Our agreement to insure you is based on your proposal, which is the basis of this agreement, and your payment of the premium. This Policy records the entire agreement between us and sets out what we insure how and when we insure it, what we expect of you and what you can expect of us.
1) Medical Expenses
If a Doctor Advices that it is necessary for you to be immediately hospitalized during the Policy Period because of accidental Bodily Injury or illness, then we will indemnify Your Reasonable and Customary Medical Expenses incurred as a result of that hospitalization per Section E below.
2) Ambulance Expenses
If we accept a claim under Cover A1), then we will also indemnify your reasonable costs of being transferred to or between Hospitals in the Hospital’s ambulance or in an ambulance provided by any ambulance service provider to a maximum of Rs.1,000/- per claim.
3) Medical Check-up
At the end of every continuous period of 4 years during which each of you have held our Silver Health policy without making a claim you may apply to us for a free medical checkup at a Bajaj Allianz Diagnostic Centre, the location of which we will specify at the time of your application.
Words or terms in Italic have the meaning as ascribed to them wherever they appear in this Policy, and references to the singular or to the masculine include references to the plural or to the female wherever the context permits:
1) Bodily Injury means physical bodily harm or injury sustained because of an accident occurring during the Policy Period for which immediate treatment by a Doctor is necessary, but does not include any mental disease or illness or sickness.
2) You, Your, yourself means the person or persons that we insure as set our in the Schedule.
3) We, Our, Us means the Bajaj Allianz General Insurance Company Limited.
4) Doctor means a person who holds a recognized qualification in allopathic medicine, is registered by the medical council of the respective State of India in which he operates and is practicing within the scope of such license.
5) Hospital means any institution in India established for the indoor medical care and treatment of patients and which either:
a) Is registered and licensed as a hospital or nursing home with the appropriate local authorities and is under the supervision of a Doctor in attendance 24 hours a day and is not, except incidentally, a clinic, nursing home, rest home, or convalescent home for the addicted, aged, mentally disturbed or similar institution,
b) Complies with at least the following criteria:
i) It has at 10 inpatient beds;
Head Office & Regd. Office: GE Plaza, Airport Road, Yerawada, Pune-411006 Tel,: (+91 20) 66026666. Fax: (+91 20) 66026667
ii) It has a fully equipped and functioning operating theatre;
iii) It has qualified nursing staff (any person who holds a certificate issued by a recognized nursing council) in attendance 24 hours per day;
iv) It has a Doctor who is in attendance 24 hours per day;
v) It maintains daily medical records for each of its patients.
6) Bajaj Allianz Network Hospitals means the Hospitals which have been empanelled by us as per the latest version of the schedule of Hospitals maintained by us, which is available to you on request.
7) Bajaj Allianz Diagnostic Centre means the diagnostic centers which have been empanelled by us as per the latest version of the schedule of diagnostic centers maintained by us, which is available to you on request.
8) Illness means sickness (a condition or an ailment affecting the general soundness and health of Your body) or disease (an affliction of the bodily organs having a defined and recognized pattern of symptoms) that is first contracted during the Policy Period (or prior thereto if this Policy is the renewal without break of an earlier Silver Health Policy issued by Us and held for a period of 1year) and manifests itself during the Policy Period and for which immediate treatment by a Doctor is necessary, but does not include any mental disease, sickness or illness.
9) Limit of indemnity means the amount specified in the Schedule which is our maximum liability to make payment for you or any of you for anyone claim and all claims in the aggregate during the Policy Period subject always to the Life time Limit of indemnity.
10) Life Time Limit of Indemnity shall mean in respect of each of you, the sum equivalent to 3 times the Limit of Indemnity specified in the earliest Silver Health Policy you held with us.
11) Medical Expenses-means the reasonable charges that you necessarily incur on the advice of a Doctor:
a) As an in-patient in a Hospital for accommodation; nursing care; the attention of medically qualified staff; undergoing medically necessary procedures; medical consumables (Hospitalization expenses); and
b) An amount equivalent to 3% of the hospitalization expenses covered in a) in respect of any and all pre-hospitalization and post-hospitalization expenses.
12) Policy means the Proposal, the Schedule (and any endorsements attaching to or forming part thereof) and this Policy Document.
13) Policy Period means the date between the commencement date and the expiry date specified in the Schedule.
14) Period of Insurance means the period between the commencement date of the earliest Silver Health Policy each of You held with us and the expiry date specified in the Schedule as long as there has been no break in cover since the date of that earliest Silver Health Policy, and shall otherwise mean the Policy Period.
15) Schedule means the schedule attached to and forming part of this Policy which is latest in time and any annexure to it.
16) Reasonable and Customary means a charge which a) is charged for medical treatment, supplies or medical services that are medically necessary to treat Your condition; b) does not exceed the usual level of charges for similar medical treatment, supplies or medical services in the locality where the expense is incurred; and c) does not include charges that would not have been made if no insurance existed.
C. What we will not pay
We will not pay for claims arising out of or howsoever connected to the following:
1) Any Illness or medical condition or complication directly or indirectly arising from it which existed before the commencement of the Policy Period (even if unknown to you), or for which care, treatment or advice was sought, recommended by or received from a Doctor (“Pre- existing Illness”). This exclusion shall cease to apply if this Policy is the renewal without break of a Silver Health Policy held with us for a continuous period of one year, and shall also not apply on subsequent renewals affected on the same basis.
2) Without derogation from (1) above during the first year of operation of the insurance cover any Medical Expenses incurred on treatment of the following diseases: cataract, benign prostatic hypertrophy, prolapsed of genitourinary/intra-abdominal organs, hernia of all types, hydrocele, fistulae, hemorrhoids, fissure in anus, dysfunctional uterine bleeding , fibromyoma, endometriosis, hysterectomy, stones in the urinary and biliary systems; surgery on ears, surgery on skin/internal tumors/cysts/nodules/polyps; treatment for benign tumors or malignant conditions or for organomegaly, surgery on joints, treatment for prolapsed intervertebral discs, surgery for gastric or duodenal ulcers.
3) Any Medical Expenses incurred during the first four consecutive annual periods during which you have the benefit of a Silver Health Policy with Us in connection with joint replacement surgery unless such joint replacement surgery is necessitated by accidental Bodily Injury.
4) Any Medical Expenses incurred for any Illness diagnosed or diagnosable within 30 days of the commencement of the Period of Insurance except those incurred as a result of accidental Bodily Injury.
5) War, invasion, acts of foreign enemies, hostilities (whether war be declared or not), civil war, commotion, unrest, rebellion, revolution, insurrection, military or usurped power or confiscation or nationalization or requisition of or damage by or under the order of any government or public local authority.
6) Cosmetic or aesthetic treatments of any type, plastic surgery (unless necessary for the treatment of accidental Bodily Injury).
7) The cost of spectacles: contact lenses, and hearing aids, crutches, artificial limbs, dentures, limbs, dentures, artificial Teeth.
8) External medical equipment of any kind used at home as post hospitalization care including cost of instrument used in the treatment of sleep apnoea syndrome (C.P.A.P), continuous ambulatory peritoneal dialysis (CAP.D.) and Oxygen concentrator for Bronchial Asthmatic condition
9) Dental treatment or surgery of any kind unless requiring hospitalization and as a result of accidental Bodily Injury.
10) Convalescence, general debility, rest cure, congenital diseases or defects or anomalies.
11) Venereal disease or any sexually transmitted disease or sickness.
12) Intentional self-injury (including but not limited to the use or misuse of any intoxicating drugs or alcohol).
13) Treatment arising from or traceable to pregnancy (whether uterine or extra uterine) and childbirth including caesarian section, and/or any treatment related to pre and post-natal care.
14) Any treatment towards infertility, sub-fertility or assisted conception procedure or sterilization procedure.
15) Any condition directly or indirectly caused by HIV (Human Immune deficiency virus) or associated with Human T-Cell Lymphotropic Virus type III (IITLB-III) or Lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome or condition of a similar kind commonly referred to as AIDS.
16) Medical Expenses relating to any hospitalization primarily and specifically for diagnostic, X-ray or laboratory examinations and investigations.
17) Any claim directly or indirectly caused by or contributed to by nuclear weapons and/or Materials.
18) Vaccination or inoculation.
19) Vitamins, tonics, nutritional supplements unless forming part of the treatment for injury or disease as certified by the attending Doctor
20) Experimental, unproven or non-standard treatment, including but not limited to chelating therapy.
21) Surgery to correct deviated septum and hypertrophied turbinates.
22) Treatment for any other system other than modern medicine (also known as Allopathic).
23) Expenses related to donor screening, treatment, including surgery to remove organs from a donor in the case of transplant surgery.
24) Treatment for any mental illness or psychiatric illness.
25) Weight management services and treatment related to weight reduction programmes including treatment of obesity.
26) Any period of hospitalization of less than 24 hours except:
a) If, as a result of Illness or accidental Bodily Injury, you are hospitalized On the advice of a Doctor for one of the specific treatments Listed below and you are discharged on the same day that such treatment was received:
- Lithotripsy (kidney stone removal)
- Coronary angiography
- Hydrocele Surgery
- Hernia repair surgery
- Endoscopic resection of the prostate (TURP)
- Therapeutic ERCP (Endoscopic retrograde cholangiopancreatography)
b) If, as a result of Illness or accidental Bodily Injury, You are hospitalized on the advice of a Doctor and the period of hospitalization extends to at least 12 continuous hours including 0300 hours.