health care supreme policy wordings - bajaj allianz · typest opfy plifycy

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HealtH Care Supreme

CIN: U66010PN2000PLC015329, UIN: IRDA/NL-HLT/BAGI/P-H/V.I/22 /13-14 HCS/V002/w.e.f. 1st Jan 2018 1

Bajaj Allianz General Insurance Company Limited

Types of Policy • IndividualHealthCaresupremePolicy• FloaterHealthCareSupremePolicy• GroupHealthCareSupremePolicy

Policy periodThisisanannualpolicy

Sections under each plan• MedicalExpensesSection:Mandatory• AddOnBenefitsSection:Optional

Medical Expenses section covers1. HospitalisationExpenses2. PreHospitalisation3. PostHospitalisation4. RoadAmbulance5. AirAmbulance6. DayCareProcedures7. OutPatientExpenses8. OrganDonorExpenses9. Recoverybenefit10. PhysiotherapyExpenses11. SumInsuredReinstatementBenefit12. Ayurvedic&HomeopathictreatmentHospitalisationExpenses13. MaternityExpenses14. NewBornBabyCover15. PreventiveHealthCheckUpAnnualFree

Add On Benefits section(Optional) covers1. AncillaryExpensesBenefit2. CriticalIllnesscover3. PersonalAccidentcover

PreambleOuragreementtoinsureYouisbasedonYourProposaltoUs,whichisthebasisofthisagreement,andYourpaymentofthepremium.ThisPolicyrecordstheentireagreementbetweenusandsetsoutwhatWeinsure,howWeinsureit,andwhatWeexpectofYouandwhatYoucanexpectofUs.

Scope of coverTheCompanyherebyagreestopayinrespectofanadmissibleclaim,anyorallofthefollowingexpensessubjecttotheSumInsured,limits,terms,conditionsanddefinitions,exclusionscontainedorotherwiseexpressedinthisPolicy.

PART I:Section 1: Medical Expenses Section

A1. Hospitalisation Expenses IfYouareHospitalisedontheadviceofaDoctorbecauseofIllnessorAccidentalBodilyInjurysustainedorcontractedduringthe

PolicyPeriod,thenWewillpayYouIn-patientTreatment-MedicalExpensesforthebelowlisteditemsuptotheSumInsuredasspecifiedunderthepolicyschedule

In-patientTreatment-MedicalExpensesfor: • Roomrent,boardingexpenses • Nursing • Intensivecareunit

HEAlTH CARE SuPREME POlICy WORdIngS

Issuing Office :

G.E. Plaza, Airport Road, Yerawada, Pune - 411006. Reg No.: 113. CIN: U66010PN2000PLC015329 E-mail: [email protected] | Website: www.bajajallianz.com


HealtH Care Supreme



• Consultationfees • Anesthesia,blood,oxygen,operationtheatrecharges,surgicalappliances • Medicines,drugsandconsumables, • Diagnosticprocedures, • TheCostofprostheticandotherdevicesorequipmentifimplantedinternallyduringaSurgicalProcedure. Note: OurmaximumliabilitycollectivelyforHospitalizationexpenses,(sectionA1),Pre-hospitalization(SectionA2),Posthospitalization

(SectionA3), Roadambulance (SectionA4),DayCareexpenses (SectionA6),Ayurvedic /HomeopathicHospitalisationExpenses(SectionA12)wouldnotexceedthehospitalizationSumInsuredasspecifiedinthepolicyschedule.

TheSumInsuredforothersectionsisasspecifiedundertherespectivecoverinthepolicyschedule

A2. Pre-Hospitalisation TheMedicalExpensesincurredduringthe60daysimmediatelybeforeyouwereHospitalised,providedthat:SuchMedicalExpenses

wereincurredforthesameillness/injuryforwhichsubsequentHospitalisationwasrequired,andWehaveacceptedaninpatientHospitalisationclaimunderBenefitHospitalisationexpenses(sectionA1).

Note: OurmaximumliabilitycollectivelyforHospitalizationexpenses,(sectionA1),Pre-hospitalization(SectionA2),Posthospitalization


A.3 Post-Hospitalisation TheMedicalExpensesincurredduringthe90daysimmediatelyafterYouweredischargedpostHospitalisationprovidedthat:Such

costsareincurredinrespectofthesameillness/injuryforwhichtheearlierHospitalisationwasrequired,andWehaveacceptedaninpatientHospitalisationclaimunderBenefitHospitalisationexpenses(sectionA1).



A4. Road Ambulance Wewillreimbursetheexpensesincurredonanambulanceofferedbyahealthcareorambulanceserviceproviderfortransferring

You to thenearestHospitalwithadequateemergency facilities for theprovisionofhealthservices followinganEmergency,providedthat:WehaveacceptedaninpatientHospitalisationclaimunderBenefitHospitalisationexpenses(sectionA1).

Wewillalso reimburse theexpenses incurredonanambulanceofferedbyahealthcareorambulanceserviceprovider fortransferringYoufromtheHospitalwhereyouwereadmittedinitiallytoanotherhospitalwithhighermedicalfacilitiesprovidedthat:WehaveacceptedaninpatientHospitalisationclaimunderBenefitHospitalisationexpenses(sectionA1).



A5. Air Ambulance Wewillpayforambulancetransportationinanairplaneorhelicopterforemergencylifethreateninghealthconditionswhichrequire

immediateandrapidambulancetransportationfromthesiteoffirstoccurrenceoftheillness/accidenttothenearesthospital.TheclaimwouldbereimburseduptotheactualexpensessubjecttoamaximumlimitasspecifiedundertheAir Ambulance sectioninthepolicyschedule.

Returntransportationtotheclient’shomebyairambulanceisexcluded

A6. day Care Procedures WewillpayyouthemedicalexpensesaslistedaboveunderSectionA1forDaycareprocedures/Surgeriestakenasaninpatientin

ahospitalordaycarecentrebutnotintheoutpatientdepartment.IndicativelistofDayCareProceduresisgivenintheannexure1ofPolicywordings



A7. Out Patient Expenses Ifyouconsultaspecialistconsultant/specialistmedicalPractitioneronOutpatientbasisfortheillness/injurycontractedduring

thepolicyperiod,wewillpayyouOutPatientexpensesfor,


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• SpecialistConsultations • Investigationsrelatedtotheillness/injuryasprescribedbythespecialist • Medicinesrelatedtotheillness/injuryasprescribedbythespecialist • DentalProcedures–RootCanalTreatment,Extractions • ConsultationsforPsychiatricdisorders OurmaximumliabilityfortheaboveexpensesshallbelimitedtotheamountspecifiedunderOutPatient Expensesinthepolicy

schedule

A8. Organ donor Expenses: Wewillpaythelumpsumamountasspecifiedunderthepolicyscheduletowardsorgandonor’streatmentforharvestingofthe

donatedorgan,providedthat, i. Theorgandonor is anypersonwhoseorganhasbeenmadeavailable inaccordanceand in compliancewithTHE

TRANSPLANTATIONOFHUMANORGANS(AMENDMENT)BILL,2011andtheorgandonatedisfortheuseoftheInsuredPerson,and

ii. WehaveacceptedaninpatientHospitalisationclaimfortheinsuredmemberunderHospitalisationexpenses(sectionA1). WewillpayonetimelumpsumbenefitamountasspecifiedunderOrgan donor Expenses inthepolicyschedule

A9. Recovery benefit: Intheeventofinsuredmemberhospitalisedforadisease/illness/injuryforacontinuousperiodexceeding7days,Wewillpaya

onetimelumpsumamountperpolicyperiod,asspecifiedunderthe Recovery benefitinthepolicyschedule. ThisbenefitwillbetriggeredprovidedthatthehospitalizationclaimisacceptedunderPartI-SectionA1-Hospitalisationexpenses.

A10. Physiotherapy Expenses: WewillpaytheexpensesincurredtowardsPhysiotherapytreatmenttakenonOutpatientBasisforillness/Injurycontractedduring

thepolicyperiod,maximumuptotheamountspecifiedunderthePhysiotherapyExpensesinthepolicyschedule,providedthat, i. The treatment isprescribedbyaSpecialistconsultant forMuskulo-skeletal /Neurologicaldiseases/ Injuriesorother

Systemicdiseases ii. Thetreatmentshouldbecarriedoutinahospitalasdefinedunderthepolicy iii. Total10sittingsofPhysiotherapysessionswouldbeconsideredperillness/injuryperpolicyperiod,maximumuptothe

specifiedlimitaspertheplanopted iv. DuringthefirstyearofHealthCareSupremepolicywithus,90dayswaitingperiodwouldbeapplicableforalltheclaims,

howeverthewaitingperiodwouldnotbeappliedduringsubsequentrenewals.

A11. Sum Insured Reinstatement Benefit: IftheHospitalisationSumInsuredandcumulativebenefit(ifany)isexhaustedduetoclaimslodgedduringthePolicyperiod,

thenitisagreedthat100%ofthehospitalizationSumInsuredspecifiedunderPartI-Hospitalisationexpenses(sectionA1)willbereinstatedfortheparticularPolicyperiodprovidedthat:

i. ThereinstatedSumInsuredwillbetriggeredonlyaftertheHospitalisationSumInsuredinclusiveoftheCumulativeBonus(Ifapplicable)hasbeencompletelyexhaustedduringthepolicyperiod;

ii. The reinstatedSum Insuredcanbeused forclaimsmadeby the InsuredPerson in respectof thebenefits stated inHospitalisationExpensesSectionA1;

iii. IftheclaimedamountishigherthantheBalanceSumInsuredinclusiveoftheCumulativeBonus(Ifapplicable)underthepolicy,thenthisbenefitwillnotbetriggeredforsuchclaims

iv. ThereinstatedSumInsuredwouldbetriggeredonlyforsubsequentclaimsmadebytheInsuredPersonandnotarisingoutofanyillness/disease(includingitscomplications)forwhichaclaimhasbeenlodgedinthecurrentpolicyyearunderHospitalisationExpensesSectionA1.

v. Thisbenefitisapplicableonlyonceduringeachpolicyperiod&willnotbecarriedforwardtothesubsequentrenewalsifthebenefitisnotutilized.

vi. AdditionalpremiumwouldnotbechargedforreinstatementoftheSumInsured.

A12. Ayurvedic & Homeopathic treatment Hospitalisation Expenses IfYouareHospitalisedfornotlessthan24hrs,inanAyurvedic/HomeopathicHospitalontheadviceofaDoctorbecauseofIllness

orAccidentalBodilyInjurysustainedorcontractedduringthePolicyPeriodthenWewillpayYou: In-patientTreatment-MedicalExpensesforAyurvedic&Homeopathictreatment: • Roomrent,boardingexpenses • Nursingcare • Consultationfees • Medicines,drugsandconsumables, • Ayurvedic&Homeopathictreatmentprocedures


HealtH Care Supreme



The claim will be admissible under the policy provided that, i. The illness/injury requires inpatientadmission& theprocedureperformedon the insuredcannotbecarriedouton

Outpatientbasis ii. thetreatmenthasbeenundergoneinagovernmenthospital Note: OurmaximumliabilitycollectivelyforHospitalizationexpenses,(sectionA1),Pre-hospitalization(SectionA2),Posthospitalization


A13. Maternity Expenses WewillpaytheMedicalExpensesforthedeliveryofababy(includingcaesareansection)and/orexpensesrelatedtomedically

recommendedandlawfulterminationofpregnancy,limitedtomaximum2deliveriesortermination(s)oreither,duringthelifetimeoftheinsuredperson,providedthat,

i. OurmaximumliabilityperdeliveryorterminationshallbelimitedtotheamountspecifiedinthepolicyScheduleaspertheplanopted.

ii. WewillpaytheMedicalExpensesofpre-natalandpost-natalhospitalizationperdeliveryorterminationuptotheamountstatedinthepolicySchedule

iii. WewillcovertheMedicalExpensesincurredforthemedicallynecessarytreatmentofthenewbornbabyuptotheamountstatedintheScheduleofBenefits

iv. ThiscoverageislimitedtoSelf&alawfullyweddedspousewhenbotharecoveredunderasinglepolicyfor24months,eitherasafamilyfloaterorindividualSumInsuredpolicy

v. Waitingperiodof24monthsfromthedateofissuanceofthefirstpolicywithus,providedthatthepolicyhasbeenrenewedcontinuouslywithuswithoutbreakforyou&yourspouse

vi. WewillnotcoverEctopicpregnancyunderthisbenefit(althoughitshallbecoveredundersectionHospitalisationA1). vii. Anycomplicationsarisingoutoforasaconsequenceofmaternity/childbirthwillbecoveredwithinthelimitofSum

Insuredavailableunderthisbenefit

A14. new Born Baby Cover CoveragefornewbornbabywillbeconsideredsubjecttoavalidclaimbeingacceptedundermaternityexpensessectionA13.

WewillpaythefollowingexpenseswithinthelimitoftheSumInsuredavailableunderthematernitycover i. MedicalExpensestowardstreatmentofyournewbornbabywhileyouarehospitalisedasaninpatientfordeliveryforthe

hospitalization, ii. Hospitalisationchargesincurredonthenewbornbabyduringpostbirthincludinganycomplicationsshallbecoveredup

toaperiodof90daysfromthedateofbirthandwithinlimitoftheSumInsuredunderMaternityCoverwithoutpaymentofanyadditionalpremium

iii. MandatoryVaccinationsofthenewbornbabyupto90days,asrecommendedbytheIndianPediatricAssociationwillbecoveredundertheMaternitySumInsured

A15. Free Annual Preventive Health Check up AftereachrenewalofHealthCareSupremepolicywithusyouwillbeentitledforaFreeAnnualPreventiveHealthCheckupat

OurempanelledDiagnosticcentersOrempanelledHospitals,listoftestsasspecifiedbelow.YouwouldhavetoapproachusforthearrangementoftheHealthCheckup.Fortheavoidanceofdoubt,Weshallnotbeliableforanyotherancillaryorperipheralcostsorexpenses(includingbutnotlimitedtothosefortransportation,accommodationorsustenance).

ThisbenefitcanbeavailedbyallmemberscoveredunderIndividualSumInsuredPolicies. Thisbenefitcanbeavailedbyproposer&spouseonlyunderFloaterSumInsuredPolicies

Eligible list of tests for Males above 25 years

Eligible list of tests for Females above 25 years

Eligible list of tests for age 5 years – 25 years

FullMedicalReportCBC(CompleteBloodCount)FBS(FastingBloodSugar)SerumCreatinineECGSerumCholesterolUltraSonographyofAbdomen&Pelvis

FullMedicalReportCBCFBSSerumCreatinineECGPAPsmearSerumCholesterolUltraSonographyofAbdomen&Pelvis

FullMedicalReportCBCChestXrayBloodGroupUrineRoutine


HealtH Care Supreme



Note: The hospitalization Sum Insured under Medical Expenses Section covers the below listed expenses TheclaimpayoutunderthebelowheadingsshouldnotexceedtheHospitalisationSumInsured. • Hospitalizationexpenses • Pre-hospitalization • Posthospitalization • Roadambulance • DayCareexpenses • Ayurvedic/HomeopathicTreatmentHospitalisationExpenses

Separate Sum Insured has been Specified for the below mentioned sections • AirAmbulance • OutPatientExpenses • OrganDonorExpenses • Recoverybenefit • PhysiotherapyExpenses • SumInsuredReinstatementBenefit • MaternityExpenses(andNewBornBabyCover)

Section 2: definitions Applicable for All Covers of this Policy

WordsortermsinItalichavethemeaningascribedtothemwherevertheyappearinthisPolicy,andreferencestothesingularortothemasculineincludereferencestothepluralortothefemininewhereverthecontextpermits:

1. Accident, Accidental Anaccidentisasudden,unforeseenandinvoluntaryeventcausedbyexternal,visibleandviolentmeans

2. Alternative treatments Alternativetreatmentsareformsoftreatmentsotherthantreatment“Allopathy”or“Modernmedicine”andincludesAyurveda,

Unani,SidhaandHomeopathyintheIndiancontext

3. Any one illness AnyoneillnessmeanscontinuousPeriodofillnessanditincludesrelapsewithin45daysfromthedateoflastconsultationwith

theHospital/NursingHomewheretreatmentmayhavebeentaken.

4. Bodily Injury/ Injury meansaccidentalphysicalbodilyharmexcludingillnessordiseasesolelyanddirectlycausedbyexternal,violentandvisibleandevidentmeanswhichisverifiedandcertifiedbyaMedicalPractitioner..

5. Bajaj Allianz network Hospitals / network Hospitals/network Provider meanstheHospitalswhichhavebeenempanelledbyUsasperthelatestversionofthescheduleofHospitalsmaintainedbyUs,whichisavailabletoYouonrequest.

6. Bajaj Allianz diagnostic CentremeansthediagnosticcentreswhichhavebeenempanelledbyUsasperthelatestversionofthescheduleofdiagnosticcentresmaintainedbyUs,whichisavailabletoYouonrequest.

7. Black listing of Hospital shallmeandebarringthehospitalonaccountofadoptingunethicalpracticesorfraudulentmeansinprovidingmedicaltreatmenttoornotfollowingthegoodindustrypracticesofhealthcare

8. Congenital Anomaly CongenitalAnomalyreferstoacondition(s)whichispresentsincebirth,andwhichisabnormalwithreferencetoform,structure

orposition. a. Internal Congenital Anomaly Congenitalanomalywhichisnotinthevisibleandaccessiblepartsofthebody b. External Congenital Anomaly Congenitalanomalywhichisinthevisibleandaccessiblepartsofthebody

9. Cashless facility “Cashlessfacility”meansafacilityextendedbytheinsurertotheinsuredwherethepayments,ofthecostsoftreatmentundergone

bytheinsuredinaccordancewiththepolicytermsandconditions,aredirectlymadetothenetworkproviderbytheinsurertotheextentpre-authorizationapproved.


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10. Condition Precedent ConditionPrecedentshallmeanapolicytermorconditionuponwhichtheInsurer’sliabilityunderthepolicyisconditionalupon.

11. Contribution Contributionisessentiallytherightofaninsurertocalluponotherinsurers,liabletothesameinsured,tosharethecostofan

indemnityclaimonaratableproportion.

12. Critical Illness meansanillness,sicknessoradiseaseoracorrectivemeasureasspecifiedinPartIISection2ofthisPolicy.

13. Critical Illness Benefit meanstheamountspecifiedintheSchedule,whichisthemaximumamountforwhichtheCompanymaybeliabletomakepaymentforanyCriticalIllness.

14. Cumulative Bonus CumulativeBonusshallmeananyincreaseintheSumInsuredgrantedbytheinsurerwithoutanassociatedincreaseinpremium.

15. day care centremeansanyinstitutionestablishedfordaycaretreatmentofsicknessand/orinjuriesoramedicalset-upwithinahospitalandwhichhasbeenregisteredwiththelocalauthorities,whereverapplicable,andisunderthesupervisionofaregisteredandqualifiedmedicalpractitionerANDmustcomplywithallminimumcriteriaasunder:-

• hasqualifiednursingstaffunderitsemployment; • hasqualifiedmedicalpractitioner/sincharge; • hasafullyequippedoperationtheatreofitsownwheresurgicalproceduresarecarriedout; • maintainsdailyrecordsofpatientsandwillmaketheseaccessibletotheinsurancecompany’sauthorizedpersonnel

16. day Care Treatment Daycaretreatmentreferstomedicaltreatment,and/orsurgicalprocedurewhichis: I. UndertakenunderGeneralorLocalAnaesthesiainahospital/daycarecentrein II. Lessthan24hrsbecauseoftechnologicaladvancement,andwhichwouldhaveotherwiserequiredahospitalizationof

morethan24hours.Treatmentnormallytakenonanout-patientbasisisnotincludedinthescopeofthiscover

17. dental Treatment Dentaltreatmentistreatmentcarriedoutbyadentalpractitionerincludingexaminations,fillings(whereappropriate),crowns,

extractionsandsurgeryexcludinganyformofcosmeticsurgery/implants.

18. dependent child Achildisconsideredadependentforinsurancepurposesuntilhis35thbirthday(evenifnotenrolledinaneducationalinstitution)

providedheisunmarried,financiallydependent,ontheproposer.

19. disclosure to information norm ThePolicyshallbevoidandallpremiumpaidhereonshallbeforfeitedtotheCompany,intheeventofmisrepresentation,mis-

descriptionornon-disclosureofanymaterialfact.

20. doctor / medical practioner AMedicalPractitionerisapersonwhoholdsavalidregistrationfromtheMedicalCouncilofanyStateorMedicalCouncilofIndia

orCouncilforIndianMedicineorforHomeopathysetupbytheGovernmentofIndiaoraStateGovernmentandistherebyentitledtopracticemedicinewithinitsjurisdiction;andisactingwithinthescopeandjurisdictionoflicence.

21. doctor for alternative treatmentmeansapersonwhoholdsarecognizedqualificationinAyurvedic/HomeopathicmedicineandisregisteredbythemedicalcouncilofanyStateofIndiainwhichheoperatesandispracticingwithinthescopeofsuchlicense

22. Ectopic Pregnancy meanspregnancyinwhichtheembryoislocatedorthefoetusdevelops,outsidetheuterus,whichisprovedbydiagnosticmeans&certifiedbyaSpecialistconsultantinwriting

23. Emergency Care Emergencycaremeansmanagement fora severe illnessor injurywhich results in symptomswhichoccur suddenlyand

unexpectedly,andrequiresimmediatecarebyamedicalpractitionertopreventdeathorseriouslongtermimpairmentoftheinsuredperson’shealth.

24. Family definitionforthepurposeofFamilyFloaterincludestheinsured;his/herlawfullyweddedspouseanddependentchildren.

25. Family definitionforthepurposeofIndividualSumInsuredpolicyincludestheinsured;his/herlawfullyweddedspouseanddependentchildren&dependantparents.


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26. grace Period Graceperiodmeansthespecifiedperiodoftimeimmediatelyfollowingthepremiumduedateduringwhichapaymentcanbe

madetoreneworcontinueapolicyinforcewithoutlossofcontinuitybenefitssuchaswaitingperiodsandcoverageofpreexistingdiseases.Coverageisnotavailablefortheperiodforwhichnopremiumisreceived.

27. Hospital Ahospitalmeansanyinstitutionestablishedforin-patientcareanddaycaretreatmentofillnessand/orinjuriesandwhichhas

beenregisteredasahospitalwiththelocalauthoritiesundertheClinicalEstablishments(RegistrationandRegulation)Act,2010orundertheenactmentsspecifiedundertheScheduleofSection56(1)ofthesaidActORcomplieswithallminimumcriteriaasunder:

--hasqualifiednursingstaffunderitsemploymentroundtheclock; --hasatleast10in-patientbedsintownshavingapopulationoflessthan10,00,000andatleast15in-patientbedsinallother

places; --hasqualifiedmedicalpractitioner(s)inchargeroundtheclock; --hasafullyequippedoperationtheatreofitsownwheresurgicalproceduresarecarriedout; --maintainsdailyrecordsofpatientsandmakestheseaccessibletotheinsurancecompany’sauthorizedpersonnel.

Hospital for Ayurvedic & Homeopathic Treatment:Ahospitalmeansgovernmenthospitals forAyurvedic&HomeopathicTreatment

28. Hospitalisation MeansadmissioninaHospitalforaminimumperiodof24inpatientCareconsecutivehoursexceptforspecifiedprocedures/

treatments,wheresuchadmissioncouldbeforaperiodoflessthan24consecutivehours.

29. Inpatient Care Inpatientcaremeanstreatmentforwhichtheinsuredpersonhastostayinahospitalformorethan24hoursforacoveredevent.

30. Intensive Care unit Intensivecareunitmeansanidentifiedsection,wardorwingofahospitalwhichisundertheconstantsupervisionofadedicated

medicalpractitioner(s),andwhichisspeciallyequippedforthecontinuousmonitoringandtreatmentofpatientswhoareinacriticalcondition,orrequirelifesupportfacilitiesandwherethelevelofcareandsupervisionisconsiderablymoresophisticatedandintensivethanintheordinaryandotherwards.

31. Illness : IllnessmeansasicknessoradiseaseorpathologicalconditionleadingtotheimpairmentofnormalphysiologicalfunctionwhichmanifestsitselfduringthePolicyPeriodandrequiresmedicaltreatment.

a. Acute condition -Acuteconditionisadisease,illnessorinjurythatislikelytorespondquicklytotreatmentwhichaimstoreturnthepersontohisorherstateofhealthimmediatelybeforesufferingthedisease/illness/injurywhichleadstofullrecovery.

b. Chronic condition -Achronicconditionisdefinedasadisease,illness,orinjurythathasoneormoreofthefollowingcharacteristics:—itneedsongoingor long-termmonitoring throughconsultations,examinations,check-ups,and/ortests—itneedsongoingorlong-termcontrolorreliefofsymptoms—itrequiresyourrehabilitationorforyoutobespeciallytrainedtocopewithit—itcontinuesindefinitely—itcomesbackorislikelytocomeback

32. Insured/Insured Personmeanstheperson(s)namedinthepolicyschedule,whoarecoveredunderthispolicy,forwhomtheinsuranceisproposed,appropriatepremiumispaid.

33. limit of IndemnitymeansOurmaximumliabilityforeachInsuredPersonforanyandallbenefitsclaimedforduringeachPolicyYear,andinrelationtoaFamilyFloaterrepresentsOurmaximumliabilityforanyandallclaimsmadebyYouandallofYourDependentsduringeachPolicyYear.

34. Medical Advice AnyconsultationoradvicefromaMedicalPractitionerincludingtheissueofanyprescriptionorrepeatprescription.

35. Medical expenses MedicalExpensesmeansthoseexpensesthatanInsuredPersonhasnecessarilyandactuallyincurredformedicaltreatmenton

accountofIllnessorAccidentontheadviceofaMedicalPractitioner,aslongasthesearenomorethanwouldhavebeenpayableiftheInsuredPersonhadnotbeeninsuredandnomorethanotherhospitalsordoctorsinthesamelocalitywouldhavechargedforthesamemedicaltreatment.


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36. Medically necessary Medicallynecessarytreatmentisdefinedasanytreatment,tests,medication,orstayinhospitalorpartofastayinhospitalwhich I. isrequiredforthemedicalmanagementoftheillnessorinjurysufferedbytheinsured; II. mustnotexceedthelevelofcarenecessarytoprovidesafe,adequateandappropriatemedicalcareinscope,duration,or

intensity; III. musthavebeenprescribedbyamedicalpractitioner, IV. mustconformtotheprofessionalstandardswidelyacceptedininternationalmedicalpracticeorbythemedicalcommunity

inIndia.

37. Maternity expense / treatmentshallincludethefollowingMedicaltreatment Expenses: I. MedicalExpensesforadelivery(includingcomplicateddeliveriesandCaesareansections)incurredduringHospitalization; II. ThelawfulmedicalterminationofpregnancyduringthePolicyPeriodlimitedto2deliveriesorterminationsoreither

duringthelifetimeoftheInsuredPerson; III. Pre-natalandpost-natalMedicalExpensesfordeliveryortermination.

38. new Born Baby NewbornbabymeansbabybornduringthePolicyPeriodandisagedbetween1dayand90days,bothdaysinclusive.

39. nomineemeansapersondesignatedbyYoutoreceivetheproceedsofthisPolicyuponYourdeath.

40. non- network Anyhospital,daycarecentreorotherproviderthatisnotpartofthenetwork

41. notification of Claim NotificationofclaimistheprocessofnotifyingaclaimtotheinsurerorTPAbyspecifyingthetimelinesaswellastheaddress/

telephonenumbertowhichitshouldbenotified.

42. Occupational diseases : Adiseaseresultingfromexposureduringemploymenttoconditionsorsubstancesthataredetrimentaltohealth

43. OPd treatment isoneinwhichtheInsuredvisitsaclinic/hospitalorassociatedfacilitylikeaconsultationroomfordiagnosisandtreatmentbasedontheadviceofaMedicalPractitioner.TheInsuredisnotadmittedasadaycareorin-patient.

44. Obesitymeansabnormalorexcessivefataccumulationthatmayimpairhealth.ObesityismeasuredinBodyMassIndex. Bodymassindex(BMI)isasimpleindexofweight-for-heightthatiscommonlyusedtoclassifyoverweightandobesityinadults.

Itisdefinedasaperson’sweightinkilogramsdividedbythesquareofhisheightinmeters(kg/m2). TheWHOdefinitionis: • BMIgreaterthanorequalto25isoverweight • BMIgreaterthanorequalto30isobesity

45. Permanent Total disability Doctorcertifiedtotal,continuousandpermanent: • Lossofthesightofbotheyes • Physicalseparationoforthelossofabilitytousebothhandsorbothfeet • Physicalseparationoforthelossofabilitytouseonehandandonefoot • Lossofsightofoneeyeandphysicalseparationoforthelossofabilitytouseeitheronehandoronefoot.

46. Permanent Partial disability Doctorcertifiedtotalandpermanentlossorimpairmentofbodypartorsensoryorgan

47. Physiotherapy Abranchofrehabilitativetreatmentthatusesspeciallydesignedexercisesandequipmenttohelppatientsregainorimprove

theirphysicalabilities

48. Policymeanstheproposal,theSchedule(andanyendorsementsattachingtoorformingpartthereof)andthepolicydocument.

49. Policy PeriodmeanstheperiodbetweenthecommencementdateandtheexpirydatespecifiedintheScheduleandincludesboththecommencementdateaswellastheexpirydate.


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50. Pre-hospitalization Medical Expenses MedicalExpensesincurredimmediatelybeforetheInsuredPersonisHospitalised,providedthat: I. SuchMedicalExpensesareincurredforthesameconditionforwhichtheInsuredPerson’sHospitalisationwasrequired,

and II. TheIn-patientHospitalizationclaimforsuchHospitalizationisadmissiblebytheInsuranceCompany.

51. Post-hospitalization Medical Expenses MedicalExpensesincurredimmediatelyaftertheInsuredPersonisHospitalised,providedthat: I. SuchMedicalExpensesareincurredforthesameconditionforwhichtheInsuredPerson’sHospitalisationwasrequired,

and II. TheIn-patientHospitalizationclaimforsuchHospitalizationisadmissiblebytheInsuranceCompany.

52. Portability Portabilitymeanstransferbyanindividualhealthinsurancepolicyholder(includingfamilycover)ofthecreditgainedforpre-

existingconditionsandtime-boundexclusionsifhe/shechoosestoswitchfromoneinsurertoanother

53. Pre -Existing ailment or disease-Anycondition,ailmentorinjuryorrelatedcondition(s)forwhichYouhadsignsorsymptoms,and/orwerediagnosedand/orreceivedmedicaladvice/treatment,within48monthspriortoinceptionofYourfirstpolicy.

54. Qualified nurse QualifiednurseisapersonwhoholdsavalidregistrationfromtheNursingCouncilofIndiaortheNursingCouncilofanystatein

India.

55. Reasonable and customary charges meansthechargesforservicesorsupplies,whicharethestandardchargeforthespecificproviderandconsistentwiththeprevailingchargesinthegeographicalareaforidenticalorsimilarservices,takingintoaccountthenatureoftheillness/injuryinvolved.

56. Renewal Renewaldefinesthetermsonwhichthecontractofinsurancecanberenewedonmutualconsentwithaprovisionofgraceperiod

fortreatingtherenewalcontinuousforthepurposeofallwaitingperiods.

57. Room rent: RoomRentshallmeantheamountchargedbyahospitalforthedeductiblesoccupyingofabedandassociatedmedicalexpenses

58. Schedulemeansthescheduleandanyannexuretoit.

59. Surgery or Surgical Proceduremeansamanualand/oroperativeprocedure(s)requiredforthetreatmentofanillnessorinjury,correctionofdeformitiesanddefects,diagnosisandcureofdiseases,reliefofsufferingorprolongationoflife,performedinaHospitalbyaMedicalPractitioner

60. Specialist ConsultantmeansapersonwhoholdsamedicalpostgraduateorhigherdegreeinthespecificlineoftreatmentunderAllopathicmedicine

61. Sum InsuredmeanstheamountstatedintheScheduleagainsttheCoverforeachinsuredpersonseparatelyforIndividualSumInsuredpolicyandaggregatelyforallinsuredmembersforaFloaterpolicy

62. Subrogationshallmeantherightoftheinsurertoassumetherightsoftheinsuredpersontorecoverexpensespaidoutunderthepolicythatmayberecoveredfromanyothersource.

63. unproven/Experimental treatment / non-standard treatment Unproven/Experimental treatment/Non-standard is treatment, includingdrugExperimental therapy,which isnotbasedon

establishedmedicalpracticeinIndia.

64. We, Our, Ours, usmeanstheBajajAllianzGeneralInsuranceCompanyLimited.

65. you, your, yourself meansthepersonorpersonsthatWeinsureassetoutintheSchedule.


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Section 3: Exclusions:

A. The below exclusions will be applicable forHospitalizationexpenses (sectionA1),Pre-hospitalization (SectionA2),Posthospitalization(SectionA3),Roadambulance(SectionA4),AirAmbulance(SectionA5),DayCareProcedures(SectionA6),Recoverybenefit(SectionA9),PhysiotherapyExpenses(SectionA10),Suminsuredreinstatementbenefit(SectionA11)andAyurvedic/HomeopathictreatmentHospitalisationExpenses(SectionA12)

We shall not be liable to make any payment for any claim directly or indirectly caused by, based on, arising out of or attributable to any of the following:

I. Waiting Period 1. BenefitswillnotbeavailableforAnyPre-existingcondition,ailmentorinjury,until24monthsofcontinuouscoverage

haveelapsed,afterthedateofinceptionofthefirstHealthCareSupremepolicy. Theaboveexclusion1shallceasetoapplyifYouhavemaintainedaHealthCareSupremePolicywithUsforacontinuous

periodofafull2yearswithoutbreakfromthedateofYourfirstHealthCareSupremePolicy. IncaseofenhancementofSumInsuredthisExclusionshallapplyafreshonlytotheextentoftheamountbywhichthe

limitofindemnityhasbeenincreased(i.e.enhancedsuminsured)ifthepolicyisarenewalofHealthCareSupremepolicywithoutbreakincover.

2. WewillalsonotpayforclaimsarisingoutoforhowsoeverconnectedtothefollowingforthefirstyearofHealthCareSupremePolicy,

1. Anytypesofgastricorduodenalulcers, 9. Cataracts,

2. Benignprostatichypertrophy 10.Herniaofalltypes

3. Alltypesofsinuses 11. Fistulae,Fissureinano

4. Haemorrhoids 12.Hydrocele

5. Dysfunctionaluterinebleeding 13. Fibromyoma

6. Endometriosis 14.Hysterectomy

7. Stonesintheurinaryandbiliarysystems 15. Surgeryforanyskinailment

8. Surgeryonears/tonsils/adenoids/paranasalsinuses 16. Surgeryonallinternalorexternaltumours/cysts/nodules/polypsofanykindincludingbreastlumpswithexceptionofMalignanttumororgrowth.

Thisexclusionshallapplyforacontinuousperiodof24monthsfromthedateofYourfirstHealthCareSupremePolicy,if

theabovereferredillnesswerepresentatthetimeofcommencementofthepolicyandifYouhaddeclaredsuchillnessatthetimeofproposingthepolicyforthefirsttime.

IncaseofenhancementofSumInsuredthewaitingperiodsshallapplyafreshonlytotheextentoftheamountbywhichthelimitofindemnityhasbeenincreased(i.e.enhancedsuminsured)ifthepolicyisarenewalofHealthCareSupremePolicywithoutbreakincover.

3. AnyMedicalExpensesincurredduringthefirsttwoconsecutiveannualperiodsduringwhichYouhavethebenefitofaHealthCareSupremePolicywithUsinconnectionwith:

• Jointreplacementsurgery, • Surgeryforprolapsedintervertebraldisc(unlessnecessitatedduetoanaccident) • SurgerytocorrectDeviatedNasalSeptumandHypertrophiedTurbinates • Congenitalinternaldiseasesoranomalies • Lasertreatmentforcorrectionofeyesightduetorefractiveerror. IncaseofenhancementofSumInsuredthewaitingperiodsshallapplyafreshonlytotheextentoftheamountbywhich

thelimitofindemnityhasbeenincreased(i.e.enhancedsuminsured)ifthepolicyisarenewalofHealthCareSupremePolicywithoutbreakincover.

4. Anydiseasecontractedand/ormedicalexpensesincurredinrespectofanydisease/illnessbytheinsuredduringthefirst30daysfromthecommencementofthepolicy,exceptforaccidentalinjuries.

Thisexclusiondoesnotapplyifyouarecoveredunderanyhealthindemnitypolicywithoutbreak,foratleast1yearpriortothispolicy.

IncaseofenhancementofSumInsuredthewaitingperiodsshallapplyafreshonlytotheextentoftheamountbywhichthelimitofindemnityhasbeenincreased(i.e.enhancedsuminsured)ifthepolicyisarenewalofHealthCareSupremePolicywithoutbreakincover.

5. Anytreatmentarisingfromortraceabletopregnancy,childbirthincludingcesareansectionuntil24monthscontinuousperiodhaselapsedsincetheinceptionofthefirstHealthCareSupremePolicywithUS.HoweverthisexclusionwillnotapplytoEctopicpregnancyprovedbydiagnosticmeans


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II. general exclusions

1. DentaltreatmentorsurgeryofanykindunlessasaresultofAccidentalBodilyInjurytonaturalteethandalsorequiringhospitalization.

2. MedicalexpenseswhereInpatientcareisnotwarrantedanddoesnotrequiresupervisionofqualifiednursingstaffandqualifiedmedicalpractitionerroundtheclock

B. Exclusions applicable for Out Patient Expenses (Section A7) We shall not be liable to make any payment for any claim directly or indirectly caused by, based on, arising out of or

attributable to any of the following:

I. Waiting Period

1. Anydiseasecontractedand/ormedicalexpensesincurredinrespectofanydisease/illnessbytheinsuredduringthefirst30daysfromthecommencementofthepolicy,exceptforaccidentalinjuries.ThisexclusionwillnotbeapplicableforHealthCareSupremeRenewalpolicies.


1. Anyexpensesforinvestigations/treatmenttakenwithoutexistenceofanydisease/illness,signs/symptoms 2. Anyexpensesfordiagnostictests,investigations/treatmenttakenwithouttheSpecialistConsultantadvisingthesame

andwhichisnotdulysupportedbyhisprescriptions 3. CostofAnnualHealthCheckup 4. AnyexpensesinexcessofthemaximumpayableamountundertheOutpatientmedicalexpenseslimit. 5. AnyexpenseforTreatmentswhichisnotspecifiedunderSectionA7(outpatientexpenses).

C. Exclusions applicable for Ayurvedic / Homeopathic Treatment Cover (section A12), The below exclusions would be in addition to the exclusions stated under section 3, part A, We shall not be liable to make any payment for any claim directly or indirectly caused by, based on, arising out of or

attributable to any of the following

I. general exclusions

1. Treatmenttakenatahospitalwhichdoesnotfulfillthecriteriaasperthepolicydefinition 2. TreatmentexceedingthelimitasspecifiedunderthePlanopted 3. AnyexpensesincurredfortreatmenttakenforotherAyurvedic/Homeopathictherapywhichisnotdefined&covered

underthepolicy 4. TreatmenttakenforUnani,naturopathyoranyotherstreamofMedicineexceptasspecifiedunderthepolicy 5. TreatmenttakeninWellnessCentre/Spa/Naturopathycenters/Panchakarmacentersoranyothertreatmentcentreswhich

donotqualifyasperthepolicydefinitionofHospital

d. Common Exclusions applicable to all the covers under Part 1 Section A (Medical expenses) : Hospitalisationexpenses,Pre-Hospitalisation,Post-HospitalisationExpenses ,RoadAmbulance,AirAmbulance,DayCareProcedures,OutPatientExpense,OrganDonorExpenses,Recoverybenefit,PhysiotherapyExpenses,SumInsuredReinstatementBenefit,Ayurvedic/HomeopathictreatmentHospitalisationExpenses,MaternityExpenses,NewBornBabyCover

We shall not be liable to make any payment for any claim directly or indirectly caused by, based on, arising out of or attributable to any of the following:


1. War,invasion,actsofforeignenemies,hostilities(whetherwarbedeclaredornot),civilwar,commotion,unrest,rebellion,revolution,insurrection,militaryorusurpedpowerorconfiscationornationalisationorrequisitionofordamagebyorundertheorderofanygovernmentorpubliclocalauthority.

2. CircumcisionunlessrequiredforthetreatmentofIllnessorAccidentalbodilyinjury,cosmeticoraesthetictreatmentsofanydescription,treatmentorsurgeryforchangeoflife/gender.

3. Anyformofplasticsurgeryunlessnecessaryforthetreatmentofcancer,burnsoraccidentalBodilyInjury 4. Thecostofspectacles,contactlenses,hearingaids,crutches,artificiallimbs,dentures,artificialteethandallotherexternal

appliancesand/ordeviceswhetherfordiagnosisortreatmentexceptforintrinsicfixturesusedfororthopedictreatmentssuchasplatesandK-wires.


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5. ExternalmedicalequipmentofanykindusedathomeasposthospitalisationcareincludingcostofinstrumentusedinthetreatmentofSleepApnoeaSyndrome(C.P.A.P),ContinuousPeritonealAmbulatoryDialysis(C.P.A.D)andOxygenconcentratorforBronchialAsthmaticcondition.

6. Convalescence,generaldebility,restcure,congenitalexternaldiseasesordefectsoranomalies,geneticdisorders,stemcellimplantationorsurgery,orgrowthhormonetherapy.

7. Intentionalself-injury(includingbutnotlimitedtotheuseormisuseofanyintoxicatingdrugsoralcohol) 8. Ailmentsrequiringtreatmentduetouseorabuseofanysubstance,drugoralcoholandtreatmentforde-addiction. 9. AnyconditiondirectlyorindirectlycausedbyorassociatedwithHumanImmunodeficiencyVirusorVariant/mutantviruses

andoranysyndromeorconditionofasimilarkindcommonlyreferredtoasAIDS. 10. MedicalExpensesrelatingtoanyhospitalisationprimarilyandspecificallyfordiagnostic,X-rayorlaboratoryexaminations

andinvestigations 11. Anyclaimdirectlyorindirectlycausedbyorcontributedtobynuclearweaponsand/ormaterials. 12. Vaccinationorinoculationunlessformingapartofpostbitetreatmentorifmedicallynecessaryandformingapartof

treatmentrecommendedbythetreatingdoctor.ThisexclusionisnotapplicableforPartIsectionA14(NewBornBabyCover).

13. Anyfertility,subfertility,impotence,assistedconceptionoperationorsterilizationprocedure. 14. Vitamins,tonics,nutritionalsupplementsunlessformingpartofthetreatmentforinjuryordiseaseascertifiedbythe

attendingDoctor 15. Experimental,unprovenornon-standardtreatment 16. Treatmentforanyothersystemotherthanmodernmedicine(alsoknownasAllopathy).Thisexclusionisnotapplicablefor

Ayurvedic/HomeopathicMedicineExpensesunderPartIsectionA12(Ayurvedic/HomeopathictreatmentHospitalisationExpenses).

17. Expensesrelatedtodonorscreening,treatment,includingsurgerytoremoveorgansfromadonorinthecaseoftransplantsurgery.ThisexclusionisnotapplicableforDonorExpensesunderPartISectionA8(OrganDonorExpenses)

18. Venerealdiseaseoranysexuallytransmitteddiseaseorsickness 19. Weightmanagementservicesandtreatmentrelatedtoweightreductionprogrammesincludingtreatmentofobesity&

treatmentforarisingdirectorindirectcomplicationsofObesity. 20. Treatmentforanymentalillnessorpsychiatricillness,Parkinson’sDisease.ThisexclusionisnotapplicableforOutPatient

ExpensesunderPartIsectionA7(OutPatientExpenses). 21. Allnon-medicalItems(Pleasevisitourwebsitewww.bajajallianz.comforcompletelistofnonmedicalitems.) 22. AnytreatmentreceivedoutsideIndiaisnotcoveredunderthispolicy.

PART II: Health Care Supreme: Add On covers:

Note:ThesebenefitsareoptionalandapplicableonlyifoptedforandissuedaccordinglyintheScheduleofBenefits

Section1: Ancillary Expenses Benefit

IfYouareHospitalisedontheadviceofaDoctorbecauseofIllnessorAccidentalBodilyInjurysustainedorcontractedduringthePolicyPeriod,thenWewillpayYou:i. TheDailyAllowanceasspecifiedunder thepolicy, foreachcontinuousandcompletedperiodof24hoursofHospitalization

necessitatedsolelybyreasonofthesaidAccidentalBodilyInjuryorIllness,subjecttoamaximumof30daysduringthePolicyPeriodforIndividualSIpolicy&60daysduringthePolicyPeriodforFloaterSIpolicy

ii. TwotimestheDailyAllowanceforeachcontinuousandcompletedperiodof24hourshospitalisationintheIntensiveCareUnitduringanyperiodofHospitalizationnecessitatedsolelyby reasonof thesaidAccidentalBodily Injuryor Illness, subject toamaximumof15daysduringthePolicyPeriodforIndividualSIpolicy&30daysduringthePolicyPeriodforFloaterSIpolicy

Note:a. Theclaimunderi&iiwouldbeadmissibleprovidedthatwehaveacceptedtheclaimunderHospitalisationcoverunderpolicy

sectionA1(Hospitalisationexpenses)b. OurmaximumliabilitycollectivelyforHospitalization&ICUhospitalizationforIndividual&Floaterpolicieswouldnotexceedthe

TotalSumInsuredasspecifiedinthepolicyschedule

definitions & Exclusions:

Alldefinitions&ExclusionsofPartIasspecifiedunderSection2(Definitions),Section3(Exclusions)wouldbeapplicabletoAncillaryExpensesBenefitsection.


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Section2. Critical Illness Benefit

A. Coverage IfyouarediagnosedassufferingfromanyoftheCriticalIllness,aslistedunderthepolicy,whichfirstoccursormanifestsitself

duringthePolicyPeriod,andfulfillsthecriteriaasdefinedunderthepolicy,wewillpayyouthelumpsumamountasspecifiedunderCriticalIllnesssectioninthepolicySchedule.

B. list & definitions of Critical Illness covered under the policy AllthecommondefinitionsofPartI(MedicalExpenses)specifiedunderSection2wouldbeapplicabletoCriticalIllnessBenefit

List&definitionofCriticalIllnesscoveredunderthepolicygivenbelow

1. CAnCER OF SPECIFIEd SEVERITy Amalignanttumorcharacterizedbytheuncontrolledgrowth&spreadofmalignantcellswithinvasion&destructionof

normaltissues.Thisdiagnosismustbesupportedbyhistologicalevidenceofmalignancy&confirmedbyapathologist.Thetermcancerincludesleukemia,lymphomaandsarcoma.

Thefollowingareexcluded– i. Tumorsshowingthemalignantchangesofcarcinomainsitu&tumorswhicharehistologicaldescribedaspre-

malignantornoninvasive,includingbutnotlimitedto:Carcinomainsituofbreasts,CervicaldysplasiaCIN-1,CIN-2&CIN-3.

ii. Anyskincancerotherthaninvasivemalignantmelanoma iii. AlltumoursoftheprostateunlesshistologicalclassifiedashavingaGleasonscoregreaterthan6orhavingprogressed

toatleastclinicalTNMclassificationT2N0M0. iv. Papillarymicro-carcinomaofthethyroidlessthan1cmindiameter v. ChroniclymphocycticleukemialessthanRAIstage3 vi. Microcarcinomaofthebladder vii. AlltumorsinthepresenceofHIVinfection. 2. FIRST HEART ATTACK – OF SPECIFIEd SEVERITy Thefirstoccurrenceofmyocardialinfarctionwhichmeansthedeathofaportionoftheheartmuscleasaresultofinadequate

bloodsupplytotherelevantarea.Thediagnosisforthiswillbeevidencedbyallofthefollowingcriteria: a) HistoryoftypicalclinicalsymptomsconsistentwiththediagnosisofAcuteMyocardialInfarction(fore.g.typical

chestpain) b) Newcharacteristicelectrocardiogramchanges c) Elevationofinfarctionspecificenzymes,Troponinsorotherspecificbiochemicalmarkers. The following are excluded: i. Non-ST-segmentelevationmyocardialinfarction(NSTEMI)withelevationofTroponinIorT; ii. OtheracuteCoronarySyndromes iii. Anytypeofanginapectoris

3. COMA OF SPECIFIEd SEVERITy Astateofunconsciousnesswithnoreactionorresponsetoexternalstimulior internalneeds, thisdiagnosismustbe

supportedbyevidenceofallofthefollowing: a. Noresponsetoexternalstimulicontinuouslyforatleast96hours; b. Lifesupportmeasuresarenecessarytosustainlife;and c. Permanentneurologicaldeficitwhichmustbeassessedatleast30daysaftertheonsetofthecoma d. Theconditionhastobeconfirmedbyaspecialistmedicalpractitioner. Exclusion: Comaresultingdirectlyfromalcoholordrugabuseisexcluded. 4. KIdnEy FAIluRE REQuIRIng REgulAR dIAlySIS Endstagerenaldiseasepresentingaschronicirreversiblefailureofbothkidneystofunction,asaresultofwhicheither

regularrenaldialysis(hemodialysisorperitonealdialysis)isinstitutedorrenaltransplantationiscarriedout.DiagnosishastobeconfirmedbyaSpecialistConsultant.

5. STROKE RESulTIng In PERMAnEnT nEuROlOgICAl SEQuElAE Anycerebrovascularincidentproducingpermanentneurologicalsequelae,thisincludesinfarctionofbraintissue,thrombosis

inanintra-cranialvessel,haemorrhageandEmbolisationfromanextra-cranialsource. Diagnosishastobeconfirmedbyaspecialistmedicalpractitionerandevidencedbytypicalclinicalsymptomsaswellas

typicalfindingsinCTScanorMRIofthebrain.Evidenceofpermanentneurologicaldeficitlastingforatleast3monthshastobeproduced.


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The following are excluded: i. Transientischemicattacks(TIA) ii. Traumaticinjuryofthebrain iii. Vasculardiseaseaffectingonlytheeyeoropticnerveorvestibularfunctions

6. MAJOR ORgAn /BOnE MARROW TRAnSPlAnT Theactualundergoingofatransplantof: a. Oneofthefollowinghumanorgans:heart,lung,liver,kidney,pancreas,thatresultedfromirreversibleend-stage

failureoftherelevantorgan,or b. Humanbonemarrowusinghaematopoieticstemcells Theundergoingofatransplanthastobeconfirmedbyaspecialistmedicalpractitioner. The following are excluded: i. Otherstem-celltransplants ii. Whereonlyisletsoflangerhansaretransplanted

7. MulTIPlE SClEROSIS WITH PERSISTIng SyMPTOMS Thedefiniteoccurrenceofmultiplesclerosis: Thediagnosismustbesupportedbyallofthefollowing: a. InvestigationsincludingtypicalMRIandCSFfindings,whichunequivocallyconfirmthediagnosistobemultiple

sclerosis; b. Theremustbecurrentclinicalimpairmentofmotororsensoryfunction,whichmusthavepersistedforacontinuous

periodofatleast6months,and c. Welldocumentedclinicalhistoryofexacerbationsandremissionsofsaidsymptomsorneurologicaldeficitswith

atleasttwoclinicallydocumentedepisodesatleastonemonthapart. Exclusion: OthercausesofneurologicaldamagesuchasSLEandHIVareexcluded.

8. APlASTIC AnEMIA Chronicpersistentbonemarrowfailurewhichresultsinanemia,neutropeniaandthrombocytopeniarequiringtreatment

withatleastoneofthefollowing: i. Bloodproducttransfusion; ii. Marrowstimulatingagents; iii. Immunosuppressiveagents;or iv. Bonemarrowtransplantation.

9. End STAgE lung dISEASE Endstagelungdisease,causingchronicrespiratoryfailure.Thisdiagnosismustbesupportedbyevidenceofallofthe

following: a. FEV1testresultswhichareconsistentlylessthan1litre; b. Permanentsupplementaryoxygentherapyforhypoxemia; c. Arterialbloodgasanalyseswithpartialoxygenpressuresof55mmHgorless(PaO2≤55mmHg);and d. Dyspneaatrest. e. ThediagnosismustbeconfirmedbyaRespiratoryPhysician

10. End STAgE lIVER FAIluRE Endstageliverfailureasevidencedbyallofthefollowing: a. Permanentjaundice; b. Ascites; c. Hepaticencephalopathy. Exclusion: Liverdiseasesecondarytoalcoholordrugabuseisexcluded. 11. PARKInSOn’S dISEASE TheunequivocaldiagnosisofidiopathicParkinson’sdiseasebyaconsultantneurologistThisdiagnosismustbesupported

byallofthefollowingconditions: a. Thediseasecannotbecontrolledwithmedication; b. Signsofprogressiveimpairment;and c. Inabilitytoperform(whetheraidedorunaided)atleast3ofthefollowing6“ActivitiesofDailyLiving”foracontinuous

periodofatleast6months:


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Activities of daily living: i. Washing-theabilitytowashinthebathorshower(includinggettingintoandoutofthebathorshower)orwash

satisfactorilybyothermeans; ii. Dressing-theabilitytoputon,takeoff,secureandunfastenallgarmentsand,asappropriate,anybraces,artificial

limbsorothersurgicalappliances; iii. Transferring-theabilitytomovefromabedtoanuprightchairorwheelchairandviceversa; iv. Mobility-theabilitytomoveindoorsfromroomtoroomonlevelsurfaces; v. Toileting-theabilitytousethe lavatoryorotherwisemanagebowelandbladderfunctionssoastomaintaina

satisfactorylevelofpersonalhygiene; vi. Feeding-theabilitytofeedoneselfoncefoodhasbeenpreparedandmadeavailable. Exclusion: Drug-inducedortoxiccausesofParkinsonismareexcluded.

12 . SuRgERy OF AORTA Theactualundergoingofmajorsurgery,torepairorcorrectananeurysm,narrowing,obstructionordissectionoftheaorta

throughsurgicalopeningofthechestorabdomen Forthepurposeofthisdefinitionaortashallmeanthethoracicandabdominalaortabutnotitsbranches. Exclusion: Surgeryperformedusingonlyminimallyinvasiveorintraarterialtechniquesareexcluded. 13. AlZHEIMER’S dISEASE Deteriorationorlossofintellectualcapacityasconfirmedbyclinicalevaluationandimagingtests,arisingfromAlzheimer’s

diseaseorirreversibleorganicdisorders,resultinginsignificantreductioninmentalandsocialfunctioningrequiringthecontinuoussupervisionoftheInsuredPerson.ThisdiagnosismustbesupportedbytheclinicalconfirmationofanSpecialistConsultantandsupportedbytheCompany’sappointeddoctor(Ifrequired).

Thefollowingareexcluded: • Non-organicdiseasessuchasneurosisandpsychiatricillnesses;and • Alcoholrelatedbraindamage.

14. PRIMARy PulMOnARy HyPERTEnSIOn ThediagnosisbyaPhysicianofprimarypulmonaryhypertensionwithsubstantialrightventricularenlargementestablished

byinvestigationsincludingcardiaccatheterization,resultinginpermanentirreversiblephysicalimpairmenttothedegreeofatleastclass3oftheNewYorkHeartAssociationClassificationofcardiacimpairmentandresultingintheInsuredbeingunabletoperformhisusualoccupation.

15. MAJOR BuRnS Burnsinvolving40%ormoreofthebodysurfacearea(ascalculatedonruleof9foreachareaofbodyaffected)OR Secondorthirddegreeburnscausedbyaccidentalthermal,electric,chemicalburninjury. Exclusion: Radiationinducedburnsarespecificallyexcluded.

C: Exclusions applicable for Critical Illness Cover: We shall not be liable to make any payment for any claim directly or indirectly caused by, based on, arising out of or

attributable to any of the following:

I. Waiting Period

1. AnyCriticalIllnessdiagnosedwithinthefirst90daysofthedateofcommencementofthePolicyisexcluded.ThisexclusionshallnotapplytoanInsuredforwhomcoveragehasbeenrenewedbytheNamedInsured,withoutabreak,forsubsequentyears.


1. AnyCriticalIllnessforwhichcare,treatment,oradvicewasrecommendedbyorreceivedfromaPhysician,orwhichfirstmanifesteditselforwascontractedbeforethestartofthePolicyPeriod,orforwhichaclaimhasorcouldhavebeenmadeunderanyearlierpolicy.

2. Anysexually transmitteddiseasesoranyconditiondirectlyor indirectlycausedbyorassociatedwithHumanT-CellLymphotropicVirustypeIII(IIILBIII)orLymphadinopathyAssociatedVirus(LAV)ortheMutantsDerivativeorVariationsDeficiencySyndromeoranySyndromeorconditionofasimilarkindcommonlyreferredtoasAIDS.


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3. Treatmentarising fromor traceable topregnancy, childbirthpostpartumcomplications includingbutnot limited tocaesariansection,birthdefectsandcongenitalanomalies

4. Occupationaldiseases.

5. War,whetherwarbedeclaredornot,invasion,actofforeignenemy,hostilities,civilwar,insurrection,terrorismorterroristactsoractivities,rebellion,revolution,mutiny,militaryorusurpedpower,riot,strike,lockout,militaryorpopularuprising,civilcommotion,martiallaworloot,sackorpillageinconnectiontherewith,confiscationordestructionbyanygovernmentorpublicauthorityoranyactorconditionincidentaltoanyoftheabove.

6. Navalormilitaryoperationsofthearmedforcesorairforceandparticipationinoperationsrequiringtheuseofarmsorwhichareorderedbymilitaryauthoritiesforcombatingterrorists,rebelsandthelike.

7. Anynaturalperil(includingbutnotlimitedtostorm,tempest,avalanche,earthquake,volcaniceruptions,hurricane,oranyotherkindofnaturalhazard).

8. Radioactivecontamination

9. Consequentiallossesofanykind,betheybywayoflossofprofit,lossofopportunity,lossofgain,businessinterruption,marketlossorotherwise,oranyclaimsarisingoutoflossofapurefinancialnaturesuchaslossofgoodwilloranylegalliabilityofanykindwhatsoever.

10. Intentionalself-injuryand/ortheuseormisuseofintoxicatingdrugsand/oralcohol.

Section 3. Personal Accident Cover

OuragreementtoinsureisbasedonyourProposaltous,whichisthebasisofthisagreement,andyourpaymentofpremium.ThisPolicyrecordstheentireagreementbetweenusandsetsoutwhatweinsure,howweinsureit,andwhatweexpectofyou.

A. What we will pay for OurliabilitytomakepaymenttoYou/yourfamilymember(s)namedinthescheduleforoneormoreoftheeventsdescribedat

1)Death,2)PermanentTotalDisability,3)PermanentPartialDisabilityto4)TemporaryTotalDisabilitybelow;islimitedtotheTotalSumAssuredasspecifiedinthepolicyscheduleforYou/yourfamilymember(s)namedintheschedule,exceptaswehaveagreedat2)PermanentTotalDisability

Youagreethatweshalldeductfromanyamountwehavetopayunder1)Death,2)PermanentTotalDisability,3)PermanentPartialDisabilityto4)TemporaryTotalDisabilityanyamountthatwehavealreadypaidunderanyof1)Death,2)PermanentTotalDisability,3)PermanentPartialDisabilityto4)TemporaryTotalDisabilitysothatourtotalpaymentsdonotexceedtheTotalSumAssuredoptedbyyou/yourfamilymembers.However,ifwebecomeliabletomakepaymentunder1)Deathor2)PermanentTotalDisability,thenthisinsurancewillceaseasfarasYou/Yourfamilymember(s)namedinthescheduleareconcerned.

1. death WewillpaytheNominee,100%oftheSumInsuredasspecifiedunderthepolicyschedule,ifduringthePolicyPeriodYouasnamed

intheschedulemeetwithAccidentalBodilyInjurythatcausesdeathwithin12Months.

2. Permanent Total disability Wewillpayyou200%oftheSumInsuredshownunderthePolicyScheduleifYou/Yourfamilymember(s)namedintheschedule

meetwithAccidentalBodilyInjuryduringthePolicyPeriodthatcausesPermanentTotalDisabilitywithin12months.

3. Permanent Partial disability Ifyou/yourfamilymember(s)namedintheSchedulemeetwithAccidentalBodilyInjuryduringthePolicyPeriodthatcauses

PermanentPartialDisabilitywithin12months,wewillpaythepercentageshowninthetablebelowappliedtotheSumInsuredshownunderthePolicySchedule


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Anarmattheshoulderjoint 70%

Anarmabovetheelbowjoint 65%

Anarmbeneaththeelbowjoint 60%

Ahandatthewrist 55%

Athumb 20%

Anindexfinger 10%

Anyotherfinger 5%

Alegabovemid-thigh 70%

Aleguptomid-thigh 60%

Aleguptobeneaththeknee 50%

Aleguptomid-calf 45%

Afootattheankle 40%

Alargetoe 5%

Anyothertoe 2%

Aneye 50%

Hearingofoneear 30%

Hearingofbothears 75%

Senseofsmell 10%

Senseoftaste 5% a) IfDisabilitywillbedecidedbyauthorizedCivilSurgeonaccordingtothedegreetowhichyou/yourfamilymember(s)

normalfunctionalphysicalcapacityhasbeenimpaired b) Ifyou/yourfamilymember(s)namedintheschedulewerealreadysufferingfromPermanentPartialDisabilitybefore

thedateyou/yourfamilymember(s)metwithAccidentalBodilyInjury,thentheamountwepaywillbereducedbythatextentYouagreethatthereductionwillbedecidedbyourmedicaladvisorsaccordingtothedegreeofPermanentPartialDisabilityfromwhichyou/yourfamilymember(s)namedintheschedulewerealreadysuffering.

4. Temporary Total disability Iftheinsuredperson(s)namedinthescheduleexceptforthedependantchildren,sufferAccidentalBodilyInjuryduringthePolicy

Periodwhichcompletelypreventstheinsuredperson(s)fromengaginginhis/herrespectiveoccupation,thenwewillmakeaweeklypaymentunderTTDbenefit.(Aspertheplanopted)

a) Wewillmakethefirstpaymentwhentheinsuredperson(s)namedintheschedulesatisfyusthattheAccidentalBodilyInjuryhascompletelypreventedtheinsuredperson(s)fromengaginginhis/heroccupation.

b) Wewillstopmakingpaymentswhenwearesatisfiedthattheinsuredperson(s)namedintheschedulecanengageinhis/heroccupationagain,orwhenwehavemadepaymentsforamaximumperiodof100weeksfromthedatetheinsuredperson(s)metwiththeAccidentalBodilyInjury,whicheverisearlier.

5. Additional Insurance a. Transportation Ifwehaveacceptedaclaimunder1)Deathfordeathofyou/yourfamilymember(s)namedintheschedule,thenwe

willpaytowardstheactualcostoftransportingtheremainsofyou/yourfamilymember(s)fromtheplaceofdeathtoahospital,cremationground,burialgroundortoinsured’shome.Theamountwepaywillbelimitedto`5,000/-.

b. Children‘s Education Benefit Ifwehaveacceptedaclaimundereither1)Deathor2)PermanentTotalDisability,thenwewillmakeaonetimepayment

of`5,000/-eachtowardsthecostofeducationofupto2ofyourdependentchildrenwhowerestudyinginanaccreditedinstitutionatthetimeyoumetwithAccidentalBodilyInjury.

B: definitions

DefinitionsofPartI(MedicalExpenses)-Section2areapplicabletoPersonalAccidentCover


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C: Exclusions applicable for Personal Accident Cover:

What we will not pay for We shall not be liable to make any payment for any claim directly or indirectly caused by, based on, arising out of or attributable to any of the following:


1. AccidentalBodilyInjurythatyou/yourfamilymembernamedintheschedulemeetswith: a) Throughsuicide,attemptedsuicideorselfinflictedinjuryorillness. b) Whileundertheinfluenceofliquorordrugs. c) Arisingorresultingfromtheinsuredpersoncommittinganybreachoflawwithcriminalintent. d) Whilstparticipatingasthedriver,co-driverorpassengerofamotorvehicleduringmotorracingortrialruns. e) Asaresultofanycurativetreatmentsorinterventionsthatyoucarryoutorhavecarriedoutonyourbody. f) Arisingoutofyourparticipationinanynaval,militaryorairforceoperationswhetherintheformofmilitaryexercisesor

wargamesoractualengagementwiththeenemy,whetherforeignordomestic. g) Whilstengaginginaviationorballooning.Whilstmountinginto,dismountingfromortravelinginanyballoonoraircraft

otherthanasapassenger(farepayingorotherwise)inanydulylicensedstandardtypeofaircraftanywhereintheworld.2. Consequentiallossesofanykindorinsuredperson’sactualorallegedlegalliability.3. Anyinjury/disablement/deathdirectlyorindirectlyarisingoutoforcontributedtoanypre-existingcondition.4. VenerealorSexuallytransmitteddiseases5. HIV(HumanImmunodeficiencyVirus)and/oranyHIVrelatedillnessincludingAIDS(AcquiredImmuneDeficiencySyndrome)

and/ormutantderivativesorvariationsthereofhowevercaused.6. War(whetherdeclaredornot),civilwar,invasion,actofforeignenemies,rebellion,revolution,insurrection,mutiny,militaryor

usurpedpower,seizure,capture,arrest,restraintordetainment,confiscationornationalizationorrequisitionofordamagebyorundertheorderofanygovernmentorpubliclocalauthority.

7. Nuclearenergy,radiation.8. Pregnancy,resultingchildbirth,miscarriage,abortion,orcomplicationsarisingoutofthese.

Part III : Conditions: Applicable for : Medical Expenses Section and Add on covers

1. Conditions precedent to the contract

i. Conditions Precedent WherethisPolicyrequiresYoutodoornottodosomething,thenthecompletesatisfactionofthatrequirementbyYouorsomeone

claimingonYourbehalfisapreconditiontoanyobligationWehaveunderthisPolicy.IfYouorsomeoneclaimingonYourbehalffailstocompletelysatisfythatrequirement,thenWemayrefusetoconsiderYourclaim.

2. Conditions when a claim arises

i. Claims Procedure IfYoumeetwithanyAccidentalBodilyInjuryorsufferanIllnessthatmayresultinaclaim,thenasaconditionprecedenttoOur

liability,Youmustcomplywiththefollowing: A. Cashless Claims Procedure: Applicable only for Hospitalisation Expenses Section IfYoumeetwithanyAccidentalBodilyInjuryorsufferanIllnessthatmayresultinaclaim,thenasaconditionprecedenttoOur

liability,Youmustcomplywiththefollowing: a. CashlessfacilitycanbeavailedonlyunderPartI,SectionA1underthepolicy b. CashlesstreatmentisonlyavailableatNetworkHospitals.Inordertoavailofcashlesstreatment,thefollowingprocedure

mustbefollowedbyYou: c. Priortotakingtreatmentand/orincurringMedicalExpensesataNetworkHospital,YoumustcallUsandrequestpre-

authorisationbywayofthewrittenformWewillprovide. d. AfterconsideringYourrequestandafterobtaininganyfurtherinformationordocumentationWehavesought,Wemayif

satisfiedsendYouortheNetworkHospital,anauthorisationletter.Theauthorisationletter,theIDcardissuedtoYoualongwiththisPolicyandanyotherinformationordocumentationthatWehavespecifiedmustbeproducedtotheNetworkHospitalidentifiedinthepre-authorisationletteratthetimeofYouradmissiontothesame.


HealtH Care Supreme



e. Iftheprocedureaboveisfollowed,YouwillnotberequiredtodirectlypayfortheMedicalExpensesintheNetworkHospitalthatWeareliabletoindemnifyunderCoverA1aboveandtheoriginalbillsandevidenceoftreatmentinrespectofthesameshallbeleftwiththeNetworkHospital.Pre-authorisationdoesnotguaranteethatallcostsandexpenseswillbecovered.WereservetherighttorevieweachclaimforMedicalExpensesandaccordinglycoveragewillbedeterminedaccordingtothetermsandconditionsofthisPolicy.Youshall,inanyevent,berequiredtosettleallotherexpensesdirectly.

B. Reimbursement Claims Procedure applicable for all sections a. YouorsomeoneclaimingonYourbehalfmustinformUsinwritingimmediatelywith48hoursofhospitalizationincase

emergencyhospitalization&48hourspriortohospitalizationincaseofplannedhospitalization b. YoumustimmediatelyconsultaDoctorandfollowtheadviceandtreatmentthatherecommends. c. YoumusttakereasonablestepsormeasuretominimizethequantumofanyclaimthatmaybemadeunderthisPolicy. d. YoumusthaveYourselfexaminedbyOurmedicaladvisorsifWeaskforthis,andasoftenasWeconsiderthistobenecessary

atinsurer’scost. e. YouorsomeoneclaimingonYourbehalfmustpromptlyandinanyeventwithin30daysofdischargefromaHospitalgiveUs

thedocumentation(writtendetailsofthequantumofanyclaimalongwithalloriginalsupportingdocumentation,includingbutnotlimitedtofirstconsultationletter,originalvouchers,billsandreceipts,birth/deathcertificate(asapplicable))andotherinformationWeaskfortoinvestigatetheclaimorOurobligationtomakepaymentforit.

f. Intheeventofthedeathoftheinsuredperson,someoneclaimingonhisbehalfmustinformUsinwritingimmediatelyandsendUsacopyofthepostmortemreport(ifany)within30days*

g. ForoutPatientexpensessectionA7ofPartI,theclaimdocumentscanbesubmittedonlytwiceduringthepolicyperiod.TheclaimpaymentwouldbeuptotheOPDSumInsuredasspecifiedundertheplan

h. Ineventofaclaim,theoriginaldocumentstobesubmitted&afterthecompletionoftheclaimsassessmentprocesstheoriginaldocumentsmaybereturnedifrequestedbytheinsuredinwriting,howeverwewillretaintheXeroxcopiesoftheclaimdocuments.

i. Iftheoriginaldocumentsaresubmittedwiththeco-insurer,theXeroxcopiesattestedbytheco-insurershouldbesubmittedalongwiththeletterconfirmingthestatusoftheclaim&settlementdetailsifany

*Note: Waiverofconditions(a)and(f)maybeconsideredinextremecasesofhardshipwhereitisprovedtothesatisfactionofthe

Companythatunderthecircumstancesinwhichtheinsuredwasplaceditwasnotpossiblefromhimoranyotherpersontogivenoticeorfileclaimwithintheprescribedtimelimit.

Waiverofconditions(a)and(f)underapplicableforoutPatientexpensessectionA7ofPartI

list of Claims documents

DocumentstobesubmittedforMedicalExpensessection&AncilliaryExpensescover

DocumentstobeSubmittedforCriticalillness

FirstConsultationletterfromtheDoctor DulycompletedClaimFormdulysignedbytheinsured

DulycompletedclaimformsignedbytheClaimant CopyofDischargeSummary/DischargeCertifcate

HospitalDischargeCard(NotapplicableforOutPatientExpens-es&PhysiotherapyExpensesSection)

CopyofFinalHospitalBill

HospitalBillgivingdetailedbreakupofallexpenseheadsmen-tionedinthebill.ClearbreakupshavetobementionedforOTCharges,Doctor’sConsultationandVisitCharges,OTCon-sumables,Transfusions,RoomRent,etc.

OriginalPolicycopy

MoneyReceipt,dulysignedwithaRevenueStamp FirstconsultationletterforIllness

AlloriginalLaboratoryandDiagnosticTestReports.E.g.X-Ray,E.C.G,USG,MRIScan,Haemogrametc

Medicalcertifcateforthedurationofillness(ifrequired)

IncaseofaCataractOperation,IOLStickerwillhavetobeen-closed

AllrequiredInvestigationReportsaspertheIllness(Ifrequired)

OtherdocumentsasmayberequiredbyBajajAllianztoprocesstheclaim

Letterfromtheemployerclarifyingthetypeofwork

Aaadharcard&PANcardCopies(Notmandatoryifthesameislinkedwiththepolicywhileissuanceorinpreviousclaim)



HealtH Care Supreme



DocumentstobesubmittedforPersonalAccidentClaim

DeathClaims PTD,PPD&TTDClaims

DulycompletedclaimformsignedbytheClaimant DulycompletedclaimformsignedbytheClaimant

AttestedcopyofDeathCertifcate AttestedcopyofFIR/Panchanama/InquestPanchanama

AttestedcopyofPostMortemReport,ifconducted CopyofMedicoLegalCertifcate

AttestedcopyofViscera/ChemicalAnalysisReport(IfVisceraispreserved)

Copyofdischargesummarytowardshospitalizationimmedi-atelyafterinjury

Diatomsreportfromforensiclabincaseofdeathonaccountofdrowning(ifsamplepreserved)

X-rayFilms/Investigationreportssupportingthediagnosis

Attestedcopyofstatementofwitness(ifany) DisabilityCertifcatefromtheGovernmentAuthoritycertifyingInsured’sdisability

Burialcertifcate(whereverapplicable) OtherdocumentsasmayberequiredbyBajajAllianztoprocesstheclaim

Legalheircertifcatecontainingaffdavitandindemnitybondbothdulysignedbyalllegalheirsandnotarizedismandatorytoprocesstheclaim

Leavecertifcatefromtheemployer

Insured’s/Claimant’sphoto-identityproof Aaadharcard&PANcardCopies(Notmandatoryifthesameislinkedwiththepolicywhileissuanceorinpreviousclaim)

Insured’s/Claimant’saddressproof

OtherdocumentsasmayberequiredbyBajajAllianztoprocesstheclaim


ii. Paying a Claim a. YouagreethatWeneedonlymakepaymentwhenYouorsomeoneclaimingonYourbehalfhasprovidedUswithnecessary

documentationandinformation.WewillmakepaymenttoYouorYourNominee.IfthereisnoNomineeandYouareincapacitatedordeceased,WewillpayYourheir,executororvalidlyappointedlegalrepresentativeandanypaymentWemakeinthiswaywillbeacompleteandfinaldischargeofOurliabilitytomakepayment.

b. Onreceiptofallthedocumentsandonbeingsatisfiedwithregardtotheadmissibilityoftheclaimasperpolicytermsandconditions,weshallofferwithinaperiodof30daysasettlementoftheclaimtotheinsured.Uponacceptanceofanofferofsettlementbytheinsured,thepaymentoftheamountdueshallbemadewithin7daysfromthedateofacceptanceoftheofferbytheinsured.Inthecasesofdelayinthepayment,theinsurershallbeliabletopayinterestataratewhichis2%abovethebankrateprevalentatthebeginningofthefinancialyearinwhichtheclaimisreviewedbyit.

c. However,where thecircumstancesofaclaimwarrantan investigation, theCompanywill initiateandcompletesuchinvestigationattheearliest,inanycasenotlaterthan30daysfromthedateofreceiptoflastnecessarydocument.Insuchcases,theCompanywillsettletheclaimwithin45daysfromthedateofreceiptoflastnecessarydocument.Incaseofdelaybeyondstipulated45days,theCompanywillbeliabletopayinterestataratewhichis2%abovethebankratefromthedateofreceiptoflastnecessarydocumenttothedateofpaymentofclaim.

d. Iftheinsurer,foranyreasonsdecidestorejecttheclaimunderthepolicythereasonsregardingtherejectionshallbecommunicatedtotheinsuredinwritingwithin30daysofthereceiptofdocuments.TheinsuredmaytakerecoursetotheGrievanceRedressalprocedure.

iii. Basis of Claims Payment a. IfYousufferarelapsewithin45daysofthedatewhenYoulastobtainedmedicaltreatmentorconsultedaDoctorandfor

whichaclaimhasbeenmade,thensuchrelapseshallbedeemedtobepartofthesameclaim. b. WeshallmakepaymentinIndianRupeesonly. c. Ifclaimeventfallswithintwopolicyperiodstheclaimsshallbeadministeredtakingintoconsiderationtheavailablesum

insuredinthetwopolicyperiods.Theclaimamounttobepayableshallbereduceduptotheextentofthepremiumforrenewal,ifthesameisnotreceivedearlier.

iv. Other Insurance/ Contribution IftwoormorepoliciesaretakenbyYouduringaperiodfromoneormoreinsurerstoindemnifytreatmentcosts,Weshallnot

applythecontributionclause,butYoushallhavetherighttorequireasettlementofyourclaimintermsofanyofyourpolicies.


HealtH Care Supreme



a. Inallsuchcasestheinsurerwhohasissuedthechosenpolicyshallbeobligedtosettletheclaimwithoutinsistingonthecontributionclauseaslongastheclaimiswithinthelimitsofandaccordingtothetermsofthechosenpolicy.

b. Iftheamounttobeclaimedexceedsthesuminsuredunderasinglepolicyafterconsideringthedeductiblesorcopay,youshallhavetherighttochooseinsurersbywhomtheclaimtobesettled.Insuchcases,theinsurermaysettletheclaimwithcontributionclause.

c. Exceptinbenefitpolicies,incaseswhereYouhavepoliciesfrommorethanoneinsurertocoverthesameriskonindemnitybasis,Youshallonlybeindemnifiedthehospitalizationcostsinaccordancewiththetermsandconditionsofthepolicy

v. Arbitration and Reconciliation a. IfanydisputeordifferenceshallariseastothequantumtobepaidunderthePolicy(liabilitybeingotherwiseadmitted),

suchdifferenceshall independentlyofallotherquestionsbereferredtodecisionofasolearbitrator inwritingbythepartiesoriftheycannotagreeuponasinglearbitratorwithin30daysofanypartyinvokingarbitration,thesameshallbereferredtoapanelofthearbitratorscomprisingoftwoarbitrators,oneappointedbyeachofthepartiestothedispute/differenceandthethirdarbitratortobeappointedbysuchtwoarbitratorsandarbitrationshallbeconductedunderandinaccordancewiththeprovisionsoftheArbitrationandConciliationAct,1996.ThelawofthearbitrationwillbeIndianlaw,andtheseatofthearbitrationandvenueforallhearingsshallbewithinIndia.

b. Itisclearlyagreedandunderstoodthatnodifferenceordisputeshallbereferabletoarbitrationashereinbeforeprovided,ifWehavedisputedornotacceptedliabilityunderorinrespectofthisPolicy.

c. ItisherebyexpresslystipulatedanddeclaredthatitshallbeaconditionprecedenttoanyrightofactionorsuituponthisPolicythatawardbysucharbitrator/arbitratorsoftheamountofthelossordamageshallbefirstobtained.

d. Ifthesearbitrationprovisionsareheldtobeinvalid,thenallsuchdisputesordifferencesshallbereferredtotheexclusivejurisdictionoftheIndianCourts.

3. Conditions for renewal of the contracti. Renewal a. Undernormalcircumstances,renewalwillnotberefusedexceptonthegroundsofYourmoralhazard,misrepresentation

non-cooperationbyyouorfraud.(SubjecttopolicyisrenewedannuallywithuswithintheGraceperiodof30daysfromdateofExpiry)

b. Incaseof0urownrenewal,agraceperiodof30daysispermissibleandthePolicywillbeconsideredascontinuousforthepurposeofallwaitingperiods.However,anytreatmentavailedforanIllnessorAccidentsustainedorcontractedduringthebreakperiodwillnotbeadmissibleunderthePolicy.

c. Forrenewalsreceivedaftercompletionof30daysgraceperiod,afreshapplicationofhealthinsuranceshouldbesubmittedtoUs,itwouldbeprocessedasperanewbusinessproposal.

d. Fordependentchildren,Policyisrenewableupto35years.Afterthecompletionofmaximumrenewalageofdependentchildren,thepolicywouldberenewedforlifetime,SubjecttoSeparateproposalformtobesubmittedtousatthetimeofrenewalwiththeinsuredmemberasproposerandsubsequentlythepolicyshouldberenewedwithusannuallyandwithintheGraceperiodof30daysfromdateofExpiry..Suitablecreditofcontinuity/waitingperiodsforallthepreviouspolicyyearswouldbeextendedinthenewpolicy,providedthepolicyhasbeenmaintainedwithoutabreak

e. Premiumpayableoranychangesinterms&conditionsonrenewalandonsubsequentcontinuationofcoveraresubjecttochangewithpriorapprovalfromIRDAI.

ii. Sum Insured Enhancement: a. TheInsuredmembercanapplyforenhancementofSumInsuredatthetimeofrenewal.Youcanapplyforenhancement

ofSumInsuredbysubmittingafreshproposalformtothecompany. b. TheacceptanceofenhancementofSumInsuredwouldbebasedonthehealthconditionoftheinsuredmembers&claim

historyofthepolicy. AllwaitingperiodsasdefinedinthePolicyshallapplyforthisenhancedSumInsuredlimitfromtheeffectivedateofenhancement

ofsuchSumInsuredconsideringsuchPolicyPeriodasthefirstPolicywiththeCompany. Inclusion of dependant members under the policy: WhereanInsuredPersonisaddedtothisPolicy,eitherbywayofendorsementoratthetimeofrenewal,thepre-existingdisease

clause,exclusionsandwaitingperiodswillbeapplicableconsideringsuchPolicyYearasthefirstyearofPolicywiththeCompanyfortheinsuredmember.

iii. Revision/ Modification of the policy ThereispossibilityofRevision/modificationofterms,conditions,coveragesorpremiumsthisproductatanytimeinfuturewith

appropriateapprovalfromIRDA. Insuchaneventofrevision/modificationoftheproductintimationshallbesetouttoalltheexistinginsuredmembersatleast3

monthspriortothedateofsuchrevision/modificationcomesintotheeffect.


HealtH Care Supreme



iv. Migration of policy a. Theinsuredcanoptformigrationofpolicytoourothersimilarorcloselysimilarproductsatthetimeofrenewal. b. ThepremiumwillbechargedasperOurUnderwritingPolicyforsuchchosennewproduct,andalltheguidelines,terms

andconditionofthechosenproductshallbeapplicable. c. Suitablecreditofcontinuity/waitingperiodsforallthepreviouspolicyyearswouldbeextendedinthenewpolicy,provided

thepolicyhasbeenmaintainedwithoutabreak

v. Withdrawal of Policy ThereispossibilityofwithdrawalthisproductatanytimeinfuturewithappropriateapprovalfromIRDA,asWereserveOurright

todosowithaintimationof3monthstoalltheexistinginsuredmembers.Insuchaneventofwithdrawalofthisproduct,atthetimeofYourseekingrenewalofthisPolicy,Youcanchoose,amongOuravailableandsimilarorcloselysimilarHealthinsuranceproducts,.UponYoursochoosingOurnewproduct,YouwillbechargedthePremiumasperOurUnderwritingPolicyforsuchchosennewproduct,asapprovedbyIRDA.

Providedhowever,ifYoudonotrespondtoOurintimationregardingthewithdrawaloftheproductunderwhichthisPolicyisissued,thenthisPolicyshallbewithdrawnandshallnotbeavailabletoYouforrenewalontherenewaldateandaccordinglyuponYourseekingrenewalofthisPolicy,YoushallhavetotakeaPolicyunderavailablenewproductsofUssubjecttoYourpayingthePremiumasperOurUnderwritingPolicyforsuchavailablenewproductchosenbyYouandalsosubjecttoPortabilitycondition.

vi. Cumulative Bonus CumulativeBonusisapplicableonlyforHospitalisationSectionA1ofPartI IfYourenewYourHealthCareSupremePolicywithUswithoutanybreakinthePolicyPeriodandtherehasbeennoclaiminthe

precedingyear,WewillincreasetheLimitofIndemnityby10%perannum,but: a. ThemaximumcumulativeincreaseintheLimitofIndemnitywillbelimitedto5yearsand/or50%ofSumInsured. b. Ifaclaimismadeinanyyearwhereacumulativeincreasehasbeenapplied,thentheincreasedLimitofIndemnityshall

bereducedby10%,savethattheLimitofIndemnityapplicabletoYourfirstHealthCareSupremePolicywithUsshallbepreserved.

c. ThisclausedoesnotaltertheannualcharacterofthisinsuranceorOurrighttodeclinetorenewortocancelthePolicy,underthecircumstancesdescribedincancellationclausestatedunderthepolicy

d. ThereisnotransferofCumulativeBonusfromotherCompanyrenewals

4. Conditions applicable during the contracti. Insured OnlythosepersonsnamedastheinsuredintheScheduleshallbecoveredunderthisPolicy.

ii. Free look Period Youhaveaperiodof15daysfromthedateofreceiptofthefirstpolicydocumenttoreviewthetermsandconditionsofthisPolicy.

IfYouhaveanyobjectionstoanyofthetermsandconditions,YouhavetheoptionofcancellingthePolicystatingthereasonsforcancellation.

IfyouhavenotmadeanyclaimduringtheFreelookperiod,youshallbeentitledtorefundofpremiumofBaseProduct&rider(ifriderisoptedunderthepolicy)subjectto,

• adeductionoftheexpensesincurredbyUsonYourmedicalexamination,stampdutycharges,iftheriskhasnotcommenced, • adeductionofthestampdutycharges,medicalexaminationcharges&proportionateriskpremiumforperiodoncover,

Iftheriskhascommenced • adeductionofsuchproportionateriskpremiumcommensuratingwiththeriskcoveredduringsuchperiod,whereonlya

partofriskhascommenced • FreeLookperiodisnotapplicableforrenewalpoliciesaswellasGroupPolicies

iii. Communications AnycommunicationmeantforUsmustbeinwritingandbedeliveredtoOuraddressshownintheSchedule.Anycommunication

meantforYouwillbesentbyUstoYouraddressshownintheSchedule.

iv. Fraud IfYoumakeorprogressanyclaimknowingittobefalseorfraudulentinanyway,thenthisPolicywillbevoidandallclaimsor

paymentsdueunderitshallbelostandthepremiumpaidshallbecomeforfeited.

v. Cancellation

a. WemaycancelthisinsurancebygivingYouatleast15dayswrittennotice,andifnoclaimhasbeenmadethenWeshallrefundapro-ratapremiumofBaseProduct&rider(ifriderisoptedunderthepolicy)fortheunexpiredPolicyPeriod.Undernormalcircumstances,Policywillnotbecancelledexceptforreasonsofmis-representation,fraud,non-disclosureofmaterialfactsorYournon-cooperation.


HealtH Care Supreme



b. YoumaycancelthisinsurancebygivingUsatleast15dayswrittennotice,andifnoclaimhasbeenmadethenWeshallrefundpremiumofBaseProduct&rider(ifriderisoptedunderthepolicy)onshorttermratesfortheunexpiredPolicyPeriodaspertheratesdetailedbelow.

Period on Risk % of Annual Premium of Base Product & rider ( if rider is opted under the policy)Refunded

Upto1month 75%

upto3months 50%

upto6months 25%

Exceeding6months Nil

vi. Portability Conditions a. RetailPolicies:AsperthePortabilityGuidelinesissuedbyIRDA,applicablebenefitsshallbepassedontoinsuredpersons

whowereholdingsimilarretailhealthinsurancepoliciesofothernon-lifeinsurers.Thepre-policymedicalexaminationrequirementsandprovisionsforsuchcasesshallremainsimilartonewbusinesscases.

b. GroupPolicies:AsperthePortabilityGuidelinesissuedbyIRDA,applicablebenefitsshallbepassedontoinsuredpersonswhowereinsuredunderOurGroupHealthCareSupremePolicyandareavailingOurHealthCareSupremePolicy.However,suchbenefitsshallbeapplicableonlyintheeventofdiscontinuation/non-renewaloftheGroupHealthCareSupremePolicy(applicableforbothemployer-employeerelationshipsandnon-employer-employeerelationships)and/ortheparticularinsuredpersonleavingthegrouponaccountofresignation/retirement(applicableforemployer-employeerelationships)orterminationofrelationshipwiththeGroupAdministrator(applicablefornon-employer-employeerelationships).Thepre-policymedicalexaminationrequirementsandprovisionsforsuchcasesshallremainsimilartofreshproposalcases.

vii. Special conditions for Personal Accident Section & Critical Illness sections UpontheoccurrenceofaneventofCriticalIllnesssectionand/orPermanentTotalDisabilityunderPersonalAccidentsection

(subjecttotheterms,conditionsandexclusionsofthisPolicy)withoutprejudicetotheCompany’sobligationtomakepayment,thesesectionsshallimmediatelyceasetoexistwithreferencetothatInsuredmember.

viii. loadingsa. Theloadingwouldbeapplicablefortheproposalswithadversehealthconditionsgivenbelow:Hypertension,Diabetes,

Obesity,CholesterolDisorder,Cardiovasculardiseases,ormultipleriskfactors.

Condition loading on premium

Diabetes 10%

Hypertension 10%

CholesterolDisorder 10%

Obesity 10%

Cardiovasculardiseases 10%

b. ForMultipleconditionscumulativeloadingwouldbeappliedonthepublishedpremium. c. Themaximumriskloadingapplicableforanindividualshallnotexceed50%ofthepublishedpremiums,foroverallrisk

perperson. d. TheseloadingsareappliedfromCommencementDateofthePolicyincludingsubsequentrenewal(s)withUsoronthe

receiptoftherequestofincreaseinSumInsured(fortheincreasedSumInsured). e. WewillinformYouabouttheapplicableriskloadingthroughacounterofferletter.YouneedtoreverttoUswithconsent

andadditionalpremium(ifany),within15daysoftheissuanceofsuchcounterofferletter.Incase,youneitheracceptthecounteroffernorreverttoUswithin15days,WeshallcancelYourapplicationandrefundthepremiumpaidwithinnext7days.

f. PleasenotethatWewillissuePolicyonlyaftergettingYourconsent.

ix. discounts A) Healthcare Supreme Individual & Floater policy discount: 1) discount applicable for new Business a. AddonCoverDiscount:5%sectionaldiscountontotalpremiumwillbeextendedunderthepolicy,ifalltheaddoncovers

areoptedalongwiththebasiccover. b. FamilyDiscount:5%familydiscountshallbeofferedif2ormorethan2ofanyoftheeligiblefamilymembersarecovered

underasinglepolicy.Moreover,thisfamilydiscountwillbeofferedforbothnewpoliciesaswellasforrenewalpolicies.FamilydiscountisnotapplicabletofloaterHealthCareSupremePolicies


HealtH Care Supreme



c. Totalmaximumdiscountof10%willbeextendedonpublishedratesforNewBusinessunderIndividualHealthCareSupremePolicies.

d. Totalmaximumdiscountof5%willbeextendedonpublishedratesforNewBusinessunderFloaterHealthCareSupremePolicies.

2) discount applicable for Renewal policies a. AddonCoverDiscount:5%sectionaldiscountontotalpremiumwillbeextendedunderthepolicy,ifalltheaddoncovers

areoptedalongwiththebasiccover. b. FamilyDiscount:5%familydiscountshallbeofferedif2ormorethan2ofanyoftheeligiblefamilymembersarecovered

underasinglepolicy.Moreover,thisfamilydiscountwillbeofferedforbothnewpoliciesaswellasforrenewalpolicies.FamilydiscountisnotapplicabletofloaterHealthCareSupremePolicies.

c. ClaimFreeRenewalDiscount:ifpolicyisclaimfreethen5%discountwillbeextendedatthetimeofrenewal d. Totalmaximumdiscountof15%willbeextendedonpublishedratesforRenewalsIndividualHealthCareSupremePolicies

policies. e. Totalmaximumdiscountof10%willbeextendedonpublishedratesforRenewalsofFloaterHealthCareSupremePolicies

policies. Note:10%additionaldiscountwillbeofferedforonlinepolicies.

B) discount applicable for group Healthcare Supreme i. AddonCoverDiscount:5%sectionaldiscountontotalpremiumwillbeextendedunderthepolicy,ifalltheaddoncovers

areoptedalongwiththebasiccover. ii. DiscountofferedinlieuofGroupsize

group Size (no. of Members) discount

2to100 5.00%

101to250 7.50%

251to500 10%

501to750 12.50%

751to1000 15.00%

1001to10000 20.00%

10001to25000 22.50%

25001to50000 25.00%

50001to100000 30.00%

Totalmaximumdiscountof35%willbeextendedonpublishedratesforNewBusinessaswellasrenewalsunderGroupHealthCareSupremepolicies

x. Territorial limits & governing law a. IncaseofPersonalAccidentCover&CriticalIllnessCoverofthisPolicy,WecovertheCriticalillnessasspecifiedunderthe

policy&theAccidentalBodilyInjury/CriticalIllnesssustainedduringthePolicyPeriodanywhereintheworld(subjecttothetravelandotherrestrictionsthattheIndianGovernmentmayimpose),butWewillonlymakepaymentwithinIndiaandinIndianRupees.

b. ForallotherCoversofthisPolicy,WecovertreatmentavailedwithinIndiaonly.OurliabilitytomakeanypaymentshallbetomakepaymentwithinIndiaandinIndianRupeesonly.

c. ThePolicyconstitutesthecompletecontractofinsurance.NochangeoralterationshallbevalidoreffectiveunlessapprovedinwritingbyUs,whichapprovalshallbeevidencedbyanendorsementontheSchedule.

d. Theconstruction,interpretationandmeaningoftheprovisionsofthisPolicyshallbedeterminedinaccordancewithIndianlaw.ThesectionheadingsofthisPolicyareincludedfordescriptivepurposesonlyanddonotformpartofthisPolicyforthepurposeofitsconstructionorinterpretation.

xi. Subrogation YouandanyclaimantunderthisPolicyshalldowhateverisnecessarytoenableUstoenforceanyrightsandremediesorobtain

relieforindemnityfromotherpartiestowhichWewouldbecomeentitledorsubrogateduponUspayingforormakinggoodanylossunderthisPolicywhethersuchactsandthingsshallbeorbecomenecessaryorrequiredbeforeorafterYourindemnificationbyUs.


HealtH Care Supreme



xii. grievance Redressal Procedure BajajAllianzGeneralInsurancehasalwaysbeenknownasaforwardlookingcustomercentricorganization.Wetakeimmensepride

inthespiritofserviceandthecultureofkeepingcustomerfirstinourschemeofthings.Inordertoprovideyouwithtop-notchserviceonallfronts,wehaveprovidedyouwithmultipleplatformsviawhichyoucanalwaysreachoneofourrepresentatives.

level 1Incaseyouhaveanyserviceconcern,youmaypleasereachouttoourCustomerExperienceteamthroughanyofthefollowingoptions:• Ourwebsite@https://general.bajajallianz.com/BagicNxt/misc/iTrack/onlineGrievance.jsp• CallusonourTollFreeNo.18002095858• [email protected],• Writeto:BajajAllianzGeneralInsuranceCo.Ltd GEPlaza,AirportRoad,Yerwada Pune,411006

level 2Incaseyouarenotsatisfiedwiththeresponsegiventoyoubyourteam,youmaywritetoourGrievanceRedressalOfficerMr.RakeshSharmaatggro@bajajallianz.co.in.

level 3Ifyouarestillnotsatisfiedwiththeresolutionprovided,youcanfurtherescalatetoMr.HiteshSindhwaniHead,CustomerExperience,atemail:[email protected].

grievance Redressal cell for Senior CitizensSeniorcitizencellforinsuredpersonwhoareseniorcitizens‘Goodthingcomeswithtime’andsoforourcustomerswhoareabove60yearsofagewehavecreatedspecialcelltoaddressanyhealthinsurancerelatedquery,Ourseniorcitizencustomerscanreachusthroughthebelowdedicatedchannelstoenableustoservicethempromptly.

Healthtollfreenumber:1800-103-2529Emailaddress:[email protected]

Incaseyourcomplaintisnotfullyaddressedbytheinsurer,YoumayusetheIntegratedGreivanceManagementSystem(IGMS)forescalatingthecomplainttoIRDAIorcall155255.ThroughIGMSyoucanregisteryourcomplainonlineandtrackitsstatus.ForregistrationpleasevisitIRDAIwebsitewww.irda.gov.in.

Iftheissuestillremainsunresolved,Youmay,subjecttovestedjurisdiction,approachInsuranceOmbudsmanfortheredressalofthegrievance.

Thecontactdetailsoftheombudsmanofficesarementionedbelow.However,werequestyoutovisithttp://www.gbic.co.inforupdateddetails.

OfficeDetails JurisdictionofOfficeUnionTerritory,District) Office details

Jurisdiction of Office union Territory, district)

AHMEdABAd - Shri/Smt........OfficeoftheInsuranceOmbudsman,JeevanPrakashBuilding,6thfloor,TilakMarg,ReliefRoad,Ahmedabad–380001.Tel.:079-25501201/02/05/06Email:[email protected]

Gujarat,Dadra&NagarHaveli,DamanandDiu.

BEngAluRu - Shri/Smt........OfficeoftheInsuranceOmbudsman,JeevanSoudhaBuilding,PIDNo.57-27-N-19GroundFloor,19/19,24thMainRoad,JPNagar,IstPhase,Bengaluru–560078.Tel.:080-26652048/26652049Email:[email protected]

Karnataka.

BHOPAl - Shri/Smt........ OfficeoftheInsuranceOmbudsman,JanakViharComplex,2ndFloor,6,MalviyaNagar,Opp.AirtelOffice,NearNewMarket,Bhopal–462003.Tel.:0755-2769201/2769202Fax:0755-2769203Email:[email protected]

MadhyaPradeshChattisgarh.

BHuBAnESHWAR - Shri/Smt........ OfficeoftheInsuranceOmbudsman,62,Forestpark,Bhubneshwar–751009.Tel.:0674-2596461/2596455Fax:0674-2596429Email:[email protected]

Orissa.


HealtH Care Supreme



CHAndIgARH - Shri/Smt........OfficeoftheInsuranceOmbudsman,S.C.O.No.101,102&103,2ndFloor,BatraBuilding,Sector17–D,Chandigarh–160017.Tel.:0172-2706196/2706468Fax:0172-2708274Email:[email protected]

Punjab,Haryana,HimachalPradesh,Jammu&Kashmir,Chandigarh.

CHEnnAI - Shri/Smt........ OfficeoftheInsuranceOmbudsman,FatimaAkhtarCourt,4thFloor,453,AnnaSalai,Teynampet,CHENNAI–600018.Tel.:044-24333668/24335284Fax:044-24333664Email:[email protected]

TamilNadu,PondicherryTownandKaraikal(whicharepartofPondicherry).

dElHI - Shri/Smt........ OfficeoftheInsuranceOmbudsman,2/2A,UniversalInsuranceBuilding,AsafAliRoad,NewDelhi–110002.Tel.:011-2323481/23213504Email:[email protected]

Delhi.

guWAHATI - Shri/Smt........ OfficeoftheInsuranceOmbudsman,JeevanNivesh,5thFloor,Nr.Panbazaroverbridge,S.S.Road,Guwahati–781001(ASSAM).Tel.:0361-2132204/2132205Fax:0361-2732937Email:[email protected]

Assam,Meghalaya,Manipur,Mizoram,ArunachalPradesh,NagalandandTripura.

HydERABAd - Shri/Smt........ OfficeoftheInsuranceOmbudsman,6-2-46,1stfloor,“MoinCourt”,LaneOpp.SaleemFunctionPalace,A.C.Guards,Lakdi-Ka-Pool,Hyderabad-500004.Tel.:040-65504123/23312122Fax:040-23376599Email:[email protected]

AndhraPradesh,Telangana,YanamandpartofTerritoryofPondicherry.

JAIPuR - Shri/Smt........ OfficeoftheInsuranceOmbudsman,JeevanNidhi–IIBldg.,Gr.Floor,BhawaniSinghMarg,Jaipur-302005.Tel.:0141-2740363Email:[email protected]

Rajasthan.

ERnAKulAM - Shri/Smt........ OfficeoftheInsuranceOmbudsman,2ndFloor,PulinatBldg.,Opp.CochinShipyard,M.G.Road,Ernakulam-682015.Tel.:0484-2358759/2359338Fax:0484-2359336Email:[email protected]

Kerala,Lakshadweep,Mahe-apartofPondicherry.

KOlKATA - Shri/Smt........OfficeoftheInsuranceOmbudsman,HindustanBldg.Annexe,4thFloor,4,C.R.Avenue,KOLKATA-700072.Tel.:033-22124339/22124340Fax:033-22124341Email:[email protected]

WestBengal,Sikkim,Andaman&NicobarIslands.

luCKnOW -Shri/Smt........OfficeoftheInsuranceOmbudsman,6thFloor,JeevanBhawan,Phase-II,NawalKishoreRoad,Hazratganj,Lucknow-226001.Tel.:0522-2231330/2231331Fax:0522-2231310Email:[email protected]

DistrictsofUttarPradesh:Laitpur,Jhansi,Mahoba,Hamirpur,Banda,Chitrakoot,Allahabad,Mirzapur,Sonbhabdra,Fatehpur,Pratapgarh,Jaunpur,Varanasi,Gazipur,Jalaun,Kanpur,Lucknow,Unnao,Sitapur,Lakhimpur,Bahraich,Barabanki,Raebareli,Sravasti,Gonda,Faizabad,Amethi,Kaushambi,Balrampur,Basti,Ambedkarnagar,Sultanpur,Maharajgang,Santkabirnagar,Azamgarh,Kushinagar,Gorkhpur,Deoria,Mau,Ghazipur,Chandauli,Ballia,Sidharathnagar.

MuMBAI - Shri/Smt........OfficeoftheInsuranceOmbudsman,3rdFloor,JeevanSevaAnnexe,S.V.Road,Santacruz(W),Mumbai-400054.Tel.:022-26106552/26106960Fax:022-26106052Email:[email protected]

Goa,MumbaiMetropolitanRegionexcludingNaviMumbai&Thane.


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nOIdA - Shri. Ajesh KumarOfficeoftheInsuranceOmbudsman,BhagwanSahaiPalace4thFloor,MainRoad,NayaBans,Sector15,Distt:GautamBuddhNagar,U.P-201301.Tel.:0120-2514250/2514252/2514253Email:[email protected]

StateofUttaranchalandthefollowingDistrictsofUttarPradesh:Agra,Aligarh,Bagpat,Bareilly,Bijnor,Budaun,Bulandshehar,Etah,Kanooj,Mainpuri,Mathura,Meerut,Moradabad,Muzaffarnagar,Oraiyya,Pilibhit,Etawah,Farrukhabad,Firozbad,Gautambodhanagar,Ghaziabad,Hardoi,Shahjahanpur,Hapur,Shamli,Rampur,Kashganj,Sambhal,Amroha,Hathras,Kanshiramnagar,Saharanpur.

PATnA - Shri/Smt........OfficeoftheInsuranceOmbudsman,1stFloor,KalpanaArcadeBuilding,,BazarSamitiRoad,Bahadurpur,Patna800006.Tel.:0612-2680952Email:[email protected]

Bihar,Jharkhand.

PunE - Shri/Smt........OfficeoftheInsuranceOmbudsman,JeevanDarshanBldg.,3rdFloor,C.T.S.No.s.195to198,N.C.KelkarRoad,NarayanPeth,Pune–411030.Tel.:020-41312555Email:[email protected]

Maharashtra,AreaofNaviMumbaiandThaneexcludingMumbaiMetropolitanRegion

Table of BenefitsMedicalExpensesSection-SumInsuredinINR

Plans HospitalisationSI(Hos-pitalisationExpenses+PreHospitalisation+PostHospitalisation+RoadAmbulance+DaycareProcedures+AyurvedicandHo-moeopathicTreatmentHospitalisation)in`

OPDSIin`

Physiother-apyonOPDbasisin`

Mater-nitySI(Includ-ingNewBornbabycover)in`

DonorExpens-esin`

AirAm-bulanceReim-burse-mentExpens-esin`

Re-coveryben-efitin`

TotalSumInsuredin`

HealthCareSupreme-Vital

PlanA 500000 2500 5000 25000 50000 50000 10000 642500

PlanB 800000 4000 8000 30000 80000 80000 10000 1012000

PlanC 1000000 5000 10000 35000 100000 100000 10000 1260000

HealthCareSupreme-Smart

PlanD

1500000 10000 15000 40000 150000 150000 25000 1890000

PlanE 2000000 15000 20000 40000 200000 200000 25000 2500000

PlanF 2500000 15000 25000 40000 250000 250000 25000 3105000

PlanG 3000000 15000 30000 50000 300000 300000 25000 3720000

HealthCareSupreme-Ultimo

PlanH

3500000 17500 35000 75000 350000 350000 50000 4377500

PlanI 4000000 20000 40000 75000 400000 400000 50000 4985000

PlanJ 4500000 25000 45000 75000 450000 450000 50000 5595000

PlanK 5000000 25000 50000 100000 500000 500000 50000 6225000


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Annexure I

Indicative list of “dAy CARE PROCEduRES”

1.Suturing-CLW-underLAorGA 2.Surgicaldebridementofwound

3.TherapeuticAsciticTapping 4.TherapeuticPleuralTapping

5.TherapeuticJointAspiration 6.Aspirationofaninternalabscessunderultrasoundguid-ance

7.Aspirationofhematoma 8.IncisionandDrainage

9.EndoscopicForeignBodyRemoval-Trachea/-pharynx-larynx/bronchus

10.EndoscopicForeignBodyRemoval-Oesophagus/stomach/rectum.

11.TruecutBiopsy-breast/-liver/-kidney-LymphNode/-Pleura/-lung/-Musclebiopsy/-Nervebiopsy/-Synovialbiopsy/-Bonetrephinebiopsy/-Pericardialbiopsy

12.Endoscopicligation/banding

13.Sclerotherapy 14.Dilatationofdigestivetractstrictures

15.Endoscopicultrasonographyandbiopsy 16.NissenfundoplicationforHiatusHernia/Gastroesopha-gealrefluxdisease

17.Endoscopicplacement/removalofstents 18.EndoscopicGastrostomy

19.ReplacementofGastrostomytube 20.Endoscopicpolypectomy

21.Endoscopicdecompressionofcolon 22.TherapeuticERCP

23.Brochoscopictreatmentofbleedinglesion 24.Brochoscopictreatmentoffistula/stenting

25.Bronchoalveolarlavage&biopsy 26.TonsillectomywithoutAdenoidectomy

27.TonsillectomywithAdenoidectomy 28.Excisionanddestructionoflingualtonsil

29.Foreignbodyremovalfromnose 30.Myringotomy

31.MyringotomywithGrommetinsertion 32.Myringoplasty/Tympanoplasty

33.AntralwashunderLA 34.Quinsydrainage

35.DirectLaryngoscopywithorw/obiopsy 36.Reductionofnasalfracture

37.Mastoidectomy 38.Removaloftympanicdrain

39.Reconstructionofmiddleear 40.Incisionofmastoidprocess&middleear

41.Excisionofnosegranuloma 42.Bloodtransfusionforrecipient

43.TherapeuticPhlebotomy 44.Haemodialysis/PeritonealDialysis

45.Chemotherapy 46.Radiotherapy

47.CoronaryAngioplasty(PTCA) 48.Pericardiocentesis

49.Insertionoffilterininferiorvenacava 50.Insertionofgelfoaminarteryorvein

51.Carotidangioplasty 52.Renalangioplasty

53.Tumorembolisation 54.TIPSprocedureforportalhypertension

55.EndoscopicDrainageofPseudopancreaticcyst 56.Lithotripsy

57.PCNS(Percutaneousnephrostomy) 58.PCNL(percutaneousnephrolithotomy)

59.Suprapubiccytostomy 60.Tranurethralresectionofbladdertumor

61.Hydrocelesurgery 62.Epididymectomy

63.Orchidectomy 64.Herniorrhaphy

65.Hernioplasty 66.Incisionandexcisionoftissueintheperianalregion

67.Surgicaltreatmentofanalfistula 68.Surgicaltreatmentofhemorrhoids

69.Sphincterotomy/Fissurectomy 70.Laparoscopicappendicectomy

71.Laparoscopiccholecystectomy 72.TURP(Resectionprostate)

73.Varicoseveinstrippingorligation 74.Excisionofdupuytren’scontracture

75.Carpaltunneldecompression 76.Excisionofgranuloma

77.Arthroscopictherapy 78.Surgeryforligamenttear

79.Surgeryformeniscustear 80.Surgeryforhemoarthrosis/pyoarthrosis


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81.Removaloffracturepins/nails 82.Removalofmetalwire

83.Incisionofbone,septicandaseptic 84.Closedreductiononfracture,luxationorepiphyseolysiswithosetosynthesis

85.Sutureandotheroperationsontendonsandtendonsheath

86.ReductionofdislocationunderGA

87.Cataractsurgery 88.Excisionoflachrymalcyst

89.Excisionofpterigium 90.GlaucomaSurgery

91.Surgeryforretinaldetachment 92.Chalazionremoval(Eye)

93.Incisionoflachrymalglands 94.Incisionofdiseasedeyelids

95.Excisionofeyelidgranuloma 96.Operationoncanthus&epicanthus

97.Correctivesurgeryforentropion&ectropion 98.Correctivesurgeryforblepharoptosis

99.Foreignbodyremovalfromconjunctiva 100.Foreignbodyremovalfromcornea

101.Incisionofcornea 102.Foreignbodyremovalfromlensoftheeye

103.Foreignbodyremovalfromposteriorchamberofeye 104.Foreignbodyremovalfromorbitandeyeball

105.Excisionofbreastlump/Fibroadenoma 106.Operationsonthenipple

107.Incision/Drainageofbreastabscess 108.Incisionofpilonidalsinus

109.Localexcisionofdiseasedtissueofskinandsubcutane-oustissue

110.Simplerestorationofsurfacecontinuityoftheskinandsubcutaneoustissue

111.Freeskintransportation,donorsite 112.Freeskintransportationrecipientsite

113.Revisionofskinplasty 114.Destructionofthediseasestissueoftheskinandsubcu-taneoustissue

115.Incision,excision,destructionofthediseasedtissueofthetongue

116.Glossectomy

117.Reconstructionofthetongue 118.Incisionandlancingofthesalivaryglandandasalivaryduct

119.Resectionofasalivaryduct 120.Reconstructionofasalivaryglandandasalivaryduct

121.Externalincisionanddrainageintheregionofthemouth,jawandface

122.Incisionofhardandsoftpalate

123.Excisionanddestructionofthediseasedhardandsoftpalate

124.Incision,excisionanddestructioninthemouth

125.Surgerytothefloorofmouth 126.Palatoplasty

127.Transoralincisionanddrainageofpharyngealabscess 128.Dilatationandcurettage

129.Myomectomies 130.SimpleOophorectomies

Note:

i) Abovementionedlistisaindicativelistofprocedures,anyothersurgeries/proceduresrequiringlessthan24hourshospitalisationduetotechnologicaladvanceswillalsobecoveredunderthispolicyprovidedsuchprocedurescomplywiththestandarddefinitionofDayCareCentreandDayCaretreatmentmentionedinthedefinitions.

ii) Thestandardexclusionsandwaitingperiodsareapplicabletoalloftheaboveproceduresdependingonthemedicalcondition/diseaseundertreatment.Only24hourshospitalizationisnotmandatory.