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Apollo Easy Individual And Family Health Plan-Exclusive


Apollo DKV Insurance Company Limited will provide the insurance cover detailed in the Policy to the Insured Person up to the Sum Insured subject to the terms and conditions of this Policy, Your payment of premium, and your statements in the Proposal, which is incorporated into the Policy and is the basis of it.

Section. 1 Benefit

Claims made in respect of any of the benefits below will be subject to the Sum Insured and will affect both the entitlement to a Cumulative bonus and a health check-up.

If any Insured Person suffers an Illness or Accident during the Policy Period that requires that Insured Person's Hospitalization as an inpatient, then we will pay:


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a)         In-patient Treatment

The Medical Expenses for:

i)          Room rent, boarding expenses,

ii)         Nursing,

iii)        Intensive care unit,

v)         A Medical Practitioner,

vi)        Anesthesia, blood, oxygen, operation theatre charges, surgical appliances,

vii)       Medicines, drugs and consumables,

viii)      Diagnostic procedures,

iv)        The Cost of prosthetic and other devices or equipment if implanted internally during a Surgical Procedure.

b)         Pre-Hospitalization

The Medical Expenses incurred due to an Illness in the 30 days immediately before the Insured Person was hospitalized, provided that:

i)          Such Medical Expenses were in fact incurred for the same condition for which the Insured Person's subsequent Hospitalization was required, and

ii)         We have accepted an inpatient Hospitalization claim under Benefit 1a).

iii)        We will pay the Medical Expenses incurred within the 60 days prior to the date of Hospitalization, if we are provided with the following at least 5 days before the Hospitalization:

(1)        Medical documents with all details about the Illness; and

(2)        The date and the place of the proposed Hospitalization.

c)         Post-hospitalization

The Medical Expenses incurred in the 60 days immediately after the Insured Person was discharged post Hospitalization provided that:

i)          Such costs are incurred in respect of the same condition for which the Insured Person's earlier Hospitalization was required, and ii) We have accepted an inpatient Hospitalization claim under Benefit 1a). iii) We will pay the Medical Expenses in the 90 days immediately after the Insured Person was discharged if We were provided with the following at least 5 days before the Hospitalization:

(1)        Medical documents with all details about the Illness; and

(2)        The date and the place of the proposed Hospitalization.

d)         Day Care Procedures

The Medical Expenses for a day care procedure or surgery mentioned in the list of Day Care Procedures in this Policy where the procedure or surgery is taken by the Insured Person as an inpatient for less than 24 hours in a Hospital (but not the outpatient department of a Hospital).

e)         Domiciliary Treatment

The Medical Expenses incurred by an Insured Person for medical treatment taken at his home which would otherwise have required Hospitalization because, on the advice of the attending Medical Practitioner, the Insured Person could not be transferred to a Hospital or a Hospital bed was unavailable, and provided that:

i)          The condition for which the medical treatment is required continues for at least 3 days, in which case We will pay the reasonable cost of any necessary medical treatment for the entire period, and

ii)         If We accept a claim under this Benefit We will not make any payment for Post-Hospitalization expenses but We will pay Pre-hospitalization expenses for up to 60 days in accordance with b) above, and

iii)        No payment will be made if the condition for which the Insured Person requires Medical treatment is:

(1)        Asthma, Bronchitis, Tonsillitis and Upper Respiratory Tract infection including Laryngitis and Pharyngitis, Cough and Cold, Influenza,

(2)        Arthritis, Gout and Rheumatism,

(3)        Chronic Nephritis and Nephritic Syndrome,

(4)        Diarrhea and all type of Dysenteries including Gastroenteritis,

(5)        Diabetes Mellitus and Insupidus,

(6)        Epilepsy,

(7)        Hypertension,

(8)        Psychiatric or Psychosomatic Disorders of all kinds,

(9)        Pyrexia of unknown Origin.

Section. 2        Additional Benefits

Claims made in respect of any of the benefits below will be subject to the Sum Insured and will affect both the entitlement to a Cumulative bonus and a health check-up.

a)         Daily Cash for choosing Shared Accommodation

A daily cash amount will be payable per day if the Insured Person is Hospitalized in Shared Accommodation in a Network Hospital for each continuous and completed period of 24 hours if the Hospitalization exceeds 48 hours, provided that:

i)          Our maximum liability shall be restricted to the amount mentioned in the Schedule of Benefits, and

ii)         The days of admission and discharge shall not be counted, and

iii)        This benefit shall not apply to time spent by the Insured Person in an intensive care unit, and

 iv)       We have accepted an inpatient Hospitalization claim under Benefit 1a),

b)         Organ Donor

The Medical Expenses for an organ donor’s treatment for the harvesting of the organ donated, provided that:

i)          The organ donor is the Insured Person's blood relative and the organ donated is for The use of the Insured Person, and ii) we will not pay the donor's pre- and post-hospitalization expenses or any other Medical treatment for the donor consequent on the harvesting, and

iii)        We have accepted an inpatient Hospitalization claim under Benefit 1a).

c)         Emergency Ambulance

We will reimburse the expenses incurred on an ambulance offered by a healthcare or ambulance service provider used to transfer the Insured Person to the nearest Hospital with adequate emergency facilities for the provision of health services following an emergency (namely a sudden, urgent, unexpected occurrence or event, bodily alteration or occasion requiring immediate medical attention), provided that:

i)          Our maximum liability shall be restricted to the amount mentioned in the Schedule of Benefits, and

ii)         We have accepted an inpatient Hospitalization claim under Benefit 1a).

d)         Daily Cash for Accompanying an Insured Child

Note:   This benefit is optional and effective only if noted as such 'n the Schedule of Benefits:

If the Insured Person Hospitalized is a child Aged 12 years or less, We will pay a daily cash amount for 1 accompanying adult for each complete period of 24 hours if Hospitalization exceeds 72 hours, provided that:

i)          Our maximum liability shall be restricted to the amount mentioned in the Schedule of Benefits, and

ii)         The days of admission and discharge shall not be counted, and

iii)        We have accepted an inpatient Hospitalization claim under Benefit 1a).

e)         Newborn baby

Note:   This benefit is optional and effective only if noted as such in the Schedule of Benefits:

We will cover the Medical Expenses of any medically necessary treatment described at 1)a) while the Insured Person is Hospitalized during the Policy Period as an inpatient for a Newborn Baby provided that:

i)          we have accepted a claim under 3a), and

ii)         You have submitted a proposal for the insurance of the newborn baby within 30 working days after the birth, and we have in our sole and absolute discretion accepted the same and received the premium sought.

Newborn Baby means those babies born to you and your spouse during the Policy Period Aged between 1 day and 90 days.

Section. 3        Additional Benefits not related to Sum Insured

Claims made in respect of any of the benefits below will not be subject to the Sum Insured and will not affect either the entitlement to a Cumulative bonus or a health check-up.

The benefits below are optional and each is only effective if shown in the Schedule to be effective.

a)         Maternity Expenses

We will pay the Medical Expenses for a delivery (including caesarean section) while Hospitalized or the lawful medical termination of pregnancy during the Policy Period limited to 2 deliveries or terminations or either during the lifetime of the Insured Person, provided that:

i)          Our maximum liability per delivery or termination shall be limited to the amount Specified in the Schedule of Benefits, and

ii)         We will pay the Medical Expenses of pre-natal and post-natal expenses per delivery or termination up to the amount stated in the Schedule of Benefits, and

iii)        We will cover the Medical Expenses incurred for the medically necessary Treatment of the new born baby up to the amount stated in the Schedule of Benefits unless the new born baby is covered under 2e), and

iv)        This benefit is not available for Dependents other than your spouse under a Family Floater, and

v)         Pre and post-hospitalization expenses under 1)b) and 1)c) are not covered under this benefit, and

vi)        The Insured Person must have been an Insured Person under Our Policy for the period of time specified in the Schedule of Benefits, and

vii)       We will not cover ectopic pregnancy under this benefit (although it shall be covered under 1a).

b)         Outpatient Dental Treatment

If You renew this Policy with Us for 3 consecutive years without a break, then from the fourth year onwards We will pay 50% of the reasonable costs of any necessary dental treatment taken from a Network dentist by an Insured Person who has been covered under this policy benefit for the previous 3 Policy Years, provided that:

i)          Our maximum liability shall be limited to the amount specified in the Schedule of Benefits, and

ii)         We will only pay for X-rays, extractions, amalgam or composite fillings, root canal treatments and prescribed drugs for the same, and

iii)        We will not pay for any dental treatment that comprises cosmetic surgery, dentures, dental prosthesis, dental implants, orthodontics, orthognathic surgery, jaw alignment or treatment for the temporomandibular (jaw) joint, or upper and lower jaw bone surgery and surgery related to the temporomandibular (jaw) unless necessitated by an acute traumatic injury or cancer.

c)         Spectacles, Contact Lenses, Hearing Aid

In every third year that an Insured Person is insured without a break under an Easy Health Individual Health Insurance Plan or Easy Health Family Floater Insurance Plan with Us, We will pay up to 50% of the actual cost of either:

i)          One pair of spectacles or contact lenses, or

ii)         A hearing aid. Excluding batteries.

Provided that:

i)          If the costs claimed are incurred as Outpatient Treatment expenses then these Items must be prescribed by a Network EYE/ENT specialized Medical Practitioner, and

ii)         Our maximum liability shall be limited to the amount mentioned in the Schedule of Benefits, and

iii)        Under a Family Floater, Our liability shall be limited to either one pair of Spectacles or hearing aid per family.

d)         E-Opinion in respect of a Critical Illness

i)          If an Insured Person suffers a Critical Illness during the Policy Period, and no previous claim has been made for this benefit in the Policy Period, then at the Insured Person's request we will arrange a second opinion from a Medical Practitioner selected by the Insured Person from Our panel. The second opinion will be based only on the information and documentation provided to the Medical Practitioner by or on behalf of the Insured Person, and the second opinion will be sent directly to the Insured Person by the Medical Practitioner,

ii)         In opting for this benefit and deciding to obtain an E-opinion, each Insured Person expressly notes and agrees that:

(1)        It is entirely for the Insured Person to decide whether to obtain an E-opinion. From which person from Our Panel to take the E-opinion and the use (if any) to which the E-opinion so obtained is put.

(2)        We do not provide an E-opinion or make any representation as to the adequacy or accuracy of the same, the Insured Person's or any other person's reliance on the same, or the use to which the E-opinion is put.

(3)        We assume no responsibility for and will not be responsible for any actual or alleged errors, omissions or representations made by any Medical Practitioner or in any E-opinion or for any consequences of any action taken or not taken in reliance thereon.

Section. 4        Critical Illness Benefit

Claims made in respect of any of the benefits below will not be subject to the Sum Insured and will not affect either the entitlement to a Cumulative bonus or a health check-up.

If the Schedule shows that the Critical Illness benefit is effective, then We will pay the Critical Illness Sum Insured as a lump sum in addition to Our payment under 1)a), provided that:

i)          The Insured Person is first diagnosed as suffering from a Critical Illness during the Policy Period, and

ii)         The Insured Person survives for at least 30 days following such diagnosis.

b)         We will not make any payment if:

i)          The Insured Person is first diagnosed as suffering from a Critical Illness within 90 days of the commencement of the Policy Period and the Insured Person has not previously been insured continuously and without interruption under an Easy Health Individual Health Insurance Plan or Easy Health Family Floater Insurance Plan.

ii)         The Insured Person has already made a claim for the same Critical Illness.

iii)        A claim for this benefit has already been made 3 times under this Policy or any other policy issued by us.

Section. 5        Renewal Incentives 

Cumulative Bonus

a)         If no claim has been made under the Policy and the Policy is renewed with us without any break, we will apply a cumulative bonus to the next Policy Year by automatically increasing the Sum Insured for the next Policy Year by 10% of the Sum Insured for this Policy Year. The maximum cumulative bonus shall not exceed 50% of the Sum Insured in any Policy Year.

b)         In relation to a Family Floater, the cumulative bonus so applied will only be available in respect of claims made by those Insured Persons who were Insured Persons in the claim free Policy Year and continue to be Insured Persons in the subsequent Policy Year.

c)         If a cumulative bonus has been applied and a claim is made, then in the subsequent Policy Year we will automatically decrease the cumulative bonus by 20% of the Sum Insured in that following Policy Year.

Health Check-up

d)         If no claim has been made in respect of any benefits and You have maintained an Easy Health Individual Hea            lth Insurance Plan or Easy Health Family Floater Insurance Plan with Us for the period of time mentioned in the Schedule of Benefits without any break, then in every subsequent Policy Year We will pay up to the percentage (mentioned in the Schedule of Benefits) of the Sum Insured for this Policy Year or the subsequent Policy Years (whichever is lower) towards the cost of a medical check-up for those Insured Persons who were insured for the number previous Policy Years mentioned in the Schedule.

Section. 6        Exclusions

Waiting Periods

a)         We are not liable for any treatment which begins during waiting periods except if any Insured Person suffers an Accident. 30 days waiting Period

b)         A waiting period of 30 days (or longer if specified in any benefit) will apply to all claims unless:

i)          The Insured Person has been insured under Easy Health Individual Health Insurance Plan or Easy Health Family Floater Insurance Plan continuously and without any break in the previous Policy Year, or

ii)         The Insured Person was insured continuously and without interruption for at least 1 year under another Indian insurer's individual health insurance policy for the reimbursement of medical costs for inpatient treatment in a hospital, and he establishes to our satisfaction that he was unaware of and had not taken any advice or medication for such Illness or treatment.

iii)        If the Insured person renews with Us or transfers from any other insurer and increases the Sum Insured (other than as a result of the application of Benefit 5a) upon renewal with Us), then this exclusion shall only apply in relation to the amount by which the Sum Insured has been increased.

Specific Waiting Periods

c)         The Illnesses and treatments listed below will be covered subject to a waiting period of 2 years as long as in the third Policy Year the Insured Person has been insured under an

Easy Health Individual Health Insurance Plan or Easy Health Family Floater Insurance Plan continuously and without any break:

i)          Illnesses: arthritis if non infective; calculus diseases of gall bladder and urogenital system; cataract; fissure/fistula in anus, hemorrhoids, pilonidal sinus, gastric and duodenal ulcers; gout and rheumatism; internal tumors, cysts, nodules, polyps including breast lumps (each of any kind unless malignant); osteoarthritis and osteoporosis if age related; polycystic ovarian diseases; sinusitis and related disorders and skin tumors unless malignant.

ii)         Treatments: benign ear, nose and throat (ENT) disorders and surgeries (including but not limited to adenoidectomy, mastoidectomy, tonsillectomy and tympanoplasty); dilatation and curettage (D&C); hysterectomy for menorrhagia or fibromyoma or prolapsed of uterus unless necessitated by malignancy; joint replacement; myomectomy for fibroids; surgery of gallbladder and bile duct unless necessitated by malignancy; surgery of genito urinary system unless necessitated by malignancy; surgery of begging prostatic hypertrophy; surgery of hernia; surgery of hydrocele; surgery for prolapsed inter vertebral disk; surgery of varicose veins and varicose ulcers; surgery on tonsils and sinuses.

iii)        However, a waiting period of 2 years will not apply if the Insured Person was insured continuously and without interruption for at least 2 years under another Indian insurer's individual health insurance policy for the reimbursement of medical costs for inpatient treatment in a hospital, and he establishes to Our satisfaction that he was unaware of and had not taken any advice or medication for such Illness or treatment.

iv)        If the Insured person renews with Us or transfers from any other insurer and increases the Sum Insured (other than as a result of the application of Benefit 5a) upon renewal with Us), then this exclusion shall only apply in relation to the amount by which the Sum Insured has been increased.

d)         Pre-existing Conditions which the Insured Person has declared in the Proposal or of which he was unaware at the inception of the Policy will be covered subject to a waiting period of 3 years as long as in the fourth Policy Year the Insured Person has been insured under an Easy Health Individual Health Insurance Plan or Easy Health Family Floater Insurance Plan continuously and without any break, but a waiting period of 1 year will apply, if the Insured Person:

i)          was insured continuously and without interruption for at least 2 years under another Indian insurer's individual health insurance policy for the reimbursement of medical costs for inpatient treatment in a Hospital, and

ii)         Establishes to Our satisfaction that he was unaware of and had not taken any advice or medication for such Illness or treatment.

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

i)          War or any act of war, invasion, act of foreign enemy, war like operations (whether war be declared or not or caused during service in the armed forces of any country), civil war, public defense, rebellion, revolution, insurrection, military or usurped acts, nuclear weapons/materials, chemical and biological weapons, radiation of any kind.

ii)         Any Insured Person committing or attempting to commit a criminal or illegal act, or intentional self injury or attempted suicide while sane or insane.

iii)        Any Insured Person's participation or involvement in naval, military or air force operation, racing, diving, aviation, scuba diving, parachuting, hang-gliding, rock or mountain climbing.

iv)        The abuse or the consequences of the abuse of intoxicants or hallucinogenic substances such as drugs and alcohol, including smoking cessation programs and the treatment of nicotine addiction or any other substance abuse treatment or services, or supplies.

v)         Obesity or morbid obesity and any weight control program, where obesity means a condition in which the Body Mass Index (BMI) is above 29 & morbid obesity means a condition where BMI is above 37.

vi)        Psychiatric, mental disorders (including mental health treatments and, sleep-apnea), Parkinson and Alzheimer's disease, general debility or exhaustion ("run-down condition"); congenital internal or external diseases, defects or anomalies, genetic disorders; stem cell implantation or surgery, or growth hormone therapy.

vii)       Venereal disease, sexually transmitted disease or illness; "AIDS" (Acquired Immune Deficiency Syndrome) and/or infection with HIV (Human immunodeficiency virus) including Dut not limited to conditions related to or arising out of HIV/AIDS such as ARC (AIDS related complex), Lymphomas in brain, Kaposi's sarcoma, tuberculosis.

viii)      Save as and to the extent provided for under 3(a), pregnancy (including voluntary termination), miscarriage (except as a result of an Accident or Illness), maternity or birth (including caesarean section) except in the case of ectopic pregnancy in relation to 1(a) only.

ix)        Sterility, treatment whether to effect or to treat infertility, any fertility, sub-fertility or assisted conception procedure, surrogate or vicarious pregnancy, birth control, contraceptive supplies or services including complications arising due to supplying services.

x)         Save as and to the extent provided for less than 3 (b), dental treatment and surgery of any kind, unless requiring Hospitalization.

xi)        Expenses for donor screening, or, save as and to the extent provided for in 2(b), the treatment of the donor (including surgery to remove organs from a donor in the case of transplant surgery).

xii)       Treatment and supplies for analysis and adjustments of spinal subluxation, diagnosis and treatment by manipulation of the skeletal structure or for muscle stimulation by any means (except treatment of fractures and dislocations of the extremities).

xiii)      Nasal septum deviation and nasal concha resection; circumcisions, laser treatment for correction of eye due to refractive error, aesthetic or change-of-life treatments of any description such as sex transformation operations, treatments to do or undo changes in appearance or carried out in childhood or at any other.

xxv)     Artificial limbs, crutches or any other external appliance and/or device used for diagnosis or treatment.

xxvi)    Any exclusion mentioned in the Schedule or the breach of any specific condition mentioned in the Schedule.


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By Kamal Kumar on Feb 4, 2016 11:49 AM

Take a Best Policy Call 9716898740
By sunil kumar on Feb 26, 2015 8:39 PM

i am 29 year old can i get 3 lacs family hailth plan my wife age 25 year old and my big son 3 year and small boy 1year.
By Devendra kumar yadav on Aug 14, 2014 5:03 PM

pls me provide helth insurance.
By N. Ramakrishnan on Nov 27, 2011 2:22 PM

I am 63 years old Can i get cover for 5.00 lacs individually for self & my wife aged 58 years If yes then how to proceed
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