|
ReAssure –
i. Having at least five in-patient beds; in charge round the clock; as required and/or has equipped operation theatre where surgical procedures are to be carried out; iv. Maintaining daily records of the patients and making them accessible to the insurance company’s authorized representative. AYUSH Hospitals referred above shall also obtain either pre-entry level certificate (or higher level of certificate) issued by National Accreditation Board for Hospitals and Healthcare Providers (NABH) or State Level Certificate (or higher level of certificate) under National Quality Assurance Standards (NQAS), issued by National Health Systems Resources Centre (NHSRC). 3.1.3. AYUSH Treatment refers to the medical and / or hospitalization treatments given under Ayurveda, Yoga and Naturopathy, Unani, Sidha and Homeopathy systems. 3.1.4. 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. 3.1.5. Condition Precedent shall mean a Policy term or condition upon which the Insurer’s liability under the Policy is conditional upon. 3.1.6. Congenital Anomaly means a condition which is present since birth, and which is abnormal with reference to form, structure or position. which is not in the visible and accessible parts of the body. which is in the visible and accessible parts of the body. 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. 3.1.8. Cumulative Bonus means any increase or addition in the Sum Insured granted by the insurer without an associated increase in premium. 3.1.9. 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; |
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
|
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. 3.1.10. 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.
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. 3.1.18. 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. 3.1.19. 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. 3.1.20. 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. 3.1.21. Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function and requires medical treatment.
ii. it needs ongoing or long-term control or relief of symptoms the patient to be specially trained to cope with it
3.1.22. 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. 3.1.23. Inpatient Care means treatment for which the Insured Person has to stay in a Hospital for more than 24 hours for a covered event. 3.1.24. Maternity Expense shall include:
|
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
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. 3.1.36. 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. 3.1.37. Portability means the right accorded to an 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. 3.1.38. 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. 3.1.39. 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. 3.1.40. 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. 3.1.41. Room Rent means the amount charged by a Hospital towards Room and Boarding expenses and shall include the associated medical expenses. 3.1.42. 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 Centre by a Medical Practitioner. 3.1.43. Unproven/Experimental treatment means the treatment including drug experimental therapy which is not based on established medical practice in India, is treatment experimental or unproven. 3.2. Specific Definitions Schedule. 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: a. Other stem-cell transplants |
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
|
b. Where only islets of langerhans are transplanted
3.2.10. 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. 3.2.11. Inpatient means admission for treatment in a Hospital for more than 24 hours for an Insured Event. 3.2.12. IRDAI means the Insurance Regulatory and Development Authority of India. 3.2.13. Event means any event specifically mentioned as covered under this Policy. 3.2.14. Insured Person means person(s) named as insured persons in the Policy Schedule. 3.2.15. 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. 3.2.16. Policymeans 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. 3.2.17. 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. 3.2.18. Policy Year means the period of one year commencing on the date of commencement specified in the Policy Schedule or any anniversary thereof. 3.2.19. 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. 3.2.20. Reimbursement means settlement of claims paid directly by Us to the Policyholder/Insured Person. 3.2.21. Service Provider means any person, organization, institution that has been empanelled with Us to provide services specified under the benefits to the Insured Person. 3.2.22. 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. 3.2.23. Sum Insured: In case of Individual Policy, Sum Insured means the total of the Base Sum Insured, Booster Benefit, and Sum Insured Safeguard (if applicable) for that Insured Person. Our maximum, total and cumulative liability for all claims during the Policy Year in respect of the Insured Person will be Sum Insured and amount provided under ReAssure benefit. In case of Family Floater Policy, Sum Insured means the total of the Base Sum Insured, Booster Benefit and Sum Insured Safeguard (if applicable). Our maximum, total and cumulative liability for all claims during the Policy Year in respect of all Insured Persons taken together will be Sum Insured and amount provided under ReAssure benefit. If the Policy Period is 2 years or 3 years, then the Sum Insured shall be applied separately for each Policy Year in the Policy Period. 3.2.24. 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. |
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
|
3.2.25. We/Our/Us means Niva Bupa Health Insurance Company Limited. 3.2.26. You/Your/Policyholder means the person named in the Policy Schedule who has concluded this Policy with Us. 4. Benefits available under the Policy The benefits available under this Policy are described below.
4.1. 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: b. Room boarding and nursing charges during Hospitalization as charged by the Hospital where the Insured Person availed medical treatment; c. Medical Practitioners’ fees, excluding any charges or fees for Standby Services; d. Investigative tests or diagnostic procedures directly related to the Insured Event which lead to the current Hospitalization; e. Medicines, drugs as prescribed by the treating Medical Practitioner related to the Insured Event that led to the current Hospitalization; f. Intravenous fluids, blood transfusion, injection administration charges, allowable consumables and /or enteral feedings; g. Operation theatre charges; implanted internally during Surgery; a. b. The Hospitalization is for Medically Necessary Treatment and advised in writing by a Medical Practitioner.
4.2. Day Care Treatment What is covered: We will indemnify the Medical Expenses incurred on the Insured Person’s under any Day Care Treatment during the Policy Period following an Illness or Injury. Conditions – The above coverage is subject to fulfilment of following conditions: Practitioner as Medically Necessary Treatment. or Chemotherapy for cancer. indemnify the Insured Person’s Pre-hospitalization Medical Expenses and Post-hospitalization Medical Expenses in accordance with Sections 4.6 and 4.7. What is not covered: a. OPD Treatment and Diagnostic Services costs are not covered under this benefit. 4.3. 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. Conditions – The above coverage is subject to fulfilment of following conditions: indemnify the Insured Person’s Pre-hospitalization Medical Expenses and Post-hospitalization Medical Expenses in accordance with Sections 4.6 and 4.7, provided that these Medical Expenses relate only to Alternative Treatments and not Allopathy. c. Any non-allopathic treatment taken by the Insured Person shall only be covered under Section 4.3 (Alternative Treatments) as per the applicable terms and conditions. What is not covered: a. Medical Expenses incurred on treatment taken under Yoga shall not be covered. 4.4. 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. |
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
|
Conditions – The above coverage is subject to fulfilment of following conditions: consecutive days, wherein 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. What is not covered: a. Sections 4.6 (Pre-hospitalization Medical Expenses) and Section 4.7 (Post- hospitalization Medical Expenses) are not payable under this benefit. 4.5. Modern Treatments What is covered:
Special condition applicable for robotic surgeries: i. Robotic total radical prostatectomy ii. Robotic cardiac surgeries 4.6. 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: or Section 4.2 (Day Care Treatment) or Section 4.3 (Alternative Treatments) or Section 4.5 (Modern Treatments). Modern Treatments claim. 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 shall reduce the Sum Insured for the Policy Year in which Inpatient Care or Day Care Treatment or Alternative Treatments or Modern Treatments claim has been incurred. Sub-limit: Expenses only for period up to 60 days immediately preceding the Insured Person’s admission for Inpatient Care or Day Care Treatment or Alternative Treatments or Modern Treatments. 4.7. 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. Conditions – The above coverage is subject to fulfilment of following conditions: or Section 4.2 (Day Care Treatment) or Section 4.3 (Alternative Treatments) or Section 4.5 (Modern Treatments). Modern Treatments claim. treating Medical Practitioner. 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 shall reduce the Sum Insured for the Policy Year in which Inpatient Care or Day Care Treatment or Alternative Treatments or Modern Treatments claim has been incurred. Sub-limit: up to 180 days immediately following the Insured Person’s discharge from Hospital or Day Care Treatment or Alternative Treatments or Modern Treatments. |
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
|
4.8. 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. Conditions – The above coverage is subject to fulfilment of following conditions: Organs Act 1994 and any amendments thereafter and the organ is for the use of the Insured Person.
What is not covered:
4.9. 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. Conditions – The above coverage is subject to fulfilment of following conditions: 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;
What is not covered: The Insured Person’s transfer to any Hospital or diagnostic centre for evaluation purposes only. 4.10. Air Ambulance What is covered: We will indemnify the costs incurred for ambulance transportation in an airplane or helicopter, for Emergency life threatening health conditions which require immediate and rapid ambulance transportation to the Hospital / medical centre that ground transportation cannot provide. Conditions – The above coverage is subject to fulfilment of following conditions: or Section 4.2 (Day Care Treatment). where the Insured Person is situated at the time of Emergency. c. The Medical Evacuation has been prescribed by a Medical Practitioner and is Medically Necessary. in India only and not overseas in any condition whatsoever. e. The air ambulance provider is registered in India. Policy Schedule for transportation of the Insured Person under this benefit. What is not covered: a. Expenses incurred in return transportation to Insured Person’s home by air ambulance is excluded. 4.11. Home Care treatment What is covered: We will indemnify the Medical Expenses incurred on the Insured Person’s treatment taken at home for Chemotherapy or Dialysis. Conditions – The above coverage is subject to fulfilment of following conditions: provider. What is not covered: a. Treatment taken by automation machine for peritoneal dialysis. b. Sections 4.6 (Pre-hospitalization Medical Expenses) and Section 4.7 (Post- hospitalization Medical Expenses) are not payable under this benefit. 4.12. Booster benefit What is covered: a. If the Policy is Renewed with Us without a break or if the Policy continues to be in force for the 2nd / 3rd Policy Year in the 2 year / 3 year Policy Period respectively (if applicable) and no claim has been made in the immediately preceding Policy Year, We will provide Booster Benefit in the form of Cumulative Bonus by increasing the Sum Insured applicable under the Policy by 50% of the Base Sum Insured of the immediately preceding Policy Year per claim free Policy Year subject to a maximum of 100% of the Base Sum Insured. There will be no change in the sub-limits applicable to various benefits due to increase in Sum Insured under this benefit. Conditions – The above coverage is subject to fulfilment of following conditions: |
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
|
Individual Policies and has an accumulated Cumulative Bonus in the expiring Policies under this benefit, and such expiring Policies are merged and Renewed with Us on a Family Floater Policy with or without an addition of a new Insured Person, then the accumulated Cumulative Bonus to be carried forward to the Family Floater Policy would be the least of the accumulated Cumulative Bonus amongst the Insured Persons of the expiring Policy.
4.13. ReAssure What is covered: This benefit is triggered with the first paid claim itself and is available for all subsequent claims in a Policy Year. Conditions – The above coverage is subject to fulfilment of following conditions:
c. Claims under this benefit will be payable only under Section 4.1 (Inpatient Care) or Section 4.2 (Day Care Treatment) or Section 4.3 (Alternative Treatments) or Section 4.4 (Domiciliary Hospitalization) or Section 4.5 (Modern Treatments) or Section 4.8 (Living Organ Donor Transplant) or Section 4.11 (Home Care Treatment) arising in that Policy Year for any or all Insured Person(s). d. For Family Floater Policies, the amount under this benefit will be available on a floater basis to all Insured Persons in that Policy Year. 4.14. Shared accommodation Cash Benefit What is covered: If We have accepted an Inpatient Care Hospitalization claim and the Insured Person has occupied a shared room accommodation during such Hospitalization in a Network Hospital, We will pay a daily cash amount as specified in the Policy Schedule for the Insured Person for each continuous and completed period of 24 hours of Hospitalization. Conditions – The above coverage is subject to fulfilment of following conditions: minimum period of 48 hours continuously. What is not covered: a. This benefit will not be payable if the Insured Person stays in an Intensive Care Unit or High Dependency Units / wards. 4.15. Health Checkup What is covered: The Insured Person may avail a health check-up, only for Diagnostic Tests, up to a sub-limit as specified in Your Policy Schedule. Conditions – The above coverage is subject to fulfilment of following conditions: must have been done on the same date. blood count, Urine Routine, Erythrocyte Sedimentation Rate (ESR), Fasting Blood Glucose, Electrocardiogram, S Cholesterol, Complete Physical Examination by Physician, Post prandial / lunch blood sugar (PPBS / PLBS), Uric Acid, Lipid Profile, Kidney function test, Serum Vitamin D, Serum Electrolytes, HbA1C, Thyroid profile (TSH), Liver Function Test (LFT), Treadmill test (TMT) and Ultrasound test. What is not covered: a. Any unutilized test or amount cannot be carried forward to the next Policy Year. 4.16. Second Medical Opinion What is covered: We will indemnify the costs incurred for availing a second medical opinion from any Medical Practitioner for which we have admitted a claim of Hospitalization. Conditions – The above coverage is subject to fulfilment of following conditions: |
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
|
or Section 4.2 (Day Care Treatment) for which opinion is sought. What is not covered:
4.17. Live Healthy benefit What is covered: We will offer a discount on Renewal premium if the eligible Insured Person(s) achieves the health points target on the mobile application provided by Us as per the grid mentioned below. Conditions – The above coverage is subject to fulfilment of following conditions: Policy Period: 1 year a. b. c. d. e. Steps taken by the Insured Person everyday, earn ‘health points’. Steps counted by the mobile App We provide you to use ONLY would be considered. Health points accumulated in last 3 months of the Policy Period would not be considered for discount on premium for the first renewal. The last 3 months are NOT LOST and will be considered in the next Policy Period. All renewals thereafter, will consider points gained in the Policy Period. The mobile app must be downloaded within 30 days of the Policy commencement to avail this benefit. The step count completed by an eligible Insured Person would be tracked on this mobile application. We reserve the right to remove or reduce any count of steps if found to be achieved in unfair manner by manipulation.
1501 –2250 2251 – 3000 3001 – 3750 >=3751 5% 2.5% 15% 7.5% 20% 10% 30% 15% Policy Period: 2 years
3001 – 4500 4501 – 6000 6001 – 7500 >=7501 5% 2.5% 15% 7.5% 20% 10% 30% 15% |
||||||||||||||||||||||||||||||||||||||||||
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
||||||||||||||||||||||||||||||||||||||||||
|
Policy Period: 3 years
4501 – 6750 6751 – 9000 9001 – 11250 >=11251 5% 2.5% 15% 7.5% 20% 10% 30% 15% 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. 1. Loss of use of limbs or sight hemiplegia) OR 2. Loss of independent living
5. 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, unless specified otherwise, on payment of the corresponding additional premium. The optional benefits ‘Personal Accident 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 Your Policy Schedule. All claims for any applicable optional benefits under the Policy must be made in accordance with the process defined under Section 8 (Claim Process & Requirements). 5.1. 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 |
|||||||||||||||||||||
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
|||||||||||||||||||||
Conditions – The above coverage is subject to fulfilment of following conditions:
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: Conditions – The above coverage is subject to fulfilment of following conditions: certificate issued by a Medical Board duly constituted by the Central and/or the State Government; and 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 c. 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 5.1.a (Accident Death) subject to the terms and conditions mentioned therein. d. 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. e. 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 5.1 (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 5.1 (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
|
||||||||||||
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
5.2. Hospital Cash What is covered: If We have accepted an Inpatient Care Hospitalization claim under Section 4.1 (In-patient 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. Conditions – The above coverage is subject to fulfilment of following conditions: minimum period of 48 hours continuously. 5.3. Safeguard What is covered:
25% 25% 10% 10% 8% 5% 20% 5% 2% 1% Conditions – The coverage under ‘Sum Insured Safeguard’ is subject to fulfilment of following conditions: under the Policy and not on Booster Benefit or any other benefit which leads to increase in Sum Insured. basket of goods and averaging them. in India under the Ministry of Statistics and Programme Implementation responsible for co-ordination of statistical activities in India, and evolving and maintaining statistical standards. d. In case of Sum Insured enhancement or reduction at the time of Renewal, any accumulated Sum Insured due to Sum Insured Safeguard Benefit will be added to the enhanced or reduced Sum Insured opted by Insured at the time of Renewal. e. All accumulated Sum Insured Safeguard benefit will lapse and will roll back to the Base Sum Insured opted if this optional benefit is not Renewed. |
|||
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
|
Illustration of calculation of inflation rate based on CPI figures 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 36 months for any Pre-existing Disease is subject to the same being declared at the time of application and accepted by Us. 6.2. Specified disease/procedure waiting period- Code- Excl02
January February March April May June July August September October November December Average 139.6 136.9 139.9 136.4 140.4 136.5 141.2 137.1 142.0 137.8 142.9 138.5 144.2 139.8 145.0 140.4 145.8 140.2 147.2 140.7 148.6 140.8 150.4 140.1 143.9 138.8
As per the table above:
6.1. 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 36 months of continuous coverage after the date of inception of the first Policy with Us. |
|||||
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
|
6.3. 30-day waiting period (Code- Excl03):
6.4. Investigation & Evaluation (Code-Excl04)
6.5. 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:
6.6. Obesity/ Weight Control (Code-Excl06) Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions: clinical protocols. i. greater than or equal to 40 or following severe co-morbidities following failure of less invasive methods of weight loss: 3. Severe Sleep Apnea 6.7. 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. 6.8. 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. 6.9. 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. 6.10. 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. 6.11. 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. 6.12. Treatment for, alcoholism, drug or substance abuse or any addictive condition and consequences thereof. (Code-Excl12) 6.13. 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) 6.14. 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) 6.15. Refractive Error (Code-Excl15) Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres. 6.16. 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. 6.17. Sterility and Infertility (Code-Excl17) Expenses related to sterility and infertility. This includes: insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI c. Gestational Surrogacy d. Reversal of sterilization 6.18. Maternity Expenses (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. |
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
|
Specific Exclusions 6.19. Personal Waiting Periods: 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. Conditions specified for an Insured Person under Personal Waiting Person has been insured continuously under the Policy without any break. 6.33. 6.20. Charges related to a Hospital stay not expressly mentioned surcharges and service charges levied by the Hospital. 6.34. 6.21. Circumcision: 6.35. Circumcision unless necessary for the treatment of a disease or necessitated by an Accident. 6.22. Conflict & Disaster: 6.36. 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. 6.23. External Congenital Anomaly: Screening, counseling or treatment related to external Congenital Anomaly. 6.24. 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. 6.25. Hormone Replacement Therapy: Treatment for any condition / illness which requires hormone replacement therapy. 6.26. Multifocal Lens and ambulatory devices such as walkers, crutches, splints, stockings of any kind and also any medical equipment which is subsequently used at home. 6.27. Sexually transmitted Infections & diseases (other than HIV / AIDS): Screening, prevention and treatment for sexually related infection or disease (other than HIV / AIDS). 6.28. Sleep disorders: Treatment for any conditions related to disturbance of normal sleep patterns or behaviors. 6.29. Any treatment or medical services received outside the geographical limits of India. 6.30. Any expenses incurred on OPD treatment. 6.31. 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. The condition which is not clinically significant or is related to anxiety, bereavement, relationship or academic problems, acculturation difficulties or work pressure. TreatmentrelatedtointentionalselfinflictedInjuryorattempted suicide by any means. Any neuro-developmental delays and disorders. Mental retardation which is a condition of arrested or incomplete development of mind of a person, specially characterized by subnormality of intelligence. Artificial life maintenance for the Insured Person who has been declared brain dead or in vegetative state as demonstrated by: c. Treatment provided by Hospital or health facility that is not recognized by the relevant authorities in India. a. Deep coma and unresponsiveness to all forms of stimulation; or b. Absent pupillary light reaction; or 6.37. If as per any or all of the medical references herein below containing guidelines and protocols for evidence based medicines, the Hospitalization for treatment under claim is not necessary or the stay at the Hospital is found unduly long: a. Medical text books, establishment act of Government of India, of India, neurological society of India etc. 6.38. Permanent Exclusions for Personal Accident Cover We shall not be liable to make any payment under any benefits under Section 5.1 (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 |
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
|
poison, except as prescribed by a Medical Practitioner other than the Policyholder or an Insured Person.
7. Claims 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 Liability under this Policy. 7.1. 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: including documents for claims within the Deductible amount, once the Deductible limit has been exhausted.
7.2. 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 Admission of 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 are 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: 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:
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 Deductibles / 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. |
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
|
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 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; whom the request is being made; taken; Injury/ Hospitalization. 7.3. Claims Documentation: Necessary information and documentation for medical claims consultation. 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 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. used and only in case of Surgery/Surgical Procedure). paid receipt. 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. 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 applicable); FIR. 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 a. b. Accident Death
Accident Permanent Total Disability or Accident Permanent Partial Disability constituted by the Central and/or the State Government. 7.4. 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. |
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
7.5. 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. 7.6. Claims process for Section 4.10 (Air Ambulance), if availed on Cashless Facility: a. In the event of an Emergency, Our Service Provider shall be contacted immediately on the helpline number. 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. 7.7. Claims process for Section 4.15 (Health Checkup), if availed on Cashless Facility: a. The Insured Person shall seek appointment by contacting Our Service Provider. b. Our Service Provider will facilitate Your appointment. the Service Provider. 7.8. Claim process for Section 4.16 (Second Medical Opinion), if availed on Cashless Facility: Opinion, Our Service Provider shall be contacted on the helpline number. 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 4.16.
8. General Terms and Conditions Standard General Terms and Clauses 8.1. Free Look Provision The Free Look Period shall be applicable at the inception of the Policy and not on renewals or at the time of porting the Policy. The Insured Person shall be allowed a period of fifteen days (30 days if the Policy with Policy Period as 3 years has been 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. If the Insured has not made any claim during the Free Look Period, the Insured shall be entitled to: the Company on medical examination of the Insured Person and the stamp duty charges. 8.2. Cancellation a. The Insured Person may cancel this Policy by giving 15days written notice and in such an event, the Company shall refund premium on short term rates for the unexpired Policy Period as per the rates detailed below. |
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
Policy in-force up to Up to 30 days 31 to 90 days 91 to 180 days exceeding 180 days Refund of Premium (%) 75% 50% 25% 0% Policy in-force up to Up to 30 days 31 to 90 days 91 to 180 days 181 to 365 days 366 to 455 days 456 to 545 days Exceeding 545 days Refund of Premium (%) 87.5% 75% 62.5% 50% 25% 12% 0% Policy in-force up to Up to 30 days 31 to 90 days 91 to 180 days 181 to 365 days 366 to 455 days 456 to 545 days 545 to 720 days Exceeding 720 days Refund of Premium (%) 90% 87.5% 75% 60% 50% 25% 12% 0% The above grid shall be applicable for ‘Yearly / Annual’ premium payment frequency. For Half Yearly or Quarterly premium payment frequencies, the Company shall refund premium as per below grid:
0 1 2 3 4 5 62.5% 50% 6 62.5% 50% 33.3% 16.7% 7 33.3% 16.7% 25% 0%825% 0% 8.3% 50% 9 8.3% 50% 4.2% 16.7% 10 4.2% 16.7% 0%0% 11 0%0% For monthly premium payment frequency, no refund shall be applicable for cancellation of the Policy b. 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.The Company may cancel the Policy at any time on grounds of mis-representation, 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 mis-representation, non-disclosure of material facts or fraud. 8.3. Renewal of Policy The Policy shall ordinarily be renewable except on grounds of fraud, moral hazard, misrepresentation by the Insured Person.
8.4. 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. For claim settlement under Reimbursement, the Company will pay the Policyholder. In 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. 8.5. Fraudulent claims If any claim made by the Insured Person, is in any respect fraudulent, or if any false statement, or declaration is made or used in support thereof, or if any fraudulent means or devices are used by the Insured Person or anyone acting on his / her behalf to obtain any benefit under this Policy, all benefits under this Policy shall be forfeited. Any amount already paid against claims which are found fraudulent later under this Policy shall be repaid by all person(s) named in the Policy Schedule, who shall be jointly and severally liable for such repayment. For the purpose of this clause, the expression “fraud” means any of the following acts committed by the Insured Person or by his agent, 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; |
|||||||||||||
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
|||||||||||||
|
c. any other act fitted to deceive; and fraudulent The Company shall not repudiate the Policy on the ground of Fraud, if the Insured Person / beneficiary can prove that the misstatement was true to the best of his knowledge and there was no deliberate intention to suppress the fact or that such mis-statement of or suppression of material fact are within the knowledge of the insurer. Onus of disproving is upon the Policyholder, if alive, or beneficiaries. 8.6. Possibility of Revision of Terms of the Policy Including the Premium Rates The Company, with prior approval of IRDAI, 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. 8.7. Withdrawal of Product
8.8. Redressal of Grievance: In case of any grievance the Insured Person may contact the company through: E-mail: [email protected] (Senior citizens may write to us at: [email protected]) Niva Bupa Health Insurance Company Limited D-5, 2nd Floor, Logix Infotech Park Insured person may also approach the grievance cell at any of the company’s branches with the details of grievance. If Insured person is not satisfied with the redressal of grievance through one of the above methods, Insured Person may contact the grievance officer at: Grievance Redressal Officer For details of grievance officer, kindly refer the link https:// www.nivabupa.com/customer-care/health-services/grievance- redressal.aspx If Insured person is not satisfied with the redressal of grievance through above methods, the Insured Person may also approach the office of Insurance Ombudsman of the respective area/region for redressal of grievance at the addresses given in Annexure III. Grievance may also be lodged at IRDAI Integrated Grievance Management System – https://igms.irda.gov.in/ 8.9. 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. 8.10. Loading on Premium a. 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) or Special Conditions on the Policy. The maximum risk loading applicable shall not exceed more than 100% of the premium per diagnosis / medical condition and an overall risk loading shall not exceed more than 150% of the premium per Insured Person. b. These loadings will be applied from inception date of the First Policy including subsequent Renewal(s) with Us. c. We may apply a specific personal Waiting Period on a medical condition/ailment depending on the past history or additional Waiting Periods on Pre-existing Diseases as part of the special conditions on the Policy. 8.11. Multiple Policies a. In case of multiple policies taken by an Insured Person during a period from one or more insurers to indemnify treatment costs, the Insured Person shall have the right to require a settlement of his / her claim in terms of any of his / her policies. In all such cases the insurer chosen by the Policyholder 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. b. Insured Person having multiple policies shall also have the right to prefer claims under this Policy for the amounts disallowed under any other policy / policies even if the sum insured is not exhausted. Then the Insurer(s) shall independently settle the claim subject to the terms and conditions of this Policy. c. If the amount to be claimed exceeds the sum insured under a single Policy after considering the deductibles or co-pay, the Insured Person shall have the right to choose insurer from whom he / she wants to claim the balance amount. d. 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 hospitalization costs in accordance with the terms and conditions of the chosen Policy. 8.12. Disclosure of Information The Policy shall be void and all premium paid thereon shall be |
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
|
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) 8.13. 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. 8.14. Migration The Insured Person will have the option to migrate the Policy to other health insurance products / plans offered by the Company policy by applying for migration of the policy 30 days before the premium due date of his / her existing Policy as per extant guidelines on Migration. If such person is presently covered and has been continuously covered without any lapses under any health insurance product / plan offered by the Company, the proposed insured person will get the accrued continuity benefits in waiting periods as per extant 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 8.15. 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 premium due date of his / her existing Policy as per extant guidelines related to portability. If such person is presently covered and has been continuously covered without any lapses under any health insurance policy with an Indian General / Health insurer, the proposed insured person will get the accrued continuity benefits in waiting periods as per extant 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 Specific Terms and conditions 8.16. Renewal Premium: Renewal premium will alter based on Age. The reference of age for calculating the premium for Family Floater Policies shall be the age of the eldest Insured Person. 8.17. 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. 8.18. Renewal for Insured Persons who have achieved Age 31: If any Insured Person who is a child and has completed Age 31 years at the time of Renewal in a Family Floater Policy, 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 such 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. 8.19. 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. 8.20. 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 shall apply afresh for this enhanced limit or any benefit’s enhanced sub-limit from the effective date of such enhancement. 8.21. 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. 8.22. 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. 8.23. Authorization to obtain all pertinent records or information: As a Condition Precedent to Admission of Liability for 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. 8.24. 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. 8.25. Territorial Jurisdiction All benefits are available in India only and all claims shall be payable in India in Indian Rupees only. |
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
|
8.26. Notices Any notice, direction or instruction given under this Policy shall be in writing and delivered by hand, post, or facsimile to:
8.27. 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. 8.28. Zonal pricing For the purpose of calculating premium, the country has been divided into the following 2 zones: Thane), Kolkata and Gujarat State 8.29. Assignment The Policy can be assigned subject to applicable laws. 8.30. Premium Payment in Installments lf the insured person has opted for Payment of Premium on an instalment basis i.e. Half Yearly, Quarterly or Monthly, as mentioned in the policy Schedule/Certificate of insurance, the following Conditions shall apply (notwithstanding any terms contrary elsewhere in the policy) i. Grace Period of 30 days in case of single premium policies, and a period of 15 days in case of other than single premium policies, would be given to pay the instalment premium due for the policy. ii. During such grace period, coverage will not be available from the due date of instalment premium till the date of receipt of premium by Company. iii. The insured person will get the accrued continuity benefit in respect of the “Waiting Periods”, “Specific Waiting Periods” in the event of payment of premium within the stipulated grace Period. iv. No interest will be charged lf the instalment premium is not paid on due date v. ln case of instalment premium due not received within the grace period, the policy will get cancelled. vi. ln the event of a claim, all subsequent premium instalments shall immediately become due and payable. The company has the right to recover and deduct all the pending installments from the claim amount due under the policy. b. Zone 2: Rest of India Niva Bupa Health Insurance Company Limited Registered office:- C-98, First Floor, Lajpat Nagar, Part 1, New Delhi-110024 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 No. 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. Customer Helpline: 1860-500-8888. Website: www.nivabupa.com. CIN: U66000DL2008PLC182918. For more details on terms and conditions, exclusions, risk factors, waiting period & benefits, please read sales brochure carefully before concluding a sale. |
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
|
Benefits Inpatient Care Day Care Treatment Alternative Treatments Domiciliary Hospitalization Modern treatments Pre-Hospitalization Medical Expenses (60 days) Post-Hospitalization Medical Expenses (180 days) Living Organ Donor Transplant Emergency Ambulance Air Ambulance Home care treatment ReAssure Shared accommodation Cash Benefit Second Medical Opinion Live healthy benefit Optional benefits Hospital Cash (1) Personal Accident cover (for insured aged 18 years & above on individual basis) Covered up to Sum Insured Covered up to Sum Insured Covered up to Sum Insured Covered up to Sum Insured Covered up to Sum Insured with sub-limit of Rs. 1Lac on few robotic surgeries Covered up to Sum Insured Covered up to Sum Insured Covered up to Sum Insured Covered upto Rs.2,000 per hospitalization Cashless claim: Covered up to Sum Insured / Reimbursement claim: Covered up to Rs. 2.5 Lacs Covered up to Sum Insured In case of claim free year, increase of 50% of expiring Base Sum Insured in a Policy Year; maximum up to 100% of Base Sum Insured (In case of a claim, reduction of accumulated Cumulative Bonus by 50% of expiring Base Sum Insured) Unlimited reinstatement up to base Sum Insured. (Applicable for both same & different illness) Rs. 800 per day; maximum Rs. 4,800 Rs. 1,000 per day; maximum Rs. 6,000 Annual (From Day 1); For defined list of tests; up to Rs. 500 for every Rs. 1 Lac Sum Insured Once for any condition for which hospitalization is triggered Discount on renewal premium basis number of steps taken 1,000/day 2,000/day 4,000/day Personal Accident cover will be equal to 5 times of Base Sum Insured; subject to maximum of Rs. 100 Lacs a. Claim Safeguard: Non-payable items paid up to Sum Insured Annexure I Product Benefit Table (all limits in INR unless defined as percentage)
Booster Benefit Health Check-up Safeguard |
||||||||||||||||||||||||||
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
||||||||||||||||||||||||||
|
Annexure II The expenses that are not covered or subsumed into room charges / procedure charges / costs of treatment List I – Expenses not covered
PART OF BED CHARGE)
List II – Items that are to be subsumed into Room Charges
6 COMB |
||||||||
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
11 TISSUE PAPER 25 CLEAN SHEET
26 BLANKET/WARMER BLANKET 31 DAILY CHART CHARGES List III – Items that are to be subsumed into Procedure Charges
13 SURGICAL DRILL 14 EYE KIT 17 BOYLES APPARATUS CHARGES 18 COTTON 21 APRON List IV – Items that are to be subsumed into costs of treatment
10 HIV KIT |
||||||||||||
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
|
Annexure III List of Insurance Ombudsmen
|
||||||||||||||||
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
|
||||||||||||||||
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
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: [email protected] |
||||||||
|
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021 |
