduction of
Division of the anal sphincter 141 drainage 172 intussusception
100 (sphincterotomy)
UGI scopy and polypectomy 173 Microdochectomy breast
101 Epididymectomy 142 stomach 174 Surgery for fracture penis
102 Incision of the breast abscess
Rigid oesophagoscopy for FB 175 Sentinel node biopsy
103 Operations on the nipple 143 removal 176 Parastomal hernia
104 Excision of single breast lump
144 Feeding jejunostomy 177 Revision colostomy
Incision and excision of tissue
105 in the perianal region 145 Colostomy 178 Prolapsed colostomy - correction
146 Ileostomy 179 Testicular biopsy
106 Surgical treatment of hemorrhoids
147 Colostomy closure Laparoscopic cardiomyotomy
107 Other operations on the ANUS 180 (hellers)
Ultrasound guided aspirations Submandibular salivary duct
108 148 stone removal
Sclerotherapy, Sentinel node biopsy malignant
109 181 melanoma
Therapeutic laparoscopy with laser Pneumatic reduction of
110 149 intussusception
Laparoscopic pyloromyotomy
111 Infected keloid excision 182 (ramstedt)
Axillary lymphadenectomy Varicose veins legs - injection
112 150 sclerotherapy 183 Excision of fistula-in-ANO
113 Wound debridement and cover
Rigid oesophagoscopy for 184 Excision juvenile polyps rectum
114 Abscess-decompression 151 plummer vinson syndrome 185 Vaginoplasty
115 Cervical lymphadenectomy
Pancreatic pseudocysts Dilatation of accidental caustic
116 Infected sebaceous CYST 152 endoscopic drainage 186 stricture oesophageal
117 Inguinal lymphadenectomy
153 Zadek's nail bed excision 187 Presacral teratomas excision
118 Incision and drainage of abscess
154 Subcutaneous mastectomy 188 Removal of vesical stone
119 Suturing of lacerations
155 Excision of ranula under GA 189 Excision sigmoid polyp
120 SCALP suturing
Rigid oesophagoscopy for 190 Sternomastoid tenotomy
121 Infected lipoma excision 156 dilation of benign strictures
Infantile hypertrophic pyloric
122 Maximal anal dilatation 191 stenosis pyloromyotomy
123 Eversion of SAC unilateral/
Piles 157 bilateral
A) injection sclerotherapy Excision of soft tissue
124 192 rhabdomyosarcoma
158 Lord's plication
125 B) piles banding
159 Jaboulay's procedure 193 Mediastinal lymph node biopsy
126 Liver abscess- catheter drainage
160 Scrotoplasty High orchidectomy for testis
127 Fissure in ANO- fissurectomy 194
161 Circumcision for trauma tumours
128 Fibroadenoma breast excision
162 Meatoplasty 195 Excision of cervical teratoma
Oesophageal varices
129 sclerotherapy Intersphincteric abscess 196 Rectal-myomectomy
163 incision and drainage
Rectal prolapse (delorme's
ERCP - pancreatic duct stone 197 procedure)
130 PSOAS abscess incision and
removal 164 drainage
198 Detorsion of torsion testis
131 Perianal abscess I&D Thyroid abscess incision and
165 199 EUA + biopsy multiple fistula
132 Perianal hematoma evacuation drainage in ANO

Cystic hygroma - injection 233 Laparoscopic cystectomy 274 CCRT - concurrent chemo + RT
200 treatment
Hymenectomy( imperforate 275 2D radiotherapy
234 hymen)
VII - Gynecology Related: 276 3D conformal radiotherapy
Operations on bartholin's 235 Endometrial ablation 277 IGRT - image guided radiotherapy
201 glands (CYST) 236 Vaginal wall cyst excision 278 IMRT- step & shoot
202 Incision of the ovary 237 Vulval cyst excision 279 Infusional bisphosphonates
203 Insufflations of the fallopian tubes Laparoscopic paratubal CYST 280 IMRT - DMLC
238 excision
Other operations on the 281 Rotational ARC therapy
204 fallopian tube 239 Repair of vagina (vaginal atresia) 282 Tele gamma therapy
205 Dilatation of the cervical canal 240 Hysteroscopy, removal of myoma 283 FSRT-fractionated SRT
206 Conisation of the uterine cervix 241 TURBT VMAT-volumetric modulated
284 arc therapy
Therapeutic curettage with Ureterocoele repair -congenital
207 colposcopy/biopsy/diathermy/ 242 internal
Cryosurgery/ SBRT-stereotactic body
285 radiotherapy
243 Vaginal mesh for POP
Laser therapy of cervix for
208 various lesions of uterus 244 Laparoscopic myomectomy 286 Helical tomotherapy
245 Surgery for SUI 287 SRS-stereotactic radiosurgery
209 Other operations on the
uterine cervix 246 Repair recto- vagina fistula 288 X-knife SRS
Pelvic floor repair( excluding 289 Gammaknife SRS
Local excision and destruction 247 fistula repair) 290 TBI- total body radiotherapy
210 of diseased tissue of the vagina
and the pouch of douglas 248 URS + ll 291 Intraluminal brachytherapy
211 Incision of vagina 249 Laparoscopic oophorectomy 292 Electron therapy
212 Incision of vulva 250 Normal vaginal delivery & variants 293 TSET-total electron skin therapy
213 Culdotomy VIII - Neurology Related: Extracorporeal irradiation of
294 blood products
Salpingo-oophorectomy via 251 Facial nerve physiotherapy
214 laparotomy
252 Nerve biopsy 295 Telecobalt therapy
215 Endoscopic polypectomy 253 Muscle biopsy 296 Telecesium therapy
216 Hysteroscopic removal of myoma 254 Epidural steroid injection 297 External mould brachytherapy
217 D&C 255 Glycerol rhizotomy 298 Interstitial brachytherapy
218 Hysteroscopic resection of septum 256 Spinal cord stimulation 299 Intracavity brachytherapy
219 Thermal cauterisation of cervix 257 Motor cortex stimulation 300 3D brachytherapy
220 Mirena insertion 258 Stereotactic radiosurgery 301 Implant brachytherapy
221 Hysteroscopic adhesiolysis 259 Percutaneous cordotomy 302 Intravesical brachytherapy
LEEP (loop electrosurgical 260 Intrathecal baclofen therapy 303 Adjuvant radiotherapy
222 excision procedure)
261 Entrapment neuropathy release Afterloading catheter
304
223 Cryocauterisation of cervix 262 Diagnostic cerebral angiography brachytherapy
224 Polypectomy endometrium 263 VP shunt Conditioning radiothearpy for
305 BMT
Hysteroscopic resection of 264 Ventriculoatrial shunt
225 fibroid IX - Oncology Related: Extracorporeal irradiation to
306 the homologous bone grafts
LLETZ (large loop excision of 265 Radiotherapy for cancer
226 transformation zone)
266 Cancer chemotherapy 307 Radical chemotherapy
227 Conization 267 IV push chemotherapy 308 Neoadjuvant radiotherapy
228 Polypectomy cervix 268 HBI-hemibody radiotherapy 309 LDR brachytherapy
Hysteroscopic resection of 269 Infusional targeted therapy 310 Palliative radiotherapy
229 endometrial polyp
270 SRT-stereotactic arc therapy 311 Radical radiotherapy
230 Vulval wart excision 271 SC administration of growth factors 312 Palliative chemotherapy
Laparoscopic paraovarian CYST Continuous infusional 313 Template brachytherapy
231 excision 272 chemotherapy 314 Neoadjuvant chemotherapy
232 Uterine artery embolization 273 Infusional chemotherapy 315 Adjuvant chemotherapy

316 Induction chemotherapy XII - Operations on the Tongue: Dacryocystorhinostomy for
365 various lesions of lacrimal gland
317 Consolidation chemotherapy Incision, excision and destruction
339 of diseased tissue of the tongue
318 Maintenance chemotherapy Laser photocoagulation to
366 treat ratinal tear
319 HDR brachytherapy 340 Partial glossectomy
X - Operations on the salivary 341 Glossectomy 367 Biopsy of tear gland
glands & salivary ducts: 342 Reconstruction of the tongue 368 Treatment of retinal lesion
Incision and lancing of a salivary 343 Small reconstruction of the tongue XIV - Orthopedics Related:
320 gland and a salivary duct
XIII - Ophthalmology related: 369 Surgery for meniscus tear
Excision of diseased tissue of a 344 Surgery for cataract 370 Incision on bone, septic & aseptic
321 salivary gland and a salivary duct 345 Incision of tear glands
Closed reduction on fracture,
322 Resection of a salivary gland 346 Other operations on the tear ducts 371 luxation or epiphyseolysis with
osteosynthesis
Reconstruction of a salivary 347 Incision of diseased eyelids
323 gland and a salivary duct
Excision and destruction of Suture and other operations on
348 diseased tissue of the eyelid 372 tendons and tendon sheath
Other operations on the salivary
324 glands and salivary ducts
Operations on the canthus and 373 Reduction of dislocation under GA
349 epicanthus
XI - Operations on the skin & 374 Arthroscopic knee aspiration
subcutaneous tissues: 375 Surgery for ligament tear
Corrective surgery for
350 entropion and ectropion
Other incisions of the skin and Surgery for hemoarthrosis/
325 subcutaneous tissues 376 pyoarthrosis
Corrective surgery for
351 blepharoptosis
Surgical wound toilet (wound 377 Removal of fracture pins/nails
debridement) and removal of
326 diseased tissue of the skin and Removal of a foreign body 378 Removal of metal wire
352 from the conjunctiva
subcutaneous tissues Closed reduction on fracture,
379 luxation
Local excision of diseased tissue Removal of a foreign body
353 from the cornea
327 of the skin and subcutaneous 380 Reduction of dislocation under GA
tissues
354 Incision of the cornea Epiphyseolysis with
381 osteosynthesis
Other excisions of the skin and 355 Operations for pterygium
328 subcutaneous tissues 356 Other operations on the cornea Excision of various lesions in
382 COCCYX
Simple restoration of surface Removal of a foreign body
357 from the lens of the eye
329 continuity of the skin and Arthroscopic repair of ACL tear
subcutaneous tissues 383 KNEE
Removal of a foreign body
Free skin transplantation, 358 from the posterior chamber 384 Closed reduction of minor fractures
330 donor site of the eye
Arthroscopic repair of PCL tear
385 KNEE
Free skin transplantation, Removal of a foreign body
331 recipient site 359 from the orbit and eyeball 386 Tendon shortening
332 Revision of skin plasty Arthroscopic meniscectomy -
Correction of eyelid PTOSIS by 387
360 levator palpebrae superioris KNEE
Other restoration and resection (bilateral)
333 reconstruction of the skin and 388 Treatment of clavicle dislocation
subcutaneous tissues Haemarthrosis KNEE- lavage
Correction of eyelid PTOSIS by 389
361 fascia lata graft (bilateral)
334 Chemosurgery to the skin 390 Abscess KNEE joint drainage
Diathermy/cryotherapy to treat 391 Carpal tunnel release
Destruction of diseased tissue 362
335 in the skin and subcutaneous retinal tear
Closed reduction of minor
tissues 392 dislocation
Anterior chamber paracentesis
Reconstruction of /cyclodiathermy /cyclocryothera 393 Repair of KNEE cap tendon
336 deformity /defect in nail bed 363 py/goniotomy / trabeculotomy
and filtering and allied ORIF with K wire fixation- small
operations to treat glaucoma 394 bones
337 Excision of bursirtis
338 Tennis elbow release 364 Enucleation of eye without implant 395 Release of midfoot joint

437 Repair of ruptured tendon Thoracoscopy assisted
396 ORIF
bones
with plating- small long
468 empyaema drainage
438 Decompress forearm space
397 Implant removal minor Revision of neck muscle XVIII - Urology related:
439 (torticollis release )
398 K wire removal 469 Haemodialysis
399 POP application 440 Lengthening of thigh tendons Lithotripsy / Nephrolithotomy
470 for renal calculus
441 Treatment fracture of radius & ulna
400 Closed
fixation
reduction and external
442 Repair of knee joint 471 Excision of renal CYST
401 Arthrotomy hip joint XV - Other operations on the Drainage of pyonephrosis /
mouth & face: 472 perinephric abscess
402 Syme's amputation
403 Arthroplasty 473 Incision of the prostate
External incision and drainage
404 Partial removal of RIB 443 in the region of the mouth, jaw Transurethral excision and
and face 474 destruction of prostate tissue
Treatment of sesamoid bone
405 fracture Incision of the hard and soft Transurethral and percutaneous
444 palate 475 destruction of prostate tissue
406 Shoulder arthroscopy / surgery
407 Elbow arthroscopy Excision and destruction of Open surgical excision and
445 diseased hard and soft palate 476 destruction of prostate tissue
408 Amputation of metacarpal bone
409 Release of thumb contracture Incision, excision and 477 Radical prostatovesiculectomy
446 destruction in the mouth
410 Incision of foot fascia Other excision and destruction
478 of prostate tissue
Calcaneum SPUR hydrocort 447 Other operations in the mouth
411 injection XVI - Plastic surgery related: 479 Operations on the seminal vesicles
Ganglion wrist hyalase 448 Construction skin pedicle flap Incision and excision of
412 injection 480 periprostatic tissue
449 Gluteal pressure ulcer-excision
413 Partial removal of metatarsal 450 Muscle-skin graft, leg 481 Other operations on the prostate
414 Repair / graft of foot tendon 451 Removal of bone for graft Incision of the scrotum and
482 tunica vaginalis testis
415 Revision/removal of knee cap 452 Muscle-skin graft duct fistula
416 Amputation follow-up surgery 453 Removal cartilage graft Operation on a testicular
483 hydrocele
417 Exploration of ankle joint 454 Myocutaneous flap
418 Remove/graft leg bone lesion 455 Fibro myocutaneous flap Excision and destruction of
484 diseased scrotal tissue
419 Repair/graft achilles tendon Breast reconstruction surgery
456 after mastectomy
420 Remove of tissue expander Other operations on the scrotum
485 and tunica vaginalis testis
421 Biopsy elbow joint lining 457 Sling operation for facial palsy
422 Removal of wrist prosthesis 458 Split skin grafting under RA 486 Incision of the testes
423 Biopsy finger joint lining 459 Wolfe skin graft Excision and destruction of
487 diseased tissue of the testes
424 Tendon lengthening Plastic surgery to the floor of
460 the mouth under GA
425 Treatment of shoulder dislocation 488 Unilateral orchidectomy
426 Lengthening of hand tendon XVII - Thoracic surgery related: 489 Bilateral orchidectomy
427 Removal of elbow bursa 461 Thoracoscopy and lung biopsy Surgical repositioning of an
490 abdominal testis
428 Fixation of knee joint Excision of cervical sympathetic
462 chain thoracoscopic
429 Treatment of foot dislocation 491 Reconstruction of the testis
430 Surgery of bunion Laser ablation of barrett's Implantation, exchange and
463 oesophagus 492 removal of a testicular prosthesis
431 Intra articular steroid injection
432 Tendon transfer procedure 464 Pleurodesis 493 Other operations on the testis
433 Removal of knee cap bursa Thoracoscopy and pleural Excision in the area of the
465 biopsy 494 epididymis
434 Treatment of fracture of ULNA
435 Treatment of scapula fracture 466 EBUS + biopsy 495 Operations on the foreskin
Removal of tumor of arm/ Thoracoscopy ligation thoracic Local excision and destruction
436 elbow under RA/GA 467 duct 496 of diseased tissue of the penis

497 Amputation of the penis 512 Suprapubic cystostomy 528 Frenular tear repair
498 Other operations on the penis 513 Percutaneous nephrostomy 529 Meatotomy for meatal stenosis
Cystoscopical removal of 514 Cystoscopy and "sling" procedure
499 stones 530 Surgery
scrotum
for fournier's gangrene
515 Tuna- prostate
500 Catheterisation of bladder 516 Excision of urethral diverticulum 531 Surgery filarial scrotum
501 Lithotripsy 517 Removal of urethral stone Surgery for watering CAN
532 perineum
Biopsy oftemporal artery for 518 Excision of urethral prolapse
502 various lesions 519 Mega-ureter reconstruction 533 Repair of penile torsion
503 External arterio-venous shunt 520 Kidney renoscopy and biopsy 534 Drainage of prostate abscess
504 AV fistula - wrist 521 Ureter endoscopy and treatment 535 Orchiectomy
505 URSL with stenting 522 Vesico ureteric reflux correction 536 Cystoscopy and removal of FB
506 URSL with lithotripsy Surgery for pelvi ureteric
523 junction obstruction
507 Cystoscopic litholapaxy
508 ESWL Anderson hynes operation
524 (open pyelopalsty )
509 Bladder neck incision
510 Cystoscopy & biopsy 525 Kidney endoscopy and biopsy
Cystoscopy and removal of 526 Paraphimosis surgery
511 polyp 527 Injury prepuce- circumcision

ANNEXURE - IV
List of tests covered under health check-up for Heartbeat Silver
Age Band <= 35 years Age Band 36 - 50 years Age Band > 50 years
Complete Blood Count Complete Blood Count Complete Blood Count
Urine Routine Analysis Urine Routine Analysis Urine Routine Analysis
Random Blood Sugar HBA1C ESR
Serum Cholesterol Serum Cholesterol HBA1C
Serum LDL Serum LDL Serum Cholesterol
Serum Creatinine Serum HDL
Urea Serum LDL
Kidney Function Test
Urea
ANNEXURE - V
ICD codes for the specified disorders / conditions
Disorder / Condition ICD Codes

F33.0, F33.1, F33.2, F33.4, F33.5, F33.6, F33.7, F33.8, F33.9, O90.6, F34.1, F32.81,
F32.0, F32.1, F32.2, F32.4, F32.5, F32.6, F32.7, 32.8, F32.9, F33.9, F30.0, F30.1,
Severe Depression
F30.2, F30.4, F30.5, F30.6, F30.7, F30.8, F30.9, F32.3, F33.3, F43.21, F32.8,
F33.40, F32.9
F20.0, F20.1, F20.2, F20.3, F20.5, F21, F22, F23, F24, F20.8, F25.0, F25.1,
Schizophrenia
F25.8, F25.9
Bipolar Disorder F31.0, F31.1, F31.2, F31.4, F31.5, F31.6, F31.7, F31.8, F31.9
Post traumatic stress disorder F43.0, F43.1, F43.2, F43.8, F43.9
Eating disorder F50.0, F50.2, F50.8, F98.3, F98.21, F50.8
Generalized anxiety disorder F40.1, F41.0, F40.2, F40.8, F40.9, F41.1, F41.3, F41.8
Obsessive compulsive disorders F42
Panic disorders F41.1, F40.1, F60.7, F93.0, F94.0
Personality disorders F60.0, F60.1, F60.2, F60.3, F60.4, F60.8, F60.6, F60.7, F60.5
Conversion disorders F44.4, F44.5, F44.6, F44.7
Dissociative disorders F44.5, F44.8, F48.1, F44.1, F44.2

Annexure - VI
The expenses that are not covered or subsumed into room charges / procedure charges / costs of treatment
List I - Expenses not covered
Sl. No. Item Sl. No. Item Sl. No. Item

1. BABY FOOD 24. ATTENDANT CHARGES 47. LUMBO SACRAL BELT
2. BABY UTILITIES CHARGES 25. EXTRA DIET OF PATIENT (OTHER THAN THAT 48. NIMBUS BED OR WATER OR AIR BED CHARGES
WHICH FORMS PART OF BED CHARGE)
3. BEAUTY SERVICES 26. BIRTH CERTIFICATE 49. AMBULANCE COLLAR
4. BELTS/ BRACES 27. CERTIFICATE CHARGES 50. AMBULANCE EQUIPMENT
5. BUDS 28. COURIER CHARGES 51. ABDOMINAL BINDER
6. COLD PACK/HOT PACK 29. CONVEYANCE CHARGES 52. PRIVATE NURSES CHARGES- SPECIAL
NURSING CHARGES
7. CARRY BAGS 30. MEDICAL CERTIFICATE 53. SUGAR FREE Tablets
CREAMS POWDERS LOTIONS
8. EMAIL / INTERNET CHARGES 31. MEDICAL RECORDS 54. (Toiletries are not payable, only prescribed
medical pharmaceuticals payable)
FOOD CHARGES (OTHER THAN PATIENT's
9. 32. PHOTOCOPIES CHARGES 55. ECG ELECTRODES
DIET PROVIDED BY HOSPITAL)
10. LEGGINGS 33. MORTUARY CHARGES 56. GLOVES
11. LAUNDRY CHARGES 34. WALKING AIDS CHARGES 57. NEBULISATION KIT
OXYGEN CYLINDER ANY KIT WITH NO DETAILS MENTIONED
12. MINERAL WATER 35. 58.
(FOR USAGE OUTSIDE THE HOSPITAL) [DELIVERY KIT, ORTHOKIT, RECOVERY KIT, ETC]
13. SANITARY PAD 36. SPACER 59. KIDNEY TRAY
14. TELEPHONE CHARGES 37. SPIROMETRE 60. MASK
15. GUEST SERVICES 38. NEBULIZER KIT 61. OUNCE GLASS
16. CREPE BANDAGE 39. STEAM INHALER 62. OXYGEN MASK
17. DIAPER OF ANY TYPE 40. ARMSLING 63. PELVIC TRACTION BELT
18. EYELET COLLAR 41. THERMOMETER 64. PAN CAN
19. SLINGS 42. CERVICAL COLLAR 65. TROLLY COVER
20. BLOOD GROUPING AND 43. SPLINT 66. UROMETER, URINE JUG
CROSS MATCHING OF DONORS SAMPLES
21. SERVICE CHARGES WHERE NURSING 44. DIABETIC FOOT WEAR 67. AMBULANCE
CHARGE ALSO CHARGED
22. TELEVISION CHARGES 45. KNEE BRACES (LONG/ SHORT/ HINGED) 68. VASOFIX SAFETY
23. SURCHARGES 46. KNEE IMMOBILIZER/SHOULDER IMMOBILIZER
List II - Items that are to be subsumed into Room Charges

1. BABY CHARGES (UNLESS SPECIFIED/INDICATED) 14. BED PAN 27. ADMISSION KIT
2. HAND WASH 15. FACE MASK 28. DIABETIC CHART CHARGES
DOCUMENTATION
3. SHOE COVER 16. FLEXI MASK 29.
CHARGES /ADMINISTRATIVE EXPENSES
4. CAPS 17. HAND HOLDER 30. DISCHARGE PROCEDURE CHARGES
5. CRADLE CHARGES 18. SPUTUM CUP 31. DAILY CHART CHARGES
6. COMB 19. DISINFECTANT LOTIONS 32. ENTRANCE PASS / VISITORS PASS CHARGES
7. EAU-DE-COLOGNE / ROOM FRESHNERS 20. LUXURY TAX 33. EXPENSES RELATED TO PRESCRIPTION
ON DISCHARGE
8. FOOT COVER 21. HVAC 34. FILE OPENING CHARGES
INCIDENTAL EXPENSES / MISC. CHARGES
9. GOWN 22. HOUSE KEEPING CHARGES 35.
(NOT EXPLAINED)
10. SLIPPERS 23. AIR CONDITIONER CHARGES 36. PATIENT IDENTIFICATION BAND / NAME TAG
11. TISSUE PAPER 24. IM IV INJECTION CHARGES 37. PULSEOXYMETER CHARGES
12. TOOTH PASTE 25. CLEAN SHEET
13. TOOTH BRUSH 26. BLANKET/WARMER BLANKET

List III - Items that are to be subsumed into Procedure Charges
1. HAIR REMOVAL CREAM 9. WARD AND THEATRE BOOKING CHARGES 17. BOYLES APPARATUS CHARGES
DISPOSABLES RAZORS CHARGES
2. 10. ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS 18. COTTON
(for site preparations)
3. EYE PAD 11. MICROSCOPE COVER 19. COTTON BANDAGE
4. EYE SHEILD 12. SURGICAL BLADES, HARMONICSCALPEL,SHAVER 20. SURGICAL TAPE
5. CAMERA COVER 13. SURGICAL DRILL 21. APRON
6. DVD, CD CHARGES 14. EYE KIT 22. TORNIQUET
7. GAUSE SOFT 15. EYE DRAPE 23. ORTHOBUNDLE, GYNAEC BUNDLE
8. GAUZE 16. X-RAY FILM
List IV - Items that are to be subsumed into costs of treatment

1. ADMISSION/REGISTRATION CHARGES 7. INFUSION PUMP- COST 13. MOUTH PAINT
2. HOSPITALISATION FOR EVALUATION/ 8. HYDROGEN PEROXIDE\SPIRIT\ 14. VACCINATION CHARGES

DIAGNOSTIC PURPOSE DISINFECTANTS ETC
3. URINE CONTAINER 9. NUTRITION PLANNING CHARGES - 15. ALCOHOL SWABES

DIETICIAN CHARGES- DIET CHARGES
4. BLOOD RESERVATION CHARGES AND 10. HIV KIT 16. SCRUB SOLUTION/STERILLIUM
ANTE NATAL BOOKING CHARGES
5. BIPAP MACHINE 11. ANTISEPTIC MOUTHWASH 17. GLUCOMETER & STRIPS
6. CPAP/ CAPD EQUIPMENTS 12. LOZENGES 18. URINE BAG

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Heartbeat

2. Deﬁnitions & Interpretation

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

3. Beneﬁts available under the Policy

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Time interval Vaccination to be done (Age) Frequency

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Disorder / Condition Description

Severe Depression Severe depression is characterized by a persistent feeling of sadness or a lack of

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Time interval Vaccination to be done (Age) Frequency

3.20 Speciﬁed Illness Cover (outside the geographical boundaries of India)

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Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

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Permanent Partial Disability Grid

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4.2 Critical Illness Cover

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

6. General Terms and Clauses

6.1 Standard General Terms and Clauses

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Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021

Product Name: Heartbeat | Product UIN: MAXHLIP21175V062021