The Insurer's agreement to extend cover to the Insured up to the Limit of Indemnity per the terms and conditions contained in this Policy is based upon the Proposer's payment of premium and the proposal, which is incorporated into the Policy and is the basis of it.
Certain words or expressions have the specific meaning given in Section B whenever they appear in bold and in Initial Capitals in this Policy.
A Coverage Parts
1) Upon the happening of the event under a) to e) below during the Policy Period , the Insurer will indemnify the Proposer up to the Limit of Indemnity as detailed below and as per the General Conditions:
a) Hospitalization Expenses:- If the Insured is diagnosed with an illness or suffers Accidental Bodily Injury, which necessitates his Hospitalization, the Insurer will reimburse the Insured's consequent Hospitalization Expenses for:
i Room and board
ii Doctors fees
iii Intensive Care Unit
iv Nursing expenses
v Surgical fees, operating theatre , anesthesia and oxygen and their administration
vi Physical therapy
vii Drugs and medicines consumed on the premises
viii Hospital miscellaneous services (such as laboratory, x-ray, diagnostic tests)
ix Dressing, ordinary splints and plaster casts
x Costs of prosthetic devices if implanted during a surgical procedure
xi Organ transplantation including the treatment costs of the donor but excluding the costs of the organ
b) Post-hospitalization Expenses
If the Insurer accepts a claim under a) above and, immediately following the Insured's discharge, he requires further medical treatment directly related to the same condition for which the Insured was Hospitalized, the Insurer will reimburse the Insured's Post-hospitalization Expenses for up to 90 days following his discharge.
c) Pre-hospitalization Expenses
If the Insured is diagnosed with an Illness which results in his Hospitalization and for which the Insurer accepts a claim under a) above, the Insurer will reimburse the Insured's Pre hospitalization Expenses for up to 60 days prior to his Hospitalization as long as the 60 day period commences and ends within the Policy Period.
Specific Conditions Applicable to a) - c) inclusive:
i) The Administrator will arrange for cash free payment to the extent of the Insurer's liability for Hospitalization Expenses incurred at Network Hospitals subject to the Insured's satisfaction of General Conditions D4) and 6).
ii) If the Insured for any reason chooses not to use a Network Hospital or opts for a higher Hospitalization Class or otherwise breaches the terms of the authorization n obtained pursuant to General Condition 4) c), then the amount payable by or on behalf of the Insurer shall be reduced as per the Co-payment Table and shall be borne by the Insured. This clause shall not apply if due to an Illness or Accidental Bodily Injury an Insured requires Emergency Hospitalization or change of Hospital so as to avoid a material risk to the Insured's life or health, and as a result the Insured is unable to obtain pre-authorization provided that:
1) The Administrator is given notice of the Insured's Hospitalization as soon as reasonably practicable, and
2) The terms of General Condition D4) are complied with as soon as the material risk to the Insured's life or health has passed.
d) Day Care Expenses
If the Insured requires a Day Care Procedure, the Insurer will reimburse the Day Care Expenses as long as the Day Care Procedure performed was pre-authorized by the Administrator.
e) Local Ambulance Services
The Insurer will also pay for Emergency ambulance road transportation by a licensed ambulance service to the nearest Hospital where Emergency Health Services can be rendered. Coverage is only provided in the event of an Emergency up to the limits given in Schedule of Benefits.
For ease of reference, the singular includes the plural and the male gender includes the female gender where appropriate to the context.
1) Accidental Bodily Injury means physical bodily harm or injury that is visible and is caused by a sudden, unexpected, fortuitous, visible and external event and which requires treatment by a Doctor.
2) Administrator means the person or organization named in the Schedule who has been appointed by the Insurer to provide administrative services on its behalf of and at its direction.
3) Cash free payment means the Administrator may authorize upon an Insured's request for direct settlement of eligible services and its according charges between a Network Hospital and the Administrator. In such cases the Administrator will directly settle all eligible amounts with the Network Hospital and the Insured may not have to pay any deposits at the commencement of the treatment or bills after the end of treatment to the extent as these services are covered under the Policy.
4) Co-payment Table means the table attached to the Schedule.
5) Day Care Expenses means the medical treatment costs (nursing; Doctors ; medically necessary procedures and medical consumables) necessary and reasonable in scope for a Day Care Procedure preauthorized by the Administrator & done in a network Hospital to the extent that such cost does not exceed the reasonable and customary charges applicable in the locality for the same Day Care Procedure.
6) Day Care Procedure means the course of medical treatment or a surgical procedure listed in the Schedule, which is undertaken under general or local anaesthesia in a Hospital by a Doctor in not less than 2 hours and not more than 24 hours. This excludes all procedures or treatment taken in the Out Patients Department.
7) Doctor means a person who holds a medical degree from a recognized institution and is currently licensed or registered by the Medical Council of the respective State of India, so long as he acts within the scope of the license or registration granted to him.
8) Emergency means a serious medical condition or symptom resulting from Injury or Sickness, which arises suddenly and requires immediate care and treatment to avoid jeopardy to the life or serious damage to the health of the Insured. The emergency continues till the condition of the Insured stabilizes and the continuing medical condition or symptoms are not considered an Emergency anymore.
9) Hospitalization or Hospitalized means the Insured's admission for a continuous period of not less than 24 hours into a Hospital, which means an institution in India, which:
a) Is properly licensed, and in areas where licensing facilities are unavailable, the institution must be one recognized in the locality as a Hospital and must satisfy b) to d) below inclusive;
b) Is primarily engaged in providing diagnostic, medical and surgical facilities for the care and treatment of injured or sick persons on an inpatient basis, and is not an institution which is primarily a rest or convalescent facility, a place for custodial care a facility for the aged or alcoholics or drug addicts or for the treatment of mental disorders;
c) Employs Doctors and qualified nursing staff who are permanently available on the premises to provide necessary medical care and attention to patients on a 24-hour basis;
d) Maintains daily medical records for each of its patients.
10) Hospitalization Class means the type of Hospital room specified in the Schedule for which the Insured has opted. The categorization types indicated denote the following:
a) Class A: Air-conditioned Single room upwards (i.e. suite, apartment).
b) Class 8: Air-conditioned or Non air-conditioned Single room.
c) Class C: Air-conditioned or Non air-conditioned Two-Bed Room.
11) Hospitalization Expenses means the medical treatment costs as per the Hospitalization Class and:
a) For a Network Hospital shall mean the rates pre-agreed between the Network Hospital and the Administrator which relate to medical treatment that is necessary and reasonable in scope to treat the condition for which the Insured was Hospitalized;
b) For any other Hospital shall mean the cost of medical treatment that is necessary and reasonable in scope to treat the condition for which the Insured was Hospitalized to the extent that such cost does not exceed the reasonable and customary charges that Hospitals in the same locality would have charged for the same medical treatment and Hospitalization Class.
12) Identification or ID card means the card issued to the Insured by the Administrator.
13) Illness means a condition affecting the general well being and health of the body or an affliction of the bodily organs having a defined and recognized pattern of symptoms that first manifests itself in the Policy Period and which requires treatment by a Doctor. 11 does not mean any mental illness (a mental or bodily condition marked primarily by sufficient disorganization of personality, mind, and emotions to seriously impair the normal psychological, social, or work performance of the individual) regardless of its cause or origin.
14) Insured means:
a) The persons named in the Schedule.
b) The Proposer's:
i) Legal spouse;
ii) Children aged between 30 days and 19 years at the commencement of the Policy Period if they are unmarried, still dependant on the Proposer and have not established their own 'independent households;
iii) Unmarried dependent children aged between 20 and 26 years at the commencement of the Policy Period if in full or part time education and primarily dependent upon the Proposer for financial support and maintenance;
iv) Unmarried dependant female children aged less than 36 years at the commencement of the Policy Period if their principal place of residence is with the Proposer and if they have no cover under any other insurance policy;
v) Any other person who during the Policy Period falls within one of the foregoing categories as long as the details of such person are notified to the Insurer within 3 months of the entitlement having arisen; any documentation or information sought by the Insurer has been provided expeditiously; the Insurer has agreed to the extension of cover, and any additional premium sought by the Insurer has been paid.
vi) Dependant Parents means the natural or legally adopted mother and/or father of the Proposer, provided that:
a) The Parent is below 69 years of age at initial participation under this Policy; and
b) Does not exceed age 70 while covered hereunder c) In the case of legally adopted parents, the legal adoption must have taken place as per act.
d) Dependant Parents shall not refer to the parents of the spouse of the main Proposer.