Health Insurance

Waiting Period:

1. The Company 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 as set out below. All these Waiting Periods shall be applicable individually for each Insured person and Claims shall be assessed accordingly.

• a) 30 days Waiting Period Exclusion:

A waiting period of 30 days from the commencement date of the first Policy will apply to all disease / illness contracted other than accidental bodily injury requiring hospitalization This exclusion shall not apply for subsequent policy years and/or if the Insured person/s has any health insurance indemnity policy in India and accepted by the Company under Portability cover, provided that there is no break in the insurance cover for that Insured Person.

• b) Two Year Waiting Period Exclusion:

A waiting period of 24 months shall apply to the treatment, of the following, whether medical or surgical for all Medical Expenses along with their complications on treatment towards: Cataract, Benign Prostatic Hypertrophy, Hernia, Hydrocele, Fistula in anus, piles, Sinusitis and related disorders, Fissure, Gastric and Duodenal ulcers, gout and rheumatism; internal tumors, cysts, nodules, polyps including breast lumps (each of any kind unless malignant); Hysterectomy / myomectomy for menorrhagia or fibromyoma or prolapse of uterus, polycystic ovarian diseases; skin tumors unless malignant, benign ear, nose and throat (ENT) disorders and surgeries (including but not limited to adenoidectomy, mastoidectomy, tonsillectomy and tympanoplasty); dilatation and curettage (D&C); & Congenital Internal Diseases. Calculus diseases of Gallbladder and Urogenital system, Hypertension and Diabetes and related complications, Joint Replacement due to Degenerative condition, Surgery for prolapsed inter vertebral disc unless arising from accident, Age related Osteoarthritis and Osteoporosis, Spondylosis / Spondylitis, Surgery of varicose veins and varicose ulcers. This exclusion shall not apply after two policy year subsequent renewals with Us and/or if the Insured person/s has any health insurance indemnity policy in India at least for a period of two years and accepted by the Company under Portability cover, provided that there is no break in the insurance cover for that Insured Person. If these diseases are pre-existing at the time of proposal or subsequently found to be pre-existing, the pre-existing waiting periods as mentioned in the Schedule to this Policy shall be applicable.

• c) Pre- Existing Condition Exclusion:

Pre-existing Conditions and any complications arising from the same will not be covered until 36 months of continuous coverage have elapsed, since inception of your first Policy with Us. This exclusion shall not apply after three policy year subsequent renewals with Us and/or if the Insured person/s has any health insurance indemnity policy in India at least for a period of three years and accepted by the Company under Portability cover, provided that there is no break in the insurance cover for that Insured Person.

2. We will not make any payment for any claim in respect of any Insured Person directly or indirectly for, caused by, arising from or in any way attributable to any of the following unless expressly stated to the contrary elsewhere in this Policy:

• I. Any condition directly or indirectly caused by or associated with any sexually transmitted disease, including Genital Warts, Syphilis, Gonorrhoea, Genital Herpes, Chlamydia, Pubic Lice & Trichomoniasis, Acquired Immuno Deficiency Syndrome (AIDS) whether or not arising out of HIV, Human T Cell Lymphotropic Virus Type III (HTLV-III or IITLBIII) or Lymphadinopathy Associated Virus (LAV) or the mutants derivative or Variations Deficiency Syndrome or any Syndrome or condition of a similar kind.
• II. Any treatment arising from or traceable to pregnancy (including voluntary termination), miscarriage (unless due to an Accident), childbirth, maternity (including caesarian section), abortion or complications of any of these. This exclusion will not apply to ectopic pregnancy.
• III. Any treatment arising from or traceable to any fertility, infertility, subfertility or assisted conception procedure or sterilization, birth control procedures, hormone replacement therapy, contraceptive supplies, or services including complications arising due to supplying services or Assisted Reproductive Technology.
• IV. Any dental treatment or surgery unless requiring hospitalization arising out of an accident.
• V. Treatment taken from anyone who is not a Medical Practitioner or from a Medical Practitioner who is practicing outside the discipline for which he is licensed or any kind of self-medication.
• VI. Charges incurred in connection with cost of spectacles and contact lenses, hearing aids, routine eye and ear examinations, laser surgery for correction of refractory errors, dentures, artificial teeth and all other similar external appliances and /or devices whether for diagnosis or treatment.
• VII. Experimental, investigational or unproven treatments which are not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any Illness for which confinement is required at a Hospital. Any Illness or treatment which is a result or consequence of undergoing such experimental or unproven treatment.
• VIII. Any expenses incurred on prosthesis, corrective devices, external durable medical equipment of any kind, like wheelchairs, walkers, belts, collars, caps, splints, braces, stockings of any kind, diabetic footwear, glucometer / thermometer, crutches, ambulatory devices, instruments used in treatment of sleep apnea syndrome (C.P.A.P) or continuous ambulatory peritoneal dialysis (C.P.A.D) and oxygen concentrator or asthmatic condition, cost of cochlear implants.
• IX. Any weight management services, procedures and treatment, services and supplies including those related to treatment of conditions and complication arising out of obesity (including morbid obesity)
• X. Any procedure, investigation, treatment related to sleep disorder or sleep apnea syndrome, general debility, convalescence, cure, rest cure, health hydros, nature cure clinics, sanatorium treatment, rehabilitation measures, private duty nursing (unless covered under the Policy), respite care, long term nursing care, custodial care or any treatment in an establishment that is not a Hospital.
• XI. External Congenital Anomaly.
• XII. Treatment of mental illness, stress, psychiatric or psychological disorders.
• XIII. Aesthetic treatment, cosmetic surgery/implants or plastic surgery or related treatment of any description, including any complication arising from these treatments, other than as may be necessitated due to an Injury or Burns.
• XIV. Any treatment / surgery for change of sex or gender reassignments including any complication arising from these treatments.
• XV. Circumcision unless necessary for treatment of an Illness or as may be necessitated due to an Accident
• XVI. All preventive care, vaccination including inoculation and immunizations (except in case of post-bite treatment or when it is medically necessary and part of the treatment), vitamins and tonics.
• XVII. Artificial life maintenance, including life support machine use, where such treatment will not result in recovery or Reload of the previous state of health.
• XVIII. Non-allopathic treatment except for the ‘Ayush Coverage’ and unless specified in the Schedule to this Policy.
• XIX. Domiciliary or any OPD treatment except pre and post – hospitalization as covered under Scope of the Policy.
• XX. Any Treatment received outside India other than in terms of the Add on ‘World-wide coverage’ if opted by the Insured and specified in the Schedule to this Policy.
• XXI. Charges incurred at Hospital Primarily for diagnostic, X-ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any Illness or Injury for which Inpatient Care/Day Care Treatment is required
• XXII. War or any act of war, invasion, act of foreign enemy, war like operations (whether war be declared or not or caused during service in the armed forces of any country), civil war, public defense, rebellion, revolution, insurrection, mutiny, military or usurped acts, seizure, capture, arrest, restraints and detainment of all kinds.
• XXIII. Any Illness or Injury arising from Insured Person committing any breach of law with criminal intent.
• XXIV. Act of self-destruction or self-inflicted, attempted suicide or suicide while sane or insane or Illness or Injury attributable to consumption, use, misuse or abuse of tobacco, intoxicating drugs and alcohol or hallucinogens.
• XXV. Any charges incurred to procure any medical certificate, treatment or Illness related documents pertaining to any period of Hospitalization or Illness.
• XXVI. Personal comfort and convenience items or services including but not limited to TV(wherever specifically charged separately), charges for access to telephone and telephone calls (wherever specifically charged separately), foodstuffs, (except patient’s diet), cosmetics, hygiene articles, body or baby care products and bath additive, barber or beauty service, guest service as well as similar incidental services and supplies.
• XXVII. Stem Cell implantation, harvesting, storage or any kind of treatment using stem cells.
• XXVIII. Expenses related to any kind of RMO charges, service charge, surcharge, admission fees, registration fees, night charges levied by the hospital under whatever head.
• XXIX. Any Hospitalisation primarily for investigation and / or diagnosis purpose.
• XXX. Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from or from any other cause or event contributing concurrently or in any other sequence to the loss, claim or expense. For the purpose of this exclusion:
  • a. Nuclear attack or weapons means the use of any nuclear weapon or device or waste or combustion of nuclear fuel or the emission, discharge, dispersal, release or escape of fissile/fusion material emitting a level of radioactivity capable of causing any Illness, incapacitating disablement or death.
  • b. Chemical attack or weapons means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing any Illness, incapacitating disablement or death.
  • c. Biological attack or weapons means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organisms and /or biologically produced toxins (including genetically modified organisms and chemically synthesized toxins) which are capable of causing any Illness, incapacitating disablement or death. In addition to the foregoing, any loss, claim or expense of whatsoever nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection with any action taken in controlling, preventing, suppressing, minimizing or in any way relating to the above shall also be excluded.
• XXXI. Impairment of an Insured Person’s intellectual faculties by abuse of stimulants or depressants.
• XXXII. Alopecia, wigs and/or toupee and all hair or hair fall treatment and products.
• XXXIII. Any treatment taken in a clinic, rest home, convalescent home for the addicted, detoxification center, sanatorium, home for the aged, mentally disturbed, remodeling clinic or similar institutions.
• XXXIV. EECP & Chelation Therapy, Rotational Field Quantum Magnetic Resonance (RFQMR) or Cytotron therapy.
• XXXV. Drugs or treatment and medical supplies not supported by a prescription from a Medical Practitioner.
• XXXVI. Costs of donor screening and organ.
• XXXVII. Any treatment/loss required arising from Insured Person’s participation in any hazardous activity including but not limited to scuba diving, engaging in speed contest or racing of any kind (other than on foot), bungee jumping, parachuting, hang gliding, rock or mountain climbing, winter sports, mountaineering (where ropes or guides are customarily used), caving or potholing, hunting or equestrian, skin diving or other underwater activity, rafting or canoeing involving white water rapids, yachting or boating outside coastal waters (2 miles), polo, snow and ice sports, professional sports or any other potentially dangerous sport.

The optional cover(s) shall be available only if the same is specifically mentioned in the Policy Schedule and available on payment of premium as applicable. The Insured has an option to select the cover/s either on individual /combination basis, along with the covers specified under Part B. Scope of Covers of the Policy. The company will pay for the Medical Expenses, in excess of deductible stated in the Policy Schedule either on per claim basis or when the aggregate of covered medical expenses exceeds the deductible applicable on policy per year basis depending upon the plan opted. However, Our total liability under this Policy for payment of any and all Claims in aggregate during each Policy Year of the Policy Period shall not exceed the Sum Insured and Reload Sum Insured if any available to the Insured and stated in the Policy Schedule.

1. Reload of Sum Insured

When the Sum Insured is exhausted due to claims made and paid during the Policy Year or made during the Policy Year and accepted as payable under Part B 1 (In-patient Hospitalization Expenses) of the Policy; the Company agrees to automatically Reload the Sum Insured equivalent to the original Sum Insured specified in the Policy Schedule, for the particular policy year, provided that:

• a. The Reload Sum Insured will be triggered immediately after the original Sum Insured and Cumulative Bonus (if any) has been completely exhausted during that Policy Year;
• b. The Reload Sum Insured is available for the medical expenses incurred only in India
• c. The Reload Sum Insured can be used only for such claims as is admissible in terms of Part B 1 (In-patient Hospitalization Expenses) of the Policy and available for the Medical expenses incurred during Inpatient hospitalization period only.
• d. The Reload Sum Insured will be available during the Policy Year till it is exhausted completely.
• e. Any unutilized Reload amount cannot be carried forward to any subsequent Policy Year/renewal of the Policy.
• f. In case of Portability, the credit for Sum Insured would be given only to the extent of the original Sum Insured.
• g. The deductible provision would apply to the Reload Sum Insured in the same manner as was applicable to the original Sum Insured i.e., on a perclaim basis in case of “Top Up” and on per year basis in case of “SuperTop Up” as stated under “Schedule of Benefits’ of the Policy Document. If the policy is a Family Floater, then the Reload Sum Insured will only be available in respect of claims made by those Insured Persons who were Insured Persons under the Policy before the Sum Insured was exhausted.

2. AYUSH Treatment

The Company will indemnify up to the amount specified in the Policy Schedule, for the Medical Expenses incurred in excess of deductible stated in the Policy Schedule either on per claim basis or when the aggregate of covered medical expenses exceeds the deductible applicable on policy per year basis depending upon the plan opted, for the treatment taken under Ayurveda, Unani, Sidha and Homeopathy in a government hospital or in any institute recognized by government and/or accredited by Quality Council of India/National Accreditation Board on Health provided that the hospitalization is not for evaluation and/or investigation purpose only and treatment is availed in India only.

3. World-wide Coverage

The Company will indemnify up to the amount specified in the Policy Schedule, as per the Sum Insured and plan chosen in excess of the Deductible as specified in the Policy Schedule, for the emergency care Medical Expenses incurred outside India, in respect of the Insured Person incurred during the Policy Year, provided that:

• i. The Insured person/s is/are outside India for the purpose other than undergoing medical treatment/procedure
• ii. The medical symptoms first originated whilst the Insured Person/s is/are outside India
• iii. The treatment is Medically Necessary and has been certified by a Medical Practitioner as an Emergency care which cannot be deferred till the date of Insured Person/s return/s to India.
• iv. The intimation of such hospitalization to the Company or our Service Provider is within 24 hours of admission
• v. The Emergency Care Medical Expenses incurred during In-patient Hospitalization only shall be covered.
• vi. Pre-existing diseases shall be excluded.
• vii. Any payments under this benefit will only be made in India, in Indian Rupees and on reimbursement basis. The payment of any claim will be based on the rate of exchange as on the date of payment to the Hospital published by Reserve Bank of India (RBI) and shall be used for conversion of foreign currency into Indian Rupees for payment of the claim under this benefit.
• viii. Waiting Periods of 30 days and Two Years as stated under Section D. Exclusions of the Policy shall be waived off under this cover.
• ix. We shall not be deemed to provide cover and shall not be liable to pay any claim or provide any benefit hereunder to the extent that the provision of such cover, payment of such claim or provision of such benefit would expose us to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States of America.
• x. The cover is available for a maximum period of 180 consecutive days.

4. Wellness & Assistance Program:

The below services will be available when the Insured/Insured member/s is/are more than 150 kilometers away, within Indian territory, from their residential address as provided in the Proposal Form. The services would be provided by Us /through our appointed Service provider, with prior intimation and acceptance by the Company and can be availed anytime during the policy period and there are no restrictions on the number of times the facility can be utilized.

• i. Medical Consultation, Evaluation and Referral: In case of any emergency situation, We/our Service Provider will evaluate, troubleshoot and make immediate recommendations including referrals to qualified doctors and/or hospitals. The company will only arrange for the medical consultant, the consultant fee will be borne by the policyholder.
• ii. ii. Medical Monitoring and Case Management: A team of doctors, nurses, and other medically trained personnel would be in regular communication with the attending physician and hospital, monitors appropriate levels of care and relay necessary and legally permissible information to the members of the Family / employer.
• iii. Emergency Medical Evacuation: If the Insured / Insured member/s becomes ill or injured in an area where appropriate care is not available, the Company /via Service Provider at its expense will intervene and use available transportation equipment and personnel necessary to evacuate the Individual safely to the nearest facility for medical care. Such emergency medical evacuation would be done either by ground or air solely at the discretion of the Company.
• iv. Compassionate Visit: When an Insured Person is/are hospitalized for more than seven (7) consecutive days, The Company/ Service Provider will arrange for a family member or a personal friend to travel to visit the Insured Person/s, by providing an appropriate means of transportation.