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Relationship Beyond Insurance
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
Relationship Beyond Insurance
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 2
Bajaj Allianz General Insurance Company Limited
• 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
(SectionA3), Roadambulance (SectionA4),DayCareexpenses (SectionA6),Ayurvedic /HomeopathicHospitalisationExpenses(SectionA12)wouldnotexceedthehospitalizationSumInsuredasspecifiedinthepolicyschedule.
A.3 Post-Hospitalisation TheMedicalExpensesincurredduringthe90daysimmediatelyafterYouweredischargedpostHospitalisationprovidedthat:Such
costsareincurredinrespectofthesameillness/injuryforwhichtheearlierHospitalisationwasrequired,andWehaveacceptedaninpatientHospitalisationclaimunderBenefitHospitalisationexpenses(sectionA1).
Note: OurmaximumliabilitycollectivelyforHospitalizationexpenses,(sectionA1),Pre-hospitalization(SectionA2),Posthospitalization
(SectionA3), Roadambulance (SectionA4),DayCareexpenses (SectionA6),Ayurvedic /HomeopathicHospitalisationExpenses(SectionA12)wouldnotexceedthehospitalizationSumInsuredasspecifiedinthepolicyschedule.
A4. Road Ambulance Wewillreimbursetheexpensesincurredonanambulanceofferedbyahealthcareorambulanceserviceproviderfortransferring
You to thenearestHospitalwithadequateemergency facilities for theprovisionofhealthservices followinganEmergency,providedthat:WehaveacceptedaninpatientHospitalisationclaimunderBenefitHospitalisationexpenses(sectionA1).
Wewillalso reimburse theexpenses incurredonanambulanceofferedbyahealthcareorambulanceserviceprovider fortransferringYoufromtheHospitalwhereyouwereadmittedinitiallytoanotherhospitalwithhighermedicalfacilitiesprovidedthat:WehaveacceptedaninpatientHospitalisationclaimunderBenefitHospitalisationexpenses(sectionA1).
Note: OurmaximumliabilitycollectivelyforHospitalizationexpenses,(sectionA1),Pre-hospitalization(SectionA2),Posthospitalization
(SectionA3), Roadambulance (SectionA4),DayCareexpenses (SectionA6),Ayurvedic /HomeopathicHospitalisationExpenses(SectionA12)wouldnotexceedthehospitalizationSumInsuredasspecifiedinthepolicyschedule.
A5. Air Ambulance Wewillpayforambulancetransportationinanairplaneorhelicopterforemergencylifethreateninghealthconditionswhichrequire
immediateandrapidambulancetransportationfromthesiteoffirstoccurrenceoftheillness/accidenttothenearesthospital.TheclaimwouldbereimburseduptotheactualexpensessubjecttoamaximumlimitasspecifiedundertheAir Ambulance sectioninthepolicyschedule.
Returntransportationtotheclient’shomebyairambulanceisexcluded
A6. day Care Procedures WewillpayyouthemedicalexpensesaslistedaboveunderSectionA1forDaycareprocedures/Surgeriestakenasaninpatientin
ahospitalordaycarecentrebutnotintheoutpatientdepartment.IndicativelistofDayCareProceduresisgivenintheannexure1ofPolicywordings
Note: OurmaximumliabilitycollectivelyforHospitalizationexpenses,(sectionA1),Pre-hospitalization(SectionA2),Posthospitalization
(SectionA3), Roadambulance (SectionA4),DayCareexpenses (SectionA6),Ayurvedic /HomeopathicHospitalisationExpenses(SectionA12)wouldnotexceedthehospitalizationSumInsuredasspecifiedinthepolicyschedule.
A7. Out Patient Expenses Ifyouconsultaspecialistconsultant/specialistmedicalPractitioneronOutpatientbasisfortheillness/injurycontractedduring
thepolicyperiod,wewillpayyouOutPatientexpensesfor,
Relationship Beyond Insurance
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 3
Bajaj Allianz General Insurance Company Limited
• 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
Relationship Beyond Insurance
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 4
Bajaj Allianz General Insurance Company Limited
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
(SectionA3), Roadambulance (SectionA4),DayCareexpenses (SectionA6),Ayurvedic /HomeopathicHospitalisationExpenses(SectionA12)wouldnotexceedthehospitalizationSumInsuredasspecifiedinthepolicyschedule.
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
Relationship Beyond Insurance
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 5
Bajaj Allianz General Insurance Company Limited
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.
Relationship Beyond Insurance
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 6
Bajaj Allianz General Insurance Company Limited
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.
Relationship Beyond Insurance
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 7
Bajaj Allianz General Insurance Company Limited
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.
Relationship Beyond Insurance
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 8
Bajaj Allianz General Insurance Company Limited
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.
Relationship Beyond Insurance
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 9
Bajaj Allianz General Insurance Company Limited
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.
II. general exclusions
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:
I. general exclusions
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.
II. general exclusions
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:
I. general exclusions
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.
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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)
Aaadharcard&PANcardCopies(Notmandatoryifthesameislinkedwiththepolicywhileissuanceorinpreviousclaim)
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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
Aaadharcard&PANcardCopies(Notmandatoryifthesameislinkedwiththepolicywhileissuanceorinpreviousclaim)
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.
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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.
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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.
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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
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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.
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Bajaj Allianz General Insurance Company Limited
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.
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Bajaj Allianz General Insurance Company Limited
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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Bajaj Allianz General Insurance Company Limited
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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Bajaj Allianz General Insurance Company Limited
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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Bajaj Allianz General Insurance Company Limited
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.