LHS Art Banner
 

Bharti AXA Smart Health Insurance Policy-Wording


Smart Health Insurance Policy

PREAMBLE

WHEREAS the Insured designated in the Schedule to this Policy having by a proposal and declaration together with any statement, report or other document which shall be the basis of this contract and shall be deemed to be incorporated herein, has applied to Bharti AXA General Insurance Company Limited (hereinafter called “the Company”) for the insurance hereinafter set forth and paid appropriate premium for the period as specified in the Schedule.

Now this Policy witnessed that subject to the terms, conditions, exclusions and definitions contained herein or endorsed or otherwise expressed here on the Company, undertakes, that if during the period as specified in the Schedule to this Policy, the Insured / Insured Person shall contract any disease, illness or sustain any injury and if such disease, illness or injury shall upon the advice of a duly qualified Medical Practitioner require such Insured/Insured Person, to incur hospitalization and / or other related expenses towards treatment of such disease, illness or injury at any Hospital/ Nursing Home in India as an inpatient or domiciliary hospitalization expenses in any of the circumstances mentioned hereunder, then the Company will pay to the Insured/Insured Person, his /her nominee, or legal representatives, as the case may be, the amount of such hospitalization or related expenses/charges as would fall under the different heads mentioned below and as are reasonably and necessarily incurred by or on behalf of such Insured / Insured Person for


Article banner

1. Hospital (Room & Boarding and Operation theatre) charges

2. Fees of Surgeon, Anesthetist, Nurse, Specialists etc.

3. Cost of diagnostic tests, medicines, blood, oxygen, appliances like pacemaker, artificial limbs and organs etc.

4. Pre and post hospitalization expenses

5. Ambulance charges in manner, for the period and to the extent of the Sum Insured as specified in this Policy. 

DEFINATIONS

Any word or expression to which a specific meaning has been assigned in any part of this Policy or the Schedule shall bear the same meaning wherever it appears. For purposes of this Policy, the terms specified below shall have the meaning set forth: 

 "Accident" means a sudden, unforeseen and unexpected physical event beyond the control of the Insured/ Insured Person resulting in bodily injury, caused by external, visible and violent means. 

"Bodily Injury / Injury" mean any accidental physical bodily harm solely and directly caused by external, violent and visible means which is verified and certified by a Physician but does not include any sickness or disease.

Critical Illnesses” mean diseases / illnesses limited to the following:

1. Cancer represented by a malignant tumor characterized by the uncontrolled growth and spread of malignant cells with invasion and destruction of normal tissue.

2. First Heart Attack involving death of a portion of the heart muscle arising from inadequate blood supply to the relevant area.

3. Coronary Artery Disease involving narrowing of the lumen of at least one coronary artery by a minimum of 75% and of two others by a minimum of 60%, as proven by coronary arteriography, regardless of whether or not any form of coronary artery surgery has been performed. Coronary arteries herein refer to left main stem, left anterior descending circumflex and right coronary artery.

4. Coronary Artery bypasses surgery involving the actual undergoing of open-chest surgery to correct the narrowing or blockage of one or more coronary arteries with bypass grafts.

5. Heart Valve Surgery involving the actual undergoing of open-heart surgery to replace or repair heart valve abnormalities.

6. Surgery to Aorta involving actual undergoing of major surgery to repair or correct aneurysm, narrowing, obstruction or dissection of the aorta through surgical opening of the chest or abdomen. For the purpose of this definition aorta shall mean the thoracic and abdominal aorta but not its branches.

7. Stroke referring to a cerebrovascular incident including infarction of brain tissue, cerebral and subarachnoid hemorrhage, cerebral embolism, and cerebral thrombosis.

8. Kidney Failure involving chronic irreversible failure of both kidneys requiring either permanent renal dialysis or kidney transplantation.

9. Aplastic Anemia involving chronic persistent bone marrow failure which results in Anemia, neutropenia and thrombocytopenia requiring treatment.

10. End Stage Lung Disease causing chronic respiratory failure. 

11. End Stage Liver Failure evidenced by permanent jaundice as cites and Hepatic Encephalopathy.

12. Coma that persists for at least 30 days.

13. Major Burns representing third degree (full thickness of the skin) burns covering at least 30% of the surface of the Insured / Insured person’s body.

14. Major Organ/Bone Marrow Transplantation involving human bone marrow using hematopoietic stem cells preceded by total bone marrow ablation; or any one of the human organs limited to heart, lung, liver, kidney or pancreas, that resulted from irreversible end stage failure of the relevant organ.

15. Multiple Sclerosis

16. Fulminate Hepatitis involving sub-massive to massive necrosis of the liver by the Hepatitis virus, leading precipitously to liver failure.

17. Motor Neuron Disease characterized by progressive degeneration of corticospinal tracts and anterior horn cells or bulbar efferent neurons which include spinal muscular atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis and primary lateral sclerosis.

18. Primary Pulmonary Hypertension with substantial right ventricular enlargement confirmed by investigations including cardiac catheterization, resulting in permanent physical impairment due to cardiac impairment resulting in not being able to engage in any physical activity without discomfort. Symptoms may be present even at rest.

19. Terminal Illness involving conclusive diagnosis of an illness that is expected to result in the death of the Insured/ Insured Person within 12 months.

20. Bacterial Meningitis involving bacterial infection causing in severe inflammation of the membranes of the brain or spinal cord resulting in significant, irreversible and permanent neurological deficit. The neurological deficit must persist for at least 6 weeks.

Day Care treatment” means treatment undertaken in a Hospital / Nursing Home on the recommendation of a Medical Practitioner for the following diseases, illness or injury which requires hospitalization for less than 24 hours and includes such of those treatments which require hospitalization for less than 24 hours due to technologically advanced treatment protocol:

(a) Dialysis

(b) Chemotherapy

(c) Radiotherapy

(d) Eye surgery 

(e) Dental surgery 

(f) Lithotripsy (kidney stone removal)

(g) Tonsillectomy

(h) Dilatation & Curettage

(i) Cardiac Catheterization

(j) Hydrocele surgery

(k) Hernia repair surgery

(l) Surgeries/procedures that require less than 24 hour’s hospitalization due to medical/technological advancement and infrastructural facilities

(m) TURP (Prostate Surgery).

"Disease" means an alteration in the state of the body or of some of its organs, interrupting or disturbing the performance of the functions, and causing or threatening pain and weakness or physical or mental disorder and certified by a Medical Practitioner.

Domiciliary hospitalization” means medical treatment for a period exceeding three days for any disease, illness or injury which in the normal course would require care and treatment at a Hospital/Nursing Home but is actually taken whilst confined at home in India under any of the following circumstances, namely: -

(a) The condition of the patient is such that he/she cannot be removed to Hospital/Nursing Home, or

(b) The patient cannot be admitted to Hospital/Nursing Home for lack of accommodation therein.

Domiciliary hospitalization benefits shall be subject to the limits as specified in the Schedule to this Policy, and shall, in no case, cover expenses incurred for:

(a) Pre and post Hospital treatment,

(b) Treatment of any of the following diseases:

(i) Asthma

(ii) Bronchitis

(iii) Chronic nephritis and nephritic syndrome

(iv) Diarrhea and all types of dysenteries including gastroenteritis

(v) Diabetes mellitus and insipidus

(vi) Epilepsy

(vii) Hypertension

(viii) Influenza, cough and cold 

(ix) All psychiatric or psychosomatic disorders

(x) Pyrexia of unknown origin for less than 10 days

(xi) Tonsillitis and upper respiratory tract infection including laryngitis and pharangitis

(xii) Arthritis, gout and rheumatism

"Family" means the Insured, his/her lawful spouse and maximum of two dependent children up to the age of 23 years.

Hospital/Nursing Home” means an establishment in India for indoor medical care and treatment of patients which:

a. is registered with the appropriate local authorities as such and benefits from the supervision of a Medical Practitioner on a 24 hour basis, or

b. complies with at least the following criteria:

i) it has at least 10 inpatient beds (at least 7 inpatient beds in places with a population of less than 10,00,000);

ii) it has a fully equipped operating theatre where surgery is performed;

iii) it employs qualified nursing staff on a 24 hour basis;

iv) Maintains daily records of patients.

c. By the nature of the medical treatment provided is an establishment properly recognized as a Hospital / Nursing Home within the locality and fulfils all the demands ordinarily or customarily of a Hospital for medical treatment, and where all medical treatment is administered by a Medical Practitioner, and is not, except incidentally, a place of rest, a place for the aged, a place for drug addicts or place for alcoholics, a hotel, health spa, massage centre or any similar establishment.

Hospitalization expenses” mean expenses on hospitalization for minimum period of 24 hours incurred in India, which are admissible under this Policy. However, this time limit will not apply for specific treatments defined under Day Care treatment taken in a Hospital / Nursing Home.

"Illness" means sickness or disease first diagnosed during the period of insurance for which immediate treatment by a Medical Practitioner is necessary.

In-patient” means an Insured / Insured Person who is admitted to Hospital / Nursing Home and stays for at least 24 hours for the sole purpose of receiving treatment.

Insured” means the individual who has a permanent place of residence in India and on whose name the Policy is issued. 

Insured Person” means the person named in the Schedule to the Policy, who has a permanent place of residence in India and for whose benefit the insurance is proposed and appropriate premium paid.

Medical Practitioner” means a person who holds a degree/diploma of a recognized institution and is registered with the Medical Council in respective states of India. The term Medical Practitioner includes a physician, specialist and surgeon, provided that this person is not a member of the Insured/Insured Person’s family.

Medical charges” mean reasonable charges unavoidably incurred by the Insured/Insured Person for the medical treatment of disease, illness or injury the subject matter of the claim as an In-patient in a Hospital/ Nursing Home, and includes the costs of a bed; treatment and care by medical staff; medical procedures, Medical Practitioner’s / Consultants/ Specialists fees, medicines and consumables including cost of pacemaker, cost of organs, artificial limbs etc. as long as these are recommended by the attending Medical Practitioner. 

Period of Insurance” means the Policy period defined here under 

Policy period” means the period between the inception date and the expiry date as specified in the Schedule to this Policy or the cancellation of this insurance, whichever is earlier.

 “Policy” means this document of Policy describing the terms and conditions of this contract of insurance including the Company’s covering letter to the Insured, if any, the Schedule attached to and forming part of this Policy, the Insured’s Proposal Form and any applicable endorsement thereon. The Policy contains details of the scope and extent of cover available to the Insured/Insured Person, the exclusions from the scope of cover and the terms and conditions of the issue of the Policy.

Post-hospitalization expenses” mean relevant follow up medical expenses incurred during a period up to the number of days specified in the Schedule to this Policy following hospitalization for treatment of disease, illness or injury sustained and considered a part of a claim admissible under this Policy.

 “Pre-existing condition” means any condition, ailment or injury or related condition(s) for which the Insured / Insured Person had signs or symptoms, and / or were diagnosed, and / or received medical advice/ treatment, within 48 months prior to Insured / Insured Person’s first policy with the company.

 “Pre-hospitalization expenses” mean relevant medical expenses incurred during a period up to the number of days specified in the Schedule to this Policy prior to hospitalization for treatment of disease, illness or injury sustained and considered a part of a claim admissible under this Policy.

 “Qualified nurse” means a person who holds a certificate of a recognized Nursing Council and is employed on recommendation of the attending Medical Practitioner.

“Third Party Administrator (TPA)” means any organization or institution that is licensed by the IRDA as a TPA and is engaged by the Company for a fee or remuneration for providing Policy and claims facilitation services to the Insured / Insured Person as well as to the Company for an insurable event.

Schedule” means Schedule attached to and forming part of this Policy mentioning the details of the Insured/ Insured Persons, the Sum Insured, the period and the limits to which benefits under the Policy are subject to.

Sum Insured” means the sum as specified in the Schedule to this Policy against the name of Insured / each Insured Person, which sum represents the Company's maximum liability for any or all claims under this Policy during the Policy period for the respective benefit(s) against which the sum is mentioned in the Schedule to this Policy.

Surgical operation” means manual and/or operative procedures for correction of deformities and defects, repair of injuries, diagnosis and cure of diseases, relief of suffering and prolongation of life.

Terrorism/Terrorist Incident” means any actual or threatened use of force or violence directed at or causing damage, injury, harm or disruption, or the commission of an act dangerous to human life or property, against any individual, property or government, with the stated or unstated objective of pursuing economic, ethnic, nationalistic, political, racial or religious interests, whether such interests are declared or not. Robberies or other criminal acts, primarily committed for personal gain and acts arising primarily from prior personal relationships between perpetrator(s) and victim(s) shall not be considered terrorist activity. Terrorism shall also include any act, which is verified or recognized by the relevant Government as an act of terrorism.

SCOPE OF COVER

The Company hereby agrees subject to the terms, conditions and exclusions herein contained or otherwise expressed, to pay and/or reimburse the following benefits in manner, for the period and to the extent of the Sum Insured as specified in the Schedule to this Policy.

Section I

a. Hospitalization Expenses

Hospitalization Expenses benefit provides cover for reimbursement / payment of hospitalization expenses which are reasonably and necessarily incurred by the Insured / Insured Person for treatment of disease, illness contracted or injury sustained by the Insured / Insured Person during the Policy period as specified in the Schedule to this Policy, in a Hospital in India as in patient which among other things, includes, Hospital (Room & Boarding and Operation theatre) charges, admission and registration charges in the Hospital, fees of Surgeon, Anesthetist, Nurses, Specialists, the cost of diagnostic tests, medicines, blood, oxygen, appliances like pacemaker, artificial limbs and organs etc.

The Insured/ Insured Person should have been hospitalized as an in-patient for a minimum period of 24 hours. However in respect of Day Care treatment undertaken in a Hospital, 24 hours hospitalization is not necessary. The benefit under this Section is limited to the Sum Insured specified for this Section in the Schedule to this Policy.

b. Pre-hospitalization

This benefit covers relevant medical expenses incurred during a period up to the number of days as specified in the Schedule to this Policy, prior to hospitalization/ Day care treatment for treatment of disease, illness contracted or injury sustained for which the Insured / Insured Person was hospitalized, giving rise to an admissible claim under this Policy. This benefit is a part of benefit available under Section 1a above and is limited to the available Sum Insured under Section 1a.

c. Post Hospitalization

This benefit covers relevant medical expenses incurred during a period up to the number of days as specified in the Schedule to this Policy, after discharge from Hospital for continuous and follow up treatment of the disease, illness contracted or injury sustained for which the Insured / Insured Person was hospitalized, giving rise to an admissible claim under this Policy. This benefit is a part of benefit available under Section 1a above and is limited to the available Sum Insured under Section 1a.

d. Pre-existing diseases

This Policy covers relevant hospitalization expenses incurred for treatment of pre-existing disease, illness or injury, in a Hospital as an in-patient, after specific waiting period as mentioned in the Schedule to this Policy. This benefit is a part of benefit available under Section 1a above and is limited to the available Sum Insured under Section 1a.

Section II. Day Care Treatment

This benefit covers relevant hospitalization expenses incurred by the Insured / Insured Person in case of day care treatment (where 24 hours of hospitalization is not required) which includes treatments such as dialysis, chemotherapy, radiotherapy, eye surgery, lithotripsy (kidney stone removal), D & C, tonsillectomy undertaken in a Hospital. The benefit under this Section is limited to the available Sum Insured under Section 1a of this Policy.

Section III. Domiciliary Hospitalization

This benefit covers payment of expenses incurred for medical treatment pertaining to domiciliary hospitalization for a period exceeding three days for disease, illness or injury, which in the normal course, would require care and treatment at a Hospital/Nursing Home, but is actually taken whilst the Insured / Insured Person is confined at home in India, under any of the following circumstances namely:

a. the condition of the patient is such that he/she cannot be removed to Hospital/Nursing Home, or

b. the patient cannot be admitted to Hospital/Nursing Home for lack of accommodation therein.

Domiciliary hospitalization benefits shall be subject to the Sum Insured as specified in the Schedule to this Policy, and shall, in no case cover expenses incurred for:

a. Pre and Post Hospital treatment,

b. Treatment of any of the following diseases / illness / injury:

(i) Asthma

(ii) Bronchitis

(iii) Chronic nephritis and nephritic syndrome

(iv) Diarrhea & all types of dysenteries including gastroenteritis

(v) Diabetes mellitus and insipidus

(vi) Epilepsy

(vii) Hypertension

(viii) Influenza, cough and cold

(ix) All psychiatric or psychosomatic disorders

(x) Pyrexia of unknown origin for less than 10 days9

(xi) Tonsillitis and upper respiratory tract infection including laryngitis & pharangitis

(xii) Arthritis, gout and rheumatism.

Domiciliary hospitalization benefits also cover expenses on nurses engaged on the recommendation of the attending Medical Practitioner. The benefit under this Section is limited to the available Sum Insured for Section 1a of this Policy.

Section IV. Critical Illness

This benefit provides for coverage of treatment for critical illness and the coverage depends upon the type of critical illness cover (benefit basis or hospitalization reimbursement basis) selected and mentioned in the Schedule to this Policy.

In case the type of cover opted is benefit basis, If 60 days after the inception of this Policy, the Insured / Insured Person is at any time during the Policy period, being diagnosed as contracting any Critical Illness and surviving for more than 30 days post such diagnosis, the Sum Insured specified in the Schedule to this Policy for this benefit shall be payable to the Insured / Insured Person as compensatory benefit.

This Section operates as a benefit cover and compensation shall be payable if the Insured / Insured Person is surviving for more than 30 days post diagnosis of any critical illness.

The Sum Insured available for this cover is separate and additional to that of Hospitalization Sum Insured available under Section Ia. In case the Insured / Insured Person is diagnosed to be suffering from any of the Critical Illnesses and survives for a period of 30 days, then the Sum Insured specified under Section IV will be paid as a lump sum. After availing the benefit under Section IV, if the Insured/Insured Person takes treatment for the Critical Illness in a Hospital, the hospitalization expenses incurred for the same would be payable/ reimbursed, subject to the terms and conditions of the Policy, out of the Sum Insured available for Hospitalization Benefit cover under Section 1a of this Policy.

However, in case of diagnosis of multiple illnesses qualified as Critical Illness as defined under this Policy, the payment of compensation shall be limited to the Sum Insured as specified above and shall be payable only once.

In case the type of cover opted is Hospitalization Reimbursement basis

If, 60 days after the inception of this Policy, the Insured / Insured Person at any time during the Policy period is diagnosed as contracting any of the Critical Illnesses and is required to undertake treatment in a Hospital for the same, the Hospitalization expenses incurred towards such treatment is covered under this benefit up to the specific Sum Insured stated against this benefit.

The Sum Insured available for this cover is separate and additional to that of Hospitalization Sum Insured available under Section Ia. In case the Insured / Insured Person is diagnosed to be suffering from any of the Critical Illnesses and takes treatment for the same in a Hospital, the hospitalization expenses incurred for the same would be payable/ reimbursed, subject to the terms and conditions of the Policy, first out of the Sum Insured available for Critical Illness Cover under Section IV. Where the hospitalization expenses incurred for the treatment of the Critical Illness are in excess of the Sum Insured available under Critical Illness Cover under Section IV, the excess may be paid / reimbursed out of the available Sum Insured under the Hospitalization Benefit under Section Ia.

The benefits available under Sections 1b, 1c and 1d of this Policy as mentioned above are also applicable and available under Critical Illness Section in case the type of cover opted is Hospitalization Reimbursement basis. In respect of pre-hospitalization and post hospitalization the limits of benefits are the same as per the respective Sections of the Policy and mentioned in the Schedule to this Policy. Where the Sum Insured under Critical Illness is exhausted the excess amounts (which are within the limits of these respective benefits) can be paid / reimbursed out of the available Sum Insured under Section 1a of the Policy.

In case of diagnosis of multiple critical illnesses requiring treatment covered this Policy the maximum liability of the Company under this Section shall not exceed the Sum Insured as mentioned against this particular Section in the Schedule to this Policy.

Critical Illnesses in respect of which benefits are payable under this Policy are as set out below:

1. Cancer: A malignant tumor characterized by the uncontrolled growth and spread of malignant cells with invasion and destruction of normal tissue. This diagnosis must be supported by histological evidence of malignancy and confirmed by an oncologist or pathologist.

The following are excluded:

(a) Tumors showing the malignant changes of carcinoma- in-situ and tumors which are histological described as pre-malignant or non-invasive, included, but not limited to: Carcinoma-in-situ of the Breasts, Cervical Dysplasia CIN-1, CIN-2 and CIN-3.

(b) Hyperkeratosis, basal cell and squamous skin cancers, and melanomas of less than 1.5 mm Breslow thickness, or less than Clark Level 3, unless there is evidence of metastases;11

(c) Prostate cancers histological described as TNM Classification T1a or T1b or Prostate cancers of another equivalent or lesser classification, T1N0M0 Papillary Micro-carcinoma of the Thyroid less than 1 cm in diameter, Papillary micro-carcinoma of the Bladder, and chronic Lymphocytic Leukaemia less than RA1 Stage 3; and

(d) All tumors in the presence of HIV infection.

2. First Heart Attack: Death of a portion of the heart muscle arising from inadequate blood supply to the relevant area. This diagnosis must be supported by three or more of the following five criteria which are consistent with a new heart attack:

(a) History of typical chest pain;

(b) New electrocardiogram (ECG) changes proving infarction;

(c) Diagnostic elevation of cardiac enzyme CK-MB;

(d) Diagnostic elevation of Troponin (T or I);

(e) Left ventricular ejection fraction less than 50% measured 3 months or more after the event.

3. Coronary Artery Disease: The narrowing of the lumen of at least one coronary artery by a minimum of 75% and of two others by a minimum of 60%, as proven by coronary arteriography, regardless of whether or not any form of coronary artery surgery has been performed. Coronary arteries herein refer to left main stem, left anterior descending circumflex and right coronary artery

4. Coronary Artery By-pass surgery: The actual undergoing of open-chest surgery to correct the narrowing or blockage of one or more coronary arteries with bypass grafts. This diagnosis must be supported by angiographic evidence of significant coronary artery obstruction and the procedure must be considered medically necessary by a consultant cardiologist. Balloon Angioplasty and /or any other intra-arterial procedures or laser relief is excluded

5. Heart Valve Surgery: The actual undergoing of open-heart surgery to replace or repair heart valve abnormalities. The diagnosis of heart valve abnormality must be supported by cardiac catheterization or echocardiogram and the procedure must be considered medically necessary by a consultant cardiologist.

6. Surgery to Aorta: The actual undergoing of major surgery to repair or correct aneurysm, narrowing, obstruction or dissection of the aorta through surgical opening of the chest or abdomen. For the purpose of this definition aorta shall mean the thoracic and abdominal aorta but not its branches. Surgery performed using only minimally invasive or intra arterial techniques are excluded.

Angioplasty and all other intra arterial, catheter based techniques, “keyhole” or laser procedures are excluded.


Previous123Next


Comments
Name
Email Id
Your Comments

By Dinesh fabwani on Mar 10, 2013 12:13 AM

Hello sir, i just wanted to ask a question that my mom 42 yrs is suffering from a brain aneurysm , and she has been treated with stent assisted coiling in oct 2012 costed 10 lacs , today i got her angiography done , the doc. Says that the coils are shifted and it needs an another operation , so could you tell in any policy that covers such type of pre-existing problems , coz i m not that much rich that i can bear the cost of another operation
By KETAN D PATEL on Oct 14, 2011 10:52 AM

I WANT TAKE BHARATI AXA MEDICALIM INSURANCE. PLEASE GIVE ME YOUR CONTACT NUMBER IN AHMEDABAD BRANCH. OR PLEASE CONTACT ME MY MOBILE NO.9879812283
Did you know?
Medimanage is the only Dedicated Health Insurance Broker in India.
Medimanage has managed more than 25000 claims end-to-end.
Medimanage insures more than 2 Lakh lives every year.
Testimonials
Thank you so much for all the support and timely intervention. I would like to place on record my highest appreciation for your effort, empathy and attitude. The procedures and policies at the hospital we were in took much time and your intervention and liaison with the insuring company and the hospital helped hasten the process.
Vivek Nair


RHS Art Banner
>