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Apollo Maxima Health Plan Policy-Wording


MAXIMA HEALTH PLAN POLICY-WORDING

Customer information sheet
The information mentioned below is illustrative and not exhaustive. Information must be read in conjunction with the product brochures and policy
document. In case of any conflict between the Key Features Document and the policy document the terms and conditions mentioned in the policy
document shall prevail.

TITLE

DESCRIPTION


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REFER TO POLICY CLAUSE NUMBER

Product Name

Maxima Insurance

 

What am I covered for:

Outpatient Module

a.  Outpatient Consultations in Network/ Non-Network (on reimbursement basis only) by a general Medical Practitioner(s) or a specialist Medical Practitioner(s).

b.   Diagnostic Tests within specified Network prescribed by a Medical Practitioner.

 

c.   Pharmacy (Medicines) within specified Network prescribed in writing by a Medical Practitioner. 

d.   Outpatient Dental Treatment within specified Network (except cosmetic treatment).

 

e.  One pair of Spectacles, Contact lenses within specified Network prescribed by a network Eye specialist.

 

f.   Annual Health Check Up within specified Network.
 

Inpatient Module

a.   In-patient Treatment - Covers hospitalization expenses for period more than 24 hrs.

 

b.  Pre-Hospitalization - Medical Expenses incurred in 30 days before the hospitalization, can be increased to 60 days if claim is intimated 5 days before hospitalization.

 

c.  Post-Hospitalisation - Medical Expenses incurred in 60 days after the hospitalisation, can be increased to 90 days if claim is intimated 5 days before hospitalisation.

 

d. Day-Care procedures – Medical Expenses for 140 listed Day care procedures.

 

e.  Domiciliary Treatment - Medical Expenses incurred for availing medical treatment at home which would otherwise have required hospitalisation.

f. Organ Donor - Medical Expenses for an organ donors treatment for organ transplantation.

 

g.  Daily Cash for choosing shared accommodation - Daily cash amount if hospitalised in Shared accommodation in Network Hospital and hospitalisation exceeds 48 hrs.

h. Daily Cash for accompanying an insured child - Daily cash amount for 1 accompanying adult if insured child aged 12 years or less is hospitalised and hospitalisation exceeds 72 hrs.

i. Emergency Ambulance – Upto Rs. 2,000 per hospitalisation for utilizing ambulance service for Transporting Insured Person to hospital in case of an emergency.

j. Maternity Expenses – Medical Expenses for maternity including pre-natal and post-natal Expenses after a waiting period of 4 years.

k.     Newborn baby – Optional Coverage for newborn from birth (day 1-90) for In-patient Treatment Benefit, subject to acceptance of proposal and premium payment in full.

Critical Illness (Optional Benefit) for listed Critical Illness, subject to first diagnosed during the policy period and the Insured Person survives 30 days after such diagnosis.

 

 

 

Part A, Section 1 a)

 

  

Part A, Section 1 b)

 

Part A, Section 1 c)

 

 

Part A, Section 1 d)

Part A, Section 1 e)

 

Part A, Section 1 f)

 

 

Part B, Section 3 a)

 

 

Part B, Section 3 b)

 

  

Part B, Section 3 c)

Part B, Section 3 d)

 

 

Part B, Section 3 e)

 

 

Part B, Section 3 g)

Part B, Section 3 f)

 

 

Part B, Section 3 i)

 

Part B, Section 3 h)

 

Part B, Section 3 j)

 

Part B, Section 3 k)

 

Part B, Section 5

What are the major exclusions in the policy:

Following is a partial list of the policy exclusions. Please refer to the policy wording for the complete List of exclusions.

Outpatient Module – Nil

Inpatient Module - War or any act of war, nuclear, chemical & biological weapons, radiation of any kind, breach of law with criminal intent, attempted suicide, participation or involvement in naval, military or air force operation, adventurous sports, abuse of intoxicants or hallucinogenic substances, treatment of obesity, Psychiatric, mental disorders, congenital internal or external diseases, defects or anomalies, genetic disorders; sleep apnoea, HIV or AIDs and related diseases, treatment of Sterility, infertility, fertility, sub-fertility, surrogate or vicarious pregnancy, birth control, plastic surgery or Cosmetic surgery, any non allopathic treatment.

Critical Illness – Any Critical Illness within 90 days of the commencement of the policy.

 

 

 

Part B, Section 6

 

 

 

Part B, Section 5

Waiting Period

Outpatient Module - Nil Inpatient Module -

•    30 days for all illnesses (except accident)

•    24 months for specific illness and treatment

•    Pre-existing diseases will be covered after a waiting period of 36 months.

 

Part B, Section 6 b)

Part B, Section 6 c)

Part B, Section 6 d)  

TITLE

DESCRIPTION

REFER TO POLICY CLAUSE NUMBER

Payout basis

Outpatient Module - Entitlement certificates to be used at network service providers. Inpatient Module – Cashless or Reimbursement of covered expenses upto specified limits. Critical Illness - Lump sum amount on the occurrence of a covered event.

Part A

Part B, Section 3

Part B, Section 5

Cost Sharing

Outpatient Module - Reimbursement for non-network Outpatient Consultations restricted up to lower of actual expenses or amount mentioned in schedule of benefits. Inpatient Module - Not applicable.

Part A, Section 1  a)

Renewal Conditions

•    Policy is ordinarily life-long renewable, subject to application for renewal and the renewal
premium in full has been received by the due dates and realization of premium.

•    For Optional Benefit of Critical Illness, renewal is allowed till the age of 70 years.

•    Grace period of 15 days for renewing the policy is provided at Our sole discretion,
any claim incurred during break-in period will not be payable under this policy.

Part C p), q), r)

Renewal Benefits

 

 

 

 

 

 

 

Outpatient Module - Carry forward 50% of the unutilized Entitlement Certificates to the next policy year except for Annual Health Checkup benefit.

Inpatient Module – 10% increase in your annual inpatient benefit sum insured for every claim free year, subject to a maximum of 50%. In case a claim is made during a policy year, the cumulative bonus would reduce by 20% in the following year.

Part A, Section 2 Part B, Section 4

 

Cancellation

This policy would be cancelled, and no claim or refund would be due to if (1) You have not correctly

disclosed details about your current and past health status OR (2) Have otherwise encouraged or

participated in any fraudulent claims under the policy.

Part C j), k), l)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

  

  

 

 

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.

Part A – Outpatient Module
Claims made in respect of any of the benefits in this Part A will not be subject to the Sum Insured and will affect the entitlement
to a Carry Forward Bonus.
However, Our maximum liability for each benefit in Section 1 to this Part A shall be limited to the amount specified in the Schedule of Benefits against such benefit. An Insured Person shall only be eligible to take the treatment, consultation or procedure under a Part A, Section 1 benefit if all of the following requirements are satisfied :
a) We have issued an Entitlement Certificate to the Insured Person for the specific treatment, consultation or procedure; and
b) The Entitlement Certificate is used for the specific treatment, consultation or procedure specified in it; and
c) Any conditions or limitations specified in the Entitlement Certificate are strictly adhered to; and
d) The Entitlement Certificate is used (and will only be effective) at only a Network service provider; and
e) The Insured Person gives the Entitlement Certificate to the Network service provider before receiving or undergoing the treatment, consultation or procedure specified in it.
f) The treatment, consultation or procedure specified in the Entitlement Certificate is taken or undergone by the Insured Peson during the Policy Period.
g) The payment of premium in full and in time.
h) If an Entitlement Certificate has been used and results in treatment to which Part B responds, then it is agreed and understood that We would be refunding the Entitlement Certificate used for pre-hospitalisation by issuing fresh Entitlement Certificate.

Section. 1 Outpatient Benefits
An Entitlement Certificate may be obtained by the Insured Person for his own use for one of the specified treatments, consultations or procedures under a benefit mentioned in a) – f) below:
a) Outpatient Consultations
Outpatient consultation by a general Medical Practitioner or a specialist Medical Practitioner as further specified in the Entitlement Certificate in a Network Hospital.
i. The non-network Outpatient consultations will be covered on reimbursement basis subject to the number of consultations and the amount specified in the Schedule of Benefits.

b) Diagnostic Tests within specified Network
Outpatient diagnostic tests taken by the Insured Person from a Network diagnostic centre (not necessarily to be prescribed by Network Medical Practitioner).

c) Pharmacy within specified Network
Medicines purchased by the Insured Person from a Network pharmacy, provided that such medicines have been prescribed in writing by a Medical Practitioner (not necessarily to be Network Medical Practitioner).

d) Outpatient Dental Treatment within specified Network
Any necessary dental treatment taken by an Insured Person from a Network dentist,

i. provided that we will not pay for any dental treatment that comprises cosmetic treatment and
ii. the benefit amount is restricted to Rs. 1,000 per Policy Year

e) Spectacles, Contact lenses within specified Network
Either one pair of spectacles or contact lenses, as specified in the Entitlement Certificate provided that
i. these have been prescribed for the Insured Person by a Eye specialist Network Medical Practitioner, and
ii. the benefit amount is restricted to Rs. 1,000 per Policy Year

f) Annual Health Check-Up within specified Network
A health check-up as specified in the Schedule of Benefits for the Insured Person in a Network Hospital. This benefit is not available to the Insured Persons below 18 years of age and above the age of 45 years in the first Policy Year with Us.

Section. 2 Carry Forward Bonus
a) If the Policy is renewed with Us without any break and there are any available Entitlement Certificates are not used by the Insured Person in a Policy Year, then We will carry forward 50% of these Entitlement Certificates to the next Policy Year.

b) It is expressly agreed and understood that:
i) a carry forward will only apply in respect of any particular Entitlement Certificate for one Policy Year; and
ii) there shall be no carry forward of any Entitlement Certificate for the benefit at Section 1f) of Part A.
iii) there will be no Carry Forward Bonus unless the originals of all unused Entitlement Certificates are returned to us before renewal (grace period of 15 days from the due date of renewal).
iv) for the purpose of computing carry forward of any Entitlement Certificate; in the event of unused Entitlement Certificates received are in odd number, We will round them off to next increased number.

c) To obtain carry forward Entitlement Certificates, You have to send Us all unused Entitlement Certificates before renewal. After verifying the Entitlement Certificates and checking the admissibility of Carry Forward Bonus as mentioned above, fresh Entitlement Certificates will be issued within 30 days of the receipt of the unused Entitlement Certificates provided that the policy is renewed with Us without a break.

Part B – Inpatient Module
Section. 3 Inpatient Benefits
Claims made in respect of any of the benefits below will be subject to the Sum Insured and will affect the entitlement to a cumulative bonus.
If any Insured Person suffers an Illness or Accident during the Policy Period that requires that Insured Person’s Hospitalisation as an inpatient, then We will pay:
a) In-patient Treatment
The Medical Expenses for:
i) Room rent, boarding expenses,
ii) Nursing,
iii) Intensive care unit,
iv) Medical Practitioner(s),
v) Anaesthesia, blood, oxygen, operation theatre charges, surgical appliances,
vi) Medicines, drugs and consumable,
vii) Diagnostic procedures,
viii) The Cost of prosthetic and other devices or equipment if implanted internally during a Surgical Procedure.

b) Pre-Hospitalisation
The Medical Expenses incurred in the 30 days immediately before the Insured Person was Hospitalised, provided that :
i) such Medical Expenses were in fact incurred for the same condition for which the Insured Person’s subsequent Hospitalisation was required, and
ii) We have accepted an inpatient Hospitalisation claim under Section 3 a).
iii) We will pay the Medical Expenses incurred within the 60 days prior to the date of Hospitalisation, if we are provided with the following at least 5 days before the Hospitalisation:
(1) medical documents with all details about the Illness; and
(2) the date and the place of the proposed Hospitalisation.
 

c) Post-hospitalisation
The Medical Expenses incurred in the 60 days immediately after the Insured Person was discharged post Hospitalisation provided that:
i) such costs are incurred in respect of the same condition for which the Insured Person’s earlier Hospitalisation was required, and
ii) We have accepted an inpatient Hospitalisation claim under Section 3 a).
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 Hospitalisation :
(1) medical documents with all details about the Illness; and
(2) the date and the place of the proposed Hospitalisation.

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 or standalone day care centre but not the outpatient department of a Hospital or standalone day care centre.

e) Domiciliary Treatment
The Medical Expenses incurred by an Insured Person for medical treatment taken at his home which would otherwise have required Hospitalisation 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-Hospitalisation expenses but We will pay Pre-hospitalisation expenses for up to 60 days in accordance with b) above, and
(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) Diarrhoea 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.

f) Daily Cash for choosing Shared Accommodation
Note: Claims made in respect of this benefit will be subject to the Sum Insured and will affect the entitlement to a cumulative bonus.
A daily cash amount will be payable per day if the Insured Person is Hospitalised in Shared Accommodation in a Network Hospital for each continuous and completed period of 24 hours if the Hospitalisation 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 Hospitalisation claim under Section 3 a).

g) 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 any person whose organ has been made available in accordance and in compliance with the Transplantation of Human Organs Act 1994 and the organ donated is for the use of the Insured Person, and
ii) We will not pay the donor’s pre- and post-hospitalisation expenses or any other medical treatment for the donor consequent on the harvesting, and
iii) We have accepted an inpatient Hospitalisation claim under Section 3 a).

h) 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 per Hospitalisation, and
ii. We have accepted an inpatient Hospitalisation claim under Section 3 a).
iii. The coverage includes the cost of the transportation of the Insured Person from a Hospital to the nearest Hospital which is prepared to admit the Insured Person and provide the necessary medical services if such medical services cannot satisfactorily be provided at a Hospital where the Insured Person is situated, provided that transportation has been prescribed by a Medical Practitioner and is medically necessary.

i) Daily Cash for Accompanying an Insured Child
Note : Claims made in respect of this benefit will be subject to the Sum Insured and will affect the entitlement to a
cumulative bonus.
If the Insured Person Hospitalised 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 Hospitalisation 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 Hospitalisation claim under Section 3 a).

j) Maternity Expenses
Note : Claims made in respect of this benefit will not be subject to the Sum Insured and will not affect the entitlement to a cumulative bonus.
We will pay the Medical Expenses for a delivery (including caesarean section) while Hospitalised 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 upto the amount stated in the Schedule of Benefits, and
iii) We will cover the Medical Expenses incurred for the medically necessary treatment of the infant baby upto the amount stated in the Schedule of Benefits unless the infant baby is covered under Section 3k), and
iv) this benefit is not available for Dependents other than Your spouse under a Family Floater, and
v) pre- and post-hospitalisation expenses under Section 3b) and Section 3c) 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 Section 3a).

k) Newborn baby
Note : This benefit is optional and effective only if noted as such in the Schedule of Benefits. The sum insured of this benefit is above the Maternity Sum Insured limit; will be equivalent to Individual Sum Insured [Rs. 300,000] under 1 Adult plan and Floater Sum Insured [Rs. 300,000] under 2 Adults & upto 2 Children plan. We will cover the Medical Expenses of any medically necessary treatment described at Section 3a) while the Insured
Person is Hospitalised during the Policy Period as an inpatient for a Newborn Baby provided that:
i) We have accepted a claim under Section 3j), 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.
New born Baby means those babies born to You and Your spouse during the Policy Period Aged between 1 day and 90 days.

Section. 4 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.

Section. 5 Optional Benefit - Critical Illness
Claims made in respect of any of the benefits below will not be subject to the Sum Insured and will not affect entitlement to a cumulative bonus.
If the Schedule shows that the Critical Illness benefit is effective, then We will pay the Critcal Illness Sum Insured as a lump sum in addition to Our payment under Section 3a), 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.
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 a Maxima Insurance Policy.
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. 6 Exclusions [Applicable to Part B only]
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 a Maxima Insurance Policy continuously and without any break in the previous Policy Year.
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 4a) 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 a Maxima Insurance Policy 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 prolapse 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 benign 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; nasal septum deviation.
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 4a) 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 will not be covered until 36 months of continuous coverage have elapsed, since inception of the first Maxima Insurance policy with Us; 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.
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 4a) upon renewal with Us), then this exclusion shall only apply in relation to the amount by which the Sum Insured has been increased.
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 defence, 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 breach of law with criminal intent, 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) Treatment of obesity and any weight control program.
vi) Psychiatric, mental disorders (including mental health treatments), 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; sleep apnoea.
vii) Venereal disease, sexually transmitted disease or illness; “AIDS” (Acquired Immune Deficiency Syndrome) and/or infection with HIV (Human Immunodeficiency Virus) including but 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 Section 3j), 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 Section 3a) 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 under Section 1d), dental treatment and surgery of any kind, unless requiring Hospitalisation.
xi) Expenses for donor screening, or, save as and to the extent provided for in Section 3g), 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, muscle stimulation by any means except for treatment of fractures (excluding hairline fractures) and dislocations of the mandible and extremities.
xiii) Treatment of nasal concha resection; circumcisions [unless medically necessary]; 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 times driven by cultural habits, fashion or the like or any procedures which improve physical appearance.
xiv) Plastic surgery or cosmetic surgery unless necessary as a part of medically necessary treatment certified by the attending Medical Practitioner for reconstruction following an Accident or Illness.
xv) Save as and to the extent provided under Section 1b), experimental, investigational or unproven treatment devices and pharmacological regimens, or measures primarily for diagnostic, X-ray or laboratory examinations or other diagnostic studies which are not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any Illness for which confinement is required at a Hospital.
xvi) Convalescence, cure, rest cure, sanatorium treatment, rehabilitation measures, private duty nursing, respite care,long-term nursing care or custodial care.
xvii) Any non allopathic treatment.
xviii) Save as and to the extent provided under Section 1b) and 1f), all preventive care, vaccination including inoculation and immunisations (except in case of post-bite treatment), any physical, psychiatric or psychological examinations or testing during these examinations; enteral feedings (infusion formulas via a tube into the upper gastrointestinal tract) and other nutritional and electrolyte supplements, unless certified to be required by the attending Medical Practitioner as a direct consequence of an otherwise covered claim.
xix) Charges related to a Hospital stay not expressly mentioned as being covered, including but not limited to charges for admission, discharge, administration, registration, documentation and filing.
xx) Items of personal comfort and convenience including but not limited to television (wherever specifically charged for), charges for access to telephone and telephone calls, foodstuffs (except patient’s diet), cosmetics, hygiene articles, body care products and bath additive, barber or beauty service, guest service as well as similar incidental services and supplies, and vitamins and tonics unless vitamins and tonics are certified to be required by the attending Medical Practitioner as a direct consequence of an otherwise covered claim.
xxi) Treatment rendered by a Medical Practitioner which is outside his discipline or the discipline for which he is licensed; treatments rendered by a Medical Practitioner who shares the same residence as an Insured Person or who is a member of an Insured Person’s family, however proven material costs are eligible for reimbursement in accordance with the applicable cover.
xxii) The costs of any procedure or treatment by any person or institution that We have told You (in writing) is not to be used; at the time of renewal or at any specific time during the Policy Period.
xxiii) Save as and to the extent provided in Section 1e), the provision or fitting of hearing aids, spectacles or contact lenses including optometric therapy, any treatment and associated expenses for alopecia, baldness, wigs, or toupees, medical supplies including elastic stockings, diabetic test strips, and similar products.
xxiv) Any treatment or part of a treatment that is not of a reasonable cost, not medically necessary; drugs or treatments which are not supported by a prescription.
xxv) Artificial limbs, crutches or any other external appliance and/or device used for diagnosis or treatment (except when used intra-operatively).
xxvi) Any exclusion mentioned in the Schedule or the breach of any specific condition mentioned in the Schedule.

 

Insured Person

 

a) The fulfilment of the terms and conditions of this Policy (including the payment of premium by the due dates mentioned in the Schedule) in so far as they relate to anything to be done or complied with by You or any Insured Person shall be conditions precedent to Our liability.

Part C: General Conditions

Condition precedent

b) Only those persons named as an Insured Person in the Schedule shall be covered under this Policy. Any person may be added during the Policy Period after his application has been accepted by Us, additional premium has been paid and We have issued an endorsement confirming the addition of such person as an Insured Person.

We may apply a risk loading on the premium payable (based upon the declarations made in the proposal form and the health status of the persons proposed for insurance). The maximum risk loading applicable for an individual shall not exceed above 100% per diagnosis / medical condition and an overall risk loading of over 150% per person. These loadings are applied from Commencement Date of the Policy including subsequent renewal(s) with Us or on the receipt of the request of increase in Sum Insured (for the increased Sum Insured).

We will inform You about the applicable risk loading through a counter offer letter. You need to revert to Us with consent and additional premium (if any), within 15 days of the issuance of such counter offer letter. In case, you neither accept the counter offer nor revert to Us within 15 days, we shall cancel your application and refund the premium paid within next 7 days.

Please note that We will issue Policy only after getting Your consent.


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