INSURANCE

Niva Bupa Reassure Plan

ReAssure –
Policy Terms & Conditions

  1. PreambleThis ‘ReAssure’ 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 of Information, 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 & InterpretationFor the purposes of interpretation and understanding of this Policy, We have defined, in Section 3, 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.

  3. Defined TermsThe terms listed below in Section 3 and used elsewhere in the Policy in Initial Capitals shall have the meaning set out against them in Section 3.

    3.1. Standard Definitions

    1. 3.1.1.  Accident or Accidental means a sudden, unforeseen andinvoluntary event caused by external, visible and violent

      means.

    2. 3.1.2.  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 five in-patient beds;
ii. Having qualified AYUSH Medical Practitioner

in charge round the clock;
iii. Having dedicated AYUSH therapy sections

as required and/or has equipped operation theatre where surgical procedures are to be carried out;

iv. Maintaining daily records of the patients and making them accessible to the insurance company’s authorized representative.

AYUSH 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.
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.
3.1.7. 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.

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.

  1. 3.1.11.  Deductible means a cost-sharing requirement under ahealth 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. 3.1.12.  Dental Treatment means a treatment related to teeth or structures supporting teeth including examinations, fillings (where appropriate), crowns, extractions and Surgery.
  3. 3.1.13.  Disclosure of Information means 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. (Note: “Material facts” for the purpose of this Policy shall mean all important, essential and relevant information sought by the Company in the proposal form and other connected documents to enable him to take informed decision in the context of underwriting the risk)
  4. 3.1.14.  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:
    1. the condition of the patient is such that he/she is not in a condition to be removed to a Hospital, or
    2. the patient takes treatment at home on account of non availability of room in a Hospital.
  5. 3.1.15.  Emergency care (Emergency) means management for an Illness or Injury which results in symptoms which occur suddenly and unexpectedly, and requires immediate care by a Medical Practitioner to prevent death or serious long term impairment of the Insured Person’s health.
  6. 3.1.16.  GracePeriodmeansthespecifiedperiodoftime(30days) 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.
  7. 3.1.17.  Hospital 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.

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.

  1. Acute condition – Acute condition is a disease, illnessor 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
  2. 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 monitoringthrough 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

  1. it continues indefinitely
  2. it recurs or is likely to recur

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:

  1. Medical Treatment Expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during Hospitalization);
  2. Expenses towards lawful medical termination of pregnancy during the Policy Period.

Product Name: ReAssure | Product UIN: MAXHLIP21060V012021

  1. 3.1.25.  Medical Advice means any consultation or advice from a Medical Practitioner including the issuance of any prescription or follow-up prescription.
  2. 3.1.26.  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.
  3. 3.1.27.  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.
  4. 3.1.28.  Medically Necessary Treatment means any treatment, tests, medication, or stay in Hospital or part of a stay in Hospital which:
    1. is required for the medical management of the Illnessor Injury suffered by the insured;
    2. must not exceed the level of care necessary toprovide safe, adequate and appropriate medical care

      in scope, duration, or intensity;

    3. must have been prescribed by a Medical Practitioner;
    4. must conform to the professional standards widelyaccepted in international medical practice or by the

      medical community in India.

  5. 3.1.29.  Migration means the right accorded to health insurancepolicyholders (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.
  6. 3.1.30.  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.
  7. 3.1.31.  Non-Network means any Hospital, Day Care Center or other provider that is not part of the network.
  8. 3.1.32.  Notification of Claim means the process of intimating a claim to the insurer or TPA through any of the recognized modes of communication.
  9. 3.1.33.  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.
  10. 3.1.34.  Pre-existing Disease means any condition, ailment, injury or disease
    1. 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
    2. 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.
  11. 3.1.35.  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.

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
3.2.1. Age means age as on last birthday.
3.2.2. Base Sum Insured means the amount stated in the Policy

Schedule.
3.2.3. 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:

a. Other stem-cell transplants

Product Name: ReAssure | Product UIN: MAXHLIP21060V012021

b. Where only islets of langerhans are transplanted

  1. 3.2.4.  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 thepremium renewal date or within 30 days thereof.
  2. 3.2.5.  Cancer means 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. Thetermcancerincludesleukemia,lymphomaandsarcoma.The following are excluded:
    1. All tumors which are histologically described ascarcinoma in situ, benign, pre-malignant, borderline malignant, low malignant potential, neoplasm of unknown behavior, or non-invasive, including but not limited to: Carcinoma in situ of breasts, Cervical dysplasia CIN-1, CIN – 2 and CIN-3.
    2. Any non-melanoma skin carcinoma unless there is evidence of metastases to lymph nodes or beyond;
    3. Malignant melanoma that has not caused invasion beyond the epidermis;
    4. 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
    5. All Thyroid cancers histologically classified as T1N0M0 (TNM Classification) or below;
    6. Chronic lymphocytic leukaemia less than RAI stage 3
    7. Non-invasive papillary cancer of the bladder histologically described as TaN0M0 or of a lesserclassification
    8. All Gastro-Intestinal Stromal Tumors histologicallyclassified as T1N0M0 (TNM Classification) or below and with mitotic count of less than or equal to 5/50 HPFs;
    9. All tumors in the presence of HIV infection.
  3. 3.2.6.  Diagnostic Services means those diagnostic tests and exploratory or therapeutic procedures required for the detection, identification and treatment of a medicalcondition.
  4. 3.2.7.  Family Floater Policy means a Policy described as such inthe Policy Schedule where the family members (two or more) named in the Policy Schedule are insured under this Policy.
  5. 3.2.8.  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.
  6. 3.2.9.  Individual Policy means a Policy described as such in the Policy Schedule where the individual(s) named in the Policy Schedule is / are the Insured Person(s) under this Policy.

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.

  1. The Policy covers Reasonable and Customary Charges incurred towards Medically Necessary 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 maybespecified in the Policy Schedule.
  2. The expenses that are not covered or subsumed into roomcharges / procedure charges / costs of treatment are placed

    as Annexure II

  3. All the benefits (including optional benefits) which areavailable 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 I.
  4. All claims under the Policy must be made in accordance with the process defined under Section 8 (Claim Process & Requirements).
  5. All claims paid under any benefit except for those admitted under Section 4.14 (Shared accommodation Cash Benefit), Section 4.15 (Health Checkup), Section 4.16 (Second Medical Opinion), Section 4.17 (Live Healthy benefit), Section 5.1 (Personal Accident Cover) and Section 5.2 (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.

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:
a. Room Rent;

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;
h. The cost of prosthetics and other devices or equipment, if

implanted internally during Surgery;
i. Intensive Care Unit Charges.
Conditions – The above coverage is subject to fulfilment of following conditions:

a. b.

The Hospitalization is for Medically Necessary Treatment and advised in writing by a Medical Practitioner.
We will pay the consultation charges for any Medical Practitioner visiting the Insured Person only if:

  1. The Medical Practitioner’s treatment or advice has been specifically sought by the Hospital; and
  2. The consultation charges are included in the Hospital’s bill

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:
a. The Day Care Treatment is advised in writing by a Medical

Practitioner as Medically Necessary Treatment.
b. The Day Care Treatment would be covered if the Insured Person is admitted for more than 2 hours and would also cover treatment taken for Angiography, Dialysis, Radiotherapy

or Chemotherapy for cancer.
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 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:
a. The treatment should be taken in AYUSH Hospital.
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 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:
a. The Domiciliary Hospitalization continues for at least 3

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:

  1. The following procedures / treatments will be covered either as Inpatient Care or as part of Day Care Treatment as per Section 4.1 and Section 4.2 respectively, in a Hospital :
    1. Uterine Artery Embolization and HIFU (High intensityfocused ultrasound)
    2. Balloon Sinuplasty
    3. Deep Brain stimulation
    4. Oral chemotherapy
    5. Immunotherapy- Monoclonal Antibody to be given asinjection
    6. Intra vitreal injections
    7. Robotic surgeries
    8. Stereotactic radio surgeries
    9. BronchicalThermoplasty
    10. Vaporisation of the prostrate (Green laser treatment orholmium laser treatment)
    11. IONM – (Intra Operative Neuro Monitoring)
    12. Stem cell therapy: Hematopoietic stem cells for bonemarrow transplant for haematological conditions to be

      covered.

  2. If We have accepted a claim under this benefit, We will alsoindemnify the Insured Person’s Pre-hospitalization Medical Expenses and Post-hospitalization Medical Expenses in accordance with Sections 4.6 and 4.7 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

4.6. 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:
a. We have accepted a claim under Section 4.1 (Inpatient Care)

or Section 4.2 (Day Care Treatment) or Section 4.3 (Alternative

Treatments) or Section 4.5 (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 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 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:
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 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:
a. We have accepted a claim under Section 4.1 (Inpatient Care)

or Section 4.2 (Day Care Treatment) or Section 4.3 (Alternative

Treatments) or Section 4.5 (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 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 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:
a. We will pay Post-hospitalization Medical Expenses only for

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:
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.

  1. The organ transplant is certified in writing by a MedicalPractitioner as Medically Necessary Treatment for the Insured

    Person.

  2. We have accepted the recipient Insured Person’s claim underSection 4.1 (Inpatient Care).

What is not covered:

  1. Stem cell donation whether or not it is Medically Necessary Treatment except for Bone Marrow Transplant.
  2. Pre-hospitalization Medical Expenses or Post-hospitalization Medical Expenses of the organ donor.
  3. 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.
  4. Transplant of any organ/tissue where the transplant is Unproven / experimental treatment or investigational in nature.
  5. Expenses related to organ transportation or preservation.
  6. Any other medical treatment or complication in respect of the donor, which is directly or indirectly consequence toharvesting.

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:
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;

  1. 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.
  2. This benefit is available for only one transfer per Hospitalization.
  3. The ambulance service shall be offered by a healthcare or ambulance Service Provider.
  4. We have accepted a claim under Section 4.1 (Inpatient Care) or Section 4.2 (Day Care Treatment).
  5. We will cover expenses up to Rs. 2,000 per Hospitalization.

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:
a. We have accepted a claim under Section 4.1 (Inpatient Care)

or Section 4.2 (Day Care Treatment).
b. Medically Necessary treatment is not available at the location

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.
d. The insured person is in India and the treatment is required

in India only and not overseas in any condition whatsoever. e. The air ambulance provider is registered in India.
f. We will cover expenses up to the amount specified in the

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:
a. These services shall be offered by a registered homecare

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:
a. If the Insured Persons in the expiring Policy is covered under

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.

  1. 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 by addition of a new Insured Person, then the accumulated Cumulative Bonus to be carried forward to the Family Floater Policy would be the accumulated Cumulative Bonus of the expiring Policy.
  2. 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 Policy, then We will provide the credit of the accumulated Cumulative Bonus to each of the split Policy.
  3. If the Insured Persons covered on a Family Floater Policy are reduced at the time of Renewal, the applicable accumulated Cumulative Bonus shall remain same under the Policy.
  4. 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.
  5. 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.
  6. This benefit is not applicable for Health Check-up, Second Medical Opinion, Personal Accident Cover and Hospital Cash. Enhancement of Sum Insured due to Booster benefit cannot be utilized for the aforementioned benefits.
  7. If a claim has been made in the immediately preceding Policy Year, We will reduce the accumulated Cumulative Bonus by 50% of expiring Base Sum Insured. Whereas, if a reported claim has been denied by Us, the Insured Persons will be eligible for this benefit.
  8. If a claim has been made in the immediately preceding Policy Year under Individual Policy, the reduction in accumulated Cumulative Bonus shall be applicable only to the Insured Person(s) who have claimed.

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:

  1. The maximum liability under a single claim under this benefitshall not be more than Base Sum Insured.
  2. The sequence of utilization of Sum Insured will be as below:i. Base Sum Insured followed by;
    ii. Sum Insured Safeguard (if applicable) followed by;
    iii. Accumulated Cumulative Bonus under Booster benefit (if

    any) followed by; iv. ReAssure benefit

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:
a. The Insured Person has been admitted in a Hospital for a

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:
a. This benefit is available only once in a Policy Year and all tests

must have been done on the same date.
b. The list of tests covered under this benefit will be Complete

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:
a. This benefit can be availed only once during a Policy Year.
b. We have accepted a claim under Section 4.1 (Inpatient Care)

Product Name: ReAssure | Product UIN: MAXHLIP21060V012021

or Section 4.2 (Day Care Treatment) for which opinion is sought.

What is not covered:

  1. The second medical opinion under this benefit shall not be valid for any medico legal purposes.
  2. 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.

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.
1 health point would be earned for every completed 1000 steps.

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.

Policy duration

End of 9 months

Points at the end of 9 months (A)
This will be considered for discount on the first renewal.

Points in next 3 months (B)

Total points considered for discount (A + B) from 2nd Policy Period onwards

Discount on renewal premium (Renewal policy start date 1st Jan 2021

NOTE: Discount applicable on the member’s premium in Individual sum insured policies and on the Policy premium in case of Floater

Individual sum insured policy and Floater policies with 1 Adult

Floater policies with more than 1 Adult

1st Jan 2020

30th September 2020

Upto 1500

0%

0%

1501 –2250

2251 – 3000

3001 – 3750

>=3751

5% 2.5%

15% 7.5%

20% 10%

30% 15%

Policy Period: 2 years

Policy duration

End of 21 months

Points at the end of 21 months (A)
This will be considered for discount on the first renewal.

Points in next 3 months (B)

Total points considered for discount (A + B) from 2nd Policy Period onwards

Discount on renewal premium (Renewal policy start date 1st Jan 2022

NOTE: Discount applicable on the member’s premium in Individual sum insured policies and on the Policy premium in case of Floater

Individual sum insured policy and Floater policies with 1 Adult

Floater policies with more than 1 Adult

1st Jan 2020

30th September 2021

Upto 3000

0%

0%

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

Policy duration

End of 33 months

Points at the end of 33 months (A)
This will be considered for discount on the first renewal.

Points in next 3 months (B)

Total points considered for discount (A + B) from 2nd Policy Period onwards

Discount on renewal premium (Renewal policy start date 1st Jan 2023

NOTE: Discount applicable on the member’s premium in Individual sum insured policies and on the Policy premium in case of Floater

Individual sum insured policy and Floater policies with 1 Adult

Floater policies with more than 1 Adult

1st Jan 2020

30th September 2022

Upto 4500

0%

0%

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
The Insured Perso3n 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

2. 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 ofcleanliness and personal hygiene.
  2. Dressing: the ability to put on and take off all necessarygarments, artificial limbs or other surgical appliances that

    are medically necessary.

  3. Feeding: the ability to transfer food from a plate or bowlto the mouth once food has been prepared and made

    available.

  4. Toileting: the ability to manage bowel and bladderfunction, maintaining an adequate and socially acceptable level of hygiene.

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

  1. Mobility: the ability to move indoors from room to room on level surfaces at the normal place of residence.
  2. 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.

Conditions – The above coverage is subject to fulfilment of following conditions:

  1. The Permanent Total Disability is proved through a disabilitycertificate issued by a Medical Board duly constituted by the

    Central and/or the State Government; and

  2. We will admit a claim under this optional benefit only if thePermanent 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
  3. 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 terms and conditions mentioned therein; and
  4. 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.
  5. If a claim under this optional benefit is admitted, then 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.

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:
a. 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
b. 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

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

  1. 1  Loss or total and permanent loss of use of both the hands from the wrist joint 100%
  2. 2  Loss or total and permanent loss of use of both feet from the ankle joint 100%
  1. 6  Total and permanent loss of speech and hearing in both ears 100%
  2. 7  Total and permanent loss of hearing in both ears 50%
  3. 8  Loss or total and permanent loss of use of one hand from wrist joint 50%
  4. 9  Loss or total and permanent loss of use of one foot from ankle joint 50%
  5. 10  Total and permanent loss of sight in one eye 50%
  6. 11  Total and permanent loss of speech 50%
  7. 12  Permanent total loss of use of four fingers and thumb of either hand 40%
  8. 13  Permanent total loss of use of four fingers of either hand 35%

S. No.

Nature of Disability

% of Personal Accident Cover Sum Insured payable

3

Loss or total and permanent loss of use of one hand from the wrist joint and of one foot from the ankle joint

100%

4

Loss or total and permanent loss of use of one hand from the wrist joint and total and permanent loss of sight in one eye

100%

5

Loss or total and permanent loss of use of one foot from the ankle joint and total and permanent loss of sight in one eye

100%

Product Name: ReAssure | Product UIN: MAXHLIP21060V012021

S. No.

Nature of Disability

% of Personal Accident Cover Sum Insured payable

  1. 14  Uniplegia
  2. 15  Permanent total loss of use of one thumb of either handa. Both joints

    b. One joint

  3. 16  Permanent total loss of use of fingers of either handa. Three joints b. Two joints c. One joint
  4. 17  Permanent total loss of use of toes of either foot a. All toes- one footb. Great toe- both joints
    c. Great toe- one joint
    d. Other than great toe, one toe

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:
a. The Insured Person has been admitted in a Hospital for a

minimum period of 48 hours continuously.

5.3. Safeguard

What is covered:

  1. Claim Safeguard: If We have accepted a Hospitalization claim under Section 4, then the items which are not payable as per List I – ‘Expenses not covered’ under Annexure II related to that particular claim will become payable.
  2. Booster Benefit Safeguard: Cumulative Bonus under Section 4.12 (Booster Benefit) will not be impacted or reduced at Renewal if any one claim or multiple claims admissible in the previous Policy Year does not exceed the overall amount of Rs. 50,000.
  3. Sum Insured Safeguard: The Base Sum Insured will be increased on Cumulative Basis at each Policy Year on the basis of inflation rate in previous year. Inflation rate would be computed as the average Consumer Price index (CPI) of the entire calendar year published by the Central Statistical Organisation (CSO).

25%

25% 10%

10% 8% 5%

20% 5% 2% 1%

Conditions – The coverage under ‘Sum Insured Safeguard’ is subject to fulfilment of following conditions:
a. The % increase will be applicable only on Base Sum Insured

under the Policy and not on Booster Benefit or any other

benefit which leads to increase in Sum Insured.
b. Consumer Price index (CPI) is a measure of inflation, changes in the CPI are used to assess price changes associated with the cost of living. It is a measure that examines the weighted average of prices of a basket of consumer goods and services, such as transportation, food and medical care. It is calculated by taking price changes for each item in the predetermined

basket of goods and averaging them.
c. The Central Statistics Office (CSO) is a government agency

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

  1. 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-days waiting period).
  2. In case of enhancement of Sum Insured the exclusion shall apply afresh to the extent of Sum Insured increase.
  3. 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.
  4. The waiting period for listed conditions shall apply even if contracted after the Policy or declared and accepted without a specific exclusion.
  5. 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.
  6. List of specific diseases/procedures:
    i. Pancreatitis and stones in biliary and urinary system
    ii. Cataract, glaucoma and other disorders of lens, disordersof retina
    iii. Hyperplasia of prostate, hydrocele and spermatocele
    iv. Abnormal utero-vaginal bleeding, female genital

    prolapse, endometriosis/adenomyosis, fibroids, PCOD, or any condition requiring dilation and curettage or hysterectomy

    v. Hemorrhoids, fissure or fistula or abscess of anal and rectal region

    vi. Hernia of all sites,
    vii. Osteoarthritis, systemic connective tissue disorders,

    dorsopathies, spondylopathies, inflammatory polyarthropathies, arthrosis such as RA, gout, intervertebral disc disorders, arthroscopic surgeries for ligament repair

    viii. Chronic kidney disease and failure
    ix. Varicose veins of lower extremities
    x. All internal or external benign or in situ neoplasms/

    tumours, cyst, sinus, polyp, nodules, swelling, mass or

    lump
    xi. Ulcer, erosion and varices of gastro intestinal tract
    xii. Surgical treatment for diseases of middle ear and mastoid

    (including otitis media, cholesteatoma, perforation of tympanic membrane), Tonsils and adenoids, nasal septum and nasal sinuses

    xiii. Internal Congenital Anomaly
    xiv. Surgery of Genito-urinary system unless necessitated by

    malignancy
    xv. Spinal disorders

Month

CPI 2019

CPI 2018

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

CPI inflation rate for calendar year 2019

3.72%
i.e. (Average CPI for 2019 – Average CPI for 2018) / Average CPI for 2018

As per the table above:

  • The average CPI for 2019 is 143.9, whereas the average CPI for2018 is 138.8
  • The increase in average CPI is calculated as:
  • (Average CPI for 2019 – Average CPI for 2018) / Average CPI for2018
  • Hence, the average increase in Base Sum Insured applicable in2020 will be 3.72%.
    Note: CPI figure for a particular month is recorded from the following link: http://mospi.nic.in/cpi

    6. Exclusions

    A permanent exclusion will be applied on any medical or physical condition or treatment of an Insured Person, if specifically mentioned in the Policy Schedule and has been accepted by You. This option as per company’s underwriting policy, will be used for such condition(s) or treatment(s) that otherwise would have resulted in rejection of insurance coverage under this Policy to such Insured Person.

    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 7.1 to 7.33 are not applicable to Section 5.1 (Personal Accident Cover).

    The permanent exclusions applicable to Section 5.2 (Personal Accident Cover) have been specified separately under Section 7.34.

    Standard Exclusions

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):

  1. 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.
  2. This exclusion shall not, however, apply if the Insured Person has continuous coverage for more than twelve months
  3. The within referred waiting period is made applicable to the enhanced Sum Insured in the event of granting higher Sum Insured subsequently.

6.4. Investigation & Evaluation (Code-Excl04)

  1. Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.
  2. Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.

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:

  1. austodial care either at home or in a nursing facility forpersonal 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.
  2. Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.

6.6. 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

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:
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

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
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 6.32. the third Policy Year for that Insured Person as long as the Insured

Person has been insured continuously under the Policy without any break.

6.33. 6.20. Charges related to a Hospital stay not expressly mentioned
as being covered. This will include charges for RMO charges ,

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
c. Absent oculovestibular and corneal reflexes; or d. Complete apnea.

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,
b. Standard treatment guidelines as stated in clinical

establishment act of Government of India,
c. World Health Organisation (WHO) protocols,
d. Published guidelines by healthcare providers,
e. Guidelines set by medical societies like cardiological society

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.

  1. 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.
  2. 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.
  3. 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 5.1(c) (Permanent Partial Disability).

 

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:
a. We advise You to submit all claims related documents,

including documents for claims within the Deductible

amount, once the Deductible limit has been exhausted.

  1. 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 circumstancespertaining to the claim.
  2. We and Our Service Provider must be given all reasonableco-operation in investigating the claim in order to assess Our

    liability and quantum in respect of the claim.

  3. 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 beenproven to be for reasons beyond the claimant’s control.

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:
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:

  1. The health card We have issued to the Insured Personat the time of inception of the Policy (if available)

    supported with KYC document;

  2. The Policy Number;
  3. Name of the Policyholder;
  4. Name and address of Insured Person in respect ofwhom the request is being made;
  5. Nature of the Illness/Injury and the treatment/Surgery required;
  6. Name and address of the attending MedicalPractitioner;
  7. Hospital where treatment/Surgery is proposed to betaken;
  8. Date of admission;
  9. First and any subsequent consultation paper /Medical Record since beginning of diagnosis of that

    treatment/Surgery;

  10. Admission note;
  11. Treating Medical Practitioner certificate forIllness / 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 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
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.

7.3. 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. 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 5.1:

a.

b.

Accident Death

  1. Copy of death certificate (issued by the office of Registrarof Births and Deaths or any other authorized legal

    institution)

  2. Copy of post mortem report wherever applicable

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.

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

  1. Claim Settlement (provision for Penal Interest):
    1. The Company shall settle or reject a claim, as the case may be, within 30 days from the date of receipt of lastnecessary document.
    2. In the case of delay in the payment of a claim, theCompany shall be liable to pay interest from the date of receipt of last necessary document to the date of payment of claim at a rate 2% above the bank rate.
    3. However, where the circumstances of a claim warrant an investigation in the opinion of the Company, it shall initiate and complete such investigation at the earliest, in any case not later than 30 days from the date of receipt of last necessary document. In such cases, the Company shall settle the claim within 45 days from the date of receipt of last necessary document.
    4. In case of delay beyond stipulated 45 days, the Company shall be liable to pay interest at a rate 2% above the bank rate from the date of receipt of last necessary document to the date of payment of claim.
  2. Complete discharge: Any payment to the Insured Person or his/ her nominees or his/ her legal representative or to the Hospital/Nursing Home or assignee, as the case may be, for any benefit under the Policy shall in all cases be a full, valid and an effectual discharge towards payment of claim by the Company to the extent of that amount for the particular claim.
  3. All admissible claims under this Policy shall be assessed by Us in the following progressive order:-
    1. If a room has been opted in a Hospital for which the roomcategory 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 4.1.
    2. The Deductible (if applicable) shall be applied to the aggregate of all claims that are either paid or payable under this Policy. Our liability to make payment shall commence only once the aggregate amount of all eligible claims as per policy terms and conditions exceeds the Deductible limit within the same Policy Year.
    3. Co-payment (if applicable) as specified in the Policy Schedule shall be applicable on the amount payable by Us.
  4. The claim amount assessed in Section 8.4 d above would be deducted from the amount / sub-limit mentioned against each benefit or treatment as per terms and conditions and Sum Insured as specified in the Policy Schedule. The amount provided under ReAssure benefit will be applied only oncethe Sum Insured is exhausted in the Policy Year.

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.
c. Reports of the medical tests can be collected directly from

the Service Provider.

7.8. Claim process for Section 4.16 (Second Medical Opinion), if availed on Cashless Facility:
a. In the event of submission of request for Second Medical

Opinion, Our Service Provider shall be contacted on the

helpline number.
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 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:
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.

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

1 year

2 years

3 years

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:

No. of completed months at the time of cancellation

Refund %

Half Yearly

Quarterly

No. of completed months at the time of cancellation

Refund %

Half Yearly

Quarterly

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.

  1. The Company shall endeavor to give notice for renewal.However, the Company is not bound to give any notice for

    renewal.

  2. Renewal shall not be denied on the ground that the Insuredhad made a claim or claims in the preceding policy years.
  3. Request for renewal along with requisite premium shall be received by the Company before the end of the Policy Period.
  4. At the end of the Policy Period, the Policy shall terminate and can be renewed within the Grace Period to maintain continuity of benefits without Break in Policy. Coverage is notavailable during the Grace Period.
  5. If not renewed within Grace Period after due renewal date,the Policy shall terminate.
  6. No loading shall apply on renewals based on individual claimsexperience.

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
d. any such act or omission as the law specially declares to be

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

  1. In the likelihood of this product being withdrawn in future with due approval of IRDAI, the Company will intimate the Insured Person about the same 90 days prior to expiry of the Policy.
  2. Insured Person will have the option to migrate to similar health insurance product available with the Company at the time of renewal with all the accrued continuity benefits such as cumulative bonus, waiver of waiting period etc. provided the Policy has been maintained without a break as per extant regulatory framework.

8.8. Redressal of Grievance:

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

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
Niva Bupa Health Insurance Company Limited
D-5, 2nd Floor, Logix Infotech Park
opp. Metro Station, Sector 59, Noida, Uttar Pradesh, 201301 Email: priority.services@nivabupa.com or GRO@nivabupa.com

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:

  1. You/the Insured Person at the address specified in the PolicySchedule or at the changed address of which We must receive

    written notice.

  2. Us at the following address:Niva Bupa Health Insurance Company Limited
    D-5, 2nd Floor, Logix Infotech Park
    opp. Metro Station, Sector 59, Noida, Uttar Pradesh, 201301 Fax No.: 011-3090-2010
  3. No insurance agents, brokers or other person/entity is authorized to receive any notice on Our behalf.
  4. 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.

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:
a. Zone 1: Delhi NCR, Mumbai (including Navi Mumbai and

Thane), Kolkata and Gujarat State
Delhi NCR includes Delhi, Baghpat, Bulandshahr, Gautam Buddh Nagar, Ghaziabad, Hapur, Meerut, Muzaffarnagar, Shamli, Charkhi Dadri, Faridabad, Gurugram, Jhajjar, Jind, Karnal, Mahendragarh, Nuh, Palwal, Panipat, Rewari, Rohtak and Sonipat

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
(Individual policy: maximum Rs. 5,000 per Insured; Family Floater policy: maximum Rs. 10,000 per policy)

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
b. Booster Benefit Safeguard: No impact on Booster benefit if claim in a policy year is less than Rs. 50,000
c. Sum Insured Safeguard: CPI linked increase in Base Sum Insured

Annexure I

Product Benefit Table (all limits in INR unless defined as percentage)

Plan Type (all limits in Rs unless defined as percentage)

Individual / Family Floater

Base Sum Insured

3 lacs

4 lacs

5 lacs

7.5 lacs

10 lacs

12.5 lacs

15 lacs

20 lacs

25 lacs

50 lacs

75 lacs

100 lacs

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

S.No

Item

S.No

Item

  1. 1  BABY FOOD
  2. 2  BABY UTILITIES CHARGES
  3. 3  BEAUTY SERVICES
  4. 4  BELTS/ BRACES
  5. 5  BUDS
  6. 6  COLD PACK/HOT PACK
  7. 7  CARRY BAGS
  8. 8  EMAIL / INTERNET CHARGES
  9. 9  FOOD CHARGES (OTHER THAN PATIENT’s DIET PROVIDED BYHOSPITAL)
  10. 10  LEGGINGS
  11. 11  LAUNDRY CHARGES
  12. 12  MINERAL WATER
  13. 13  SANITARY PAD
  14. 14  TELEPHONE CHARGES
  15. 15  GUEST SERVICES
  16. 16  CREPE BANDAGE
  17. 17  DIAPER OF ANY TYPE
  18. 18  EYELET COLLAR
  19. 19  SLINGS
  20. 20  BLOOD GROUPING AND CROSS MATCHING OF DONORSSAMPLES
  21. 21  SERVICE CHARGES WHERE NURSING CHARGE ALSOCHARGED
  22. 22  TELEVISION CHARGES
  23. 23  SURCHARGES
  24. 24  ATTENDANT CHARGES
  25. 25  EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH FORMS

PART OF BED CHARGE)

  1. 26  BIRTH CERTIFICATE
  2. 27  CERTIFICATE CHARGES
  3. 28  COURIER CHARGES
  4. 29  CONVEYANCE CHARGES
  5. 30  MEDICAL CERTIFICATE
  6. 31  MEDICAL RECORDS
  7. 32  PHOTOCOPIES CHARGES
  8. 33  MORTUARY CHARGES
  1. 34  WALKING AIDS CHARGES
  2. 35  OXYGEN CYLINDER (FOR USAGE OUTSIDE THE HOSPITAL)
  3. 36  SPACER
  4. 37  SPIROMETRE
  5. 38  NEBULIZER KIT
  6. 39  STEAM INHALER
  7. 40  ARMSLING
  8. 41  THERMOMETER
  9. 42  CERVICAL COLLAR
  10. 43  SPLINT
  11. 44  DIABETIC FOOT WEAR
  12. 45  KNEE BRACES (LONG/ SHORT/ HINGED)
  13. 46  KNEE IMMOBILIZER/SHOULDER IMMOBILIZER
  14. 47  LUMBO SACRAL BELT
  15. 48  NIMBUS BED OR WATER OR AIR BED CHARGES
  16. 49  AMBULANCE COLLAR
  17. 50  AMBULANCE EQUIPMENT
  18. 51  ABDOMINAL BINDER
  19. 52  PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES
  20. 53  SUGAR FREE Tablets
  21. 54  CREAMS POWDERS LOTIONS (Toiletries are not payable,only prescribed medical pharmaceuticals payable)
  22. 55  ECG ELECTRODES
  23. 56  GLOVES
  24. 57  NEBULISATION KIT
  25. 58  ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT,ORTHOKIT, RECOVERY KIT, ETC]
  26. 59  KIDNEY TRAY
  27. 60  MASK
  28. 61  OUNCE GLASS
  29. 62  OXYGEN MASK
  30. 63  PELVIC TRACTION BELT
  31. 64  PAN CAN
  32. 65  TROLLY COVER
  33. 66  UROMETER, URINE JUG
  34. 67  AMBULANCE
  35. 68  VASOFIX SAFETY

List II – Items that are to be subsumed into Room Charges

S.No

Item

S.No

Item

  1. 1  BABY CHARGES (UNLESS SPECIFIED/INDICATED)
  2. 2  HAND WASH
  3. 3  SHOE COVER
  4. 4  CAPS
  5. 5  CRADLE CHARGES

6 COMB
7 EAU-DE-COLOGNE / ROOM FRESHNERS 8 FOOT COVER
9 GOWN
10 SLIPPERS

Product Name: ReAssure | Product UIN: MAXHLIP21060V012021

S.No

Item

S.No

Item

11 TISSUE PAPER 25 CLEAN SHEET

  1. 12  TOOTH PASTE
  2. 13  TOOTH BRUSH
  3. 14  BED PAN
  4. 15  FACE MASK
  5. 16  FLEXI MASK
  6. 17  HAND HOLDER
  7. 18  SPUTUM CUP
  8. 19  DISINFECTANT LOTIONS
  9. 20  LUXURY TAX
  10. 21  HVAC
  11. 22  HOUSE KEEPING CHARGES
  12. 23  AIR CONDITIONER CHARGES
  13. 24  IM IV INJECTION CHARGES

26 BLANKET/WARMER BLANKET
27 ADMISSION KIT
28 DIABETIC CHART CHARGES
29 DOCUMENTATION CHARGES / ADMINISTRATIVE EXPENSES 30 DISCHARGE PROCEDURE CHARGES

31 DAILY CHART CHARGES
32 ENTRANCE PASS / VISITORS PASS CHARGES
33 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE
34 FILE OPENING CHARGES
35 INCIDENTAL EXPENSES / MISC. CHARGES (NOT EXPLAINED) 36 PATIENT IDENTIFICATION BAND / NAME TAG
37 PULSEOXYMETER CHARGES

List III – Items that are to be subsumed into Procedure Charges

S.No

Item

S.No

Item

  1. 1  HAIR REMOVAL CREAM
  2. 2  DISPOSABLES RAZORS CHARGES (for site preparations)
  3. 3  EYE PAD
  4. 4  EYE SHEILD
  5. 5  CAMERA COVER
  6. 6  DVD, CD CHARGES
  7. 7  GAUSE SOFT
  8. 8  GAUZE
  9. 9  WARD AND THEATRE BOOKING CHARGES
  10. 10  ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS
  11. 11  MICROSCOPE COVER
  12. 12  SURGICAL BLADES, HARMONICSCALPEL,SHAVER

13 SURGICAL DRILL 14 EYE KIT
15 EYE DRAPE
16 X-RAY FILM

17 BOYLES APPARATUS CHARGES 18 COTTON
19 COTTON BANDAGE
20 SURGICAL TAPE

21 APRON
22 TORNIQUET
23 ORTHOBUNDLE, GYNAEC BUNDLE

List IV – Items that are to be subsumed into costs of treatment

S.No

Item

S.No

Item

  1. 1  ADMISSION/REGISTRATION CHARGES
  2. 2  HOSPITALISATION FOR EVALUATION/ DIAGNOSTICPURPOSE
  3. 3  URINE CONTAINER
  4. 4  BLOOD RESERVATION CHARGES AND ANTE NATAL BOOKING CHARGES
  5. 5  BIPAP MACHINE
  6. 6  CPAP/ CAPD EQUIPMENTS
  7. 7  INFUSION PUMP– COST
  8. 8  HYDROGEN PEROXIDE\SPIRIT\ DISINFECTANTS ETC
  9. 9  NUTRITION PLANNING CHARGES – DIETICIAN CHARGES- DIET CHARGES

10 HIV KIT
11 ANTISEPTIC MOUTHWASH
12 LOZENGES
13 MOUTH PAINT
14 VACCINATION CHARGES
15 ALCOHOL SWABES
16 SCRUB SOLUTION/STERILLIUM 17 GLUCOMETER & STRIPS
18 URINE BAG

Product Name: ReAssure | Product UIN: MAXHLIP21060V012021

Annexure III

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. Tel.: 079 – 25501201/02/05/06
Email: bimalokpal.ahmedabad@cioins.co.in

Gujarat,
UT of Dadra & Nagar Haveli, Daman and Diu.

BENGALURU – Smt. Neerja Shah

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

Karnataka.

BHOPAL – Shri Guru Saran Shrivastava

Office of the Insurance Ombudsman,
Janak Vihar Complex, 2nd Floor, 6, Malviya Nagar, Opp. Airtel Office, Near New Market, Bhopal – 462 003.
Tel.: 0755 – 2769201 / 2769202
Fax: 0755 – 2769203
Email: bimalokpal.bhopal@cioins.co.in

Madhya Pradesh Chhattisgarh.

BHUBANESHWAR – Shri Suresh Chandra Panda

Office of the Insurance Ombudsman,
62, Forest park, Bhubneshwar – 751 009. Tel.: 0674 – 2596461 /2596455
Fax: 0674 – 2596429
Email: bimalokpal.bhubaneswar@cioins.co.in

Orissa.

CHANDIGARH – Dr. Dinesh Kumar Verma

Office of the Insurance Ombudsman,
S.C.O. No. 101, 102 & 103, 2nd Floor,
Batra Building, Sector 17 – D, Chandigarh – 160 017. Tel.: 0172 – 2706196 / 2706468
Fax: 0172 – 2708274
Email: bimalokpal.chandigarh@cioins.co.in

Punjab, Haryana (excluding Gurugram, Faridabad, Sonepat and Bahadurgarh), Himachal Pradesh,
UT of Jammu & Kashmir, Ladakh and Chandigarh.

CHENNAI – Shri M. Vasantha Krishna

Office of the Insurance Ombudsman,
Fatima Akhtar Court, 4th Floor, 453,
Anna Salai, Teynampet, CHENNAI – 600 018. Tel.: 044 – 24333668 / 24335284
Fax: 044 – 24333664
Email: bimalokpal.chennai@cioins.co.in

Tamil Nadu, UT-Pondicherry Town and Karaikal (which are part of UT of Pondicherry).

DELHI – Shri Sudhir Krishna

Office of the Insurance Ombudsman, 2/2 A, Universal Insurance Building, Asaf Ali Road, New Delhi – 110 002. Tel.: 011 – 23232481/23213504 Email: bimalokpal.delhi@cioins.co.in

Delhi & Following Districts of Haryana – Gurugram, Faridabad, Sonepat & Bahadurgarh.

Product Name: ReAssure | Product UIN: MAXHLIP21060V012021

Office Details

Jurisdiction of Office Union Territory, District)

GUWAHATI – Shri Kiriti .B. Saha

Office of the Insurance Ombudsman,
Jeevan Nivesh, 5th Floor, Nr. Panbazar over bridge, S.S. Road, Guwahati – 781001(ASSAM).
Tel.: 0361 – 2632204 / 2602205
Email: bimalokpal.guwahati@cioins.co.in

Assam, Meghalaya, Manipur, Mizoram, Arunachal Pradesh, Nagaland and Tripura.

HYDERABAD – Shri I. Suresh Babu

Office of the Insurance Ombudsman,
6-2-46, 1st floor, “Moin Court”, Lane Opp. Saleem Function Palace, A. C. Guards, Lakdi-Ka-Pool, Hyderabad – 500 004.
Tel.: 040 – 23312122
Fax: 040 – 23376599
Email: bimalokpal.hyderabad@cioins.co.in

Andhra Pradesh, Telangana, UT of Yanam and part of UT of Pondicherry

JAIPUR – Smt. Sandhya Baliga

Office of the Insurance Ombudsman, Jeevan Nidhi – II Bldg., Gr. Floor, Bhawani Singh Marg, Jaipur – 302 005. Tel.: 0141 – 2740363

Email: bimalokpal.jaipur@cioins.co.in

Rajasthan.

ERNAKULAM – Ms. Poonam Bodra

Office of the Insurance Ombudsman,
2nd Floor, Pulinat Bldg., Opp. Cochin Shipyard, M. G. Road, Ernakulam – 682 015.
Tel.: 0484 – 2358759 / 2359338
Fax: 0484 – 2359336
Email: bimalokpal.ernakulam@cioins.co.in

Kerala, UT of Lakshadweep, Mahe-a part of UT of Pondicherry.

KOLKATA – Shri P. K. Rath

Office of the Insurance Ombudsman,
Hindustan Bldg. Annexe, 4th Floor, 4, C.R. Avenue, KOLKATA – 700 072.
Tel.: 033 – 22124339 / 22124340
Fax : 033 – 22124341
Email: bimalokpal.kolkata@cioins.co.in

West Bengal, Sikkim, UT of Andaman & Nicobar Islands.

LUCKNOW -Shri Justice Anil Kumar Srivastava

Office of the Insurance Ombudsman,
6th Floor, Jeevan Bhawan, Phase-II,
Nawal Kishore Road, Hazratganj, Lucknow – 226 001. Tel.: 0522 – 2231330 / 2231331
Fax: 0522 – 2231310
Email: bimalokpal.lucknow@cioins.co.in

Districts of Uttar Pradesh :
Lalitpur, Jhansi, Mahoba, Hamirpur, Banda, Chitrakoot, Allahabad, Mirzapur, Sonbhabdra, Fatehpur, Pratapgarh, Jaunpur,Varanasi, Gazipur, Jalaun, Kanpur, Lucknow, Unnao, Sitapur, Lakhimpur, Bahraich, Barabanki, Raebareli, Sravasti, Gonda, Faizabad, Amethi, Kaushambi, Balrampur, Basti, Ambedkarnagar, Sultanpur, Maharajgang, Santkabirnagar, Azamgarh, Kushinagar, Gorkhpur, Deoria, Mau, Ghazipur, Chandauli, Ballia, Sidharathnagar.

MUMBAI – Shri Milind A. Kharat

Office of the Insurance Ombudsman,
3rd Floor, Jeevan Seva Annexe,
S. V. Road, Santacruz (W), Mumbai – 400 054. Tel.: 022 – 26106552 / 26106960
Fax: 022 – 26106052
Email: bimalokpal.mumbai@cioins.co.in

Goa,
Mumbai Metropolitan Region excluding Navi Mumbai & Thane

Product Name: ReAssure | Product UIN: MAXHLIP21060V012021

Office Details

Jurisdiction of Office Union Territory, District)

NOIDA – Shri Chandra Shekhar Prasad

Office of the Insurance Ombudsman,
Bhagwan Sahai Palace 4th Floor, Main Road,
Naya Bans, Sector 15, Distt: Gautam Buddh Nagar, U.P-201301. Tel.: 0120-2514252 / 2514253
Email: bimalokpal.noida@cioins.co.in

State of Uttaranchal and the following Districts of Uttar Pradesh: Agra, Aligarh, Bagpat, Bareilly, Bijnor, Budaun, Bulandshehar, Etah, Kanooj, Mainpuri, Mathura, Meerut, Moradabad, Muzaffarnagar, Oraiyya, Pilibhit, Etawah, Farrukhabad, Firozbad, Gautambodhanagar, Ghaziabad, Hardoi, Shahjahanpur,

Hapur, Shamli, Rampur, Kashganj, Sambhal, Amroha, Hathras, Kanshiramnagar, Saharanpur.

PATNA – Shri N. K. Singh

Office of the Insurance Ombudsman,
1st Floor, Kalpana Arcade Building,,
Bazar Samiti Road, Bahadurpur, Patna 800 006. Tel.: 0612-2680952
Email: bimalokpal.patna@cioins.co.in

Bihar, Jharkhand.

PUNE – Shri Vinay Sah

Office of the Insurance Ombudsman,
Jeevan Darshan Bldg., 3rd Floor, C.T.S. No.s. 195 to 198, N.C. Kelkar Road, Narayan Peth, Pune – 411 030.
Tel.: 020-41312555
Email: bimalokpal.pune@cioins.co.in

Maharashtra,
Area of Navi Mumbai and Thane excluding Mumbai Metropolitan Region.

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

Product Name: ReAssure | Product UIN: MAXHLIP21060V012021

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