Health Guard Policy Wordings Print

Bajaj Allianz General Insurance Company Limited
Bajaj Allianz House, Airport Road, Yerawada, Pune - 411 006. Reg. No.: 113
For more details, log on to : www.bajajallianz.com | E-mail: [email protected] or
call at : Sales - 1800 209 0144 / Service - 1800 209 5858 (Toll Free No.)
Issuing Office :
HEALTH GUARD
Policy Wordings
Preamble
Whereas the insured described in the Policy Schedule hereto (hereinafter called the ‘Insured’) has made to Bajaj Allianz General Insurance Company Limited
(hereinafter called the “Company” or “Insurer” or “Insurance Company”) a proposal or Proposal as mentioned in the transcript of the Proposal, which shall be the basis of
this Contract and is deemed to be incorporated herein, containing certain undertakings, declarations, information/particulars and statements, which is hereby agreed to
be the basis of this Contract and be considered as incorporated herein, for the insurance Contract hereinafter contained and has paid the premium
specified in the Policy Schedule hereto as consideration for such insurance Contract, now the Company agrees, subject always to the Policy Schedule and the
following terms, conditions, exclusions, and limitations of the Policy, and in excess of the amount of the Deductible, to indemnify the Insured in the manner and to the
extent hereinafter stated:
Types of Policy
• Health Guard-Individual
• Health Guard-Family Floater
Tenure of Policy:
• Health Guard-Individual: 1year, 2 years or 3 years
• Health Guard-Family Floater: 1year, 2 years or 3 years
Scope of cover:
The Company hereby agrees to pay in respect of an admissible claim, any or all of the following covers subject to the Sum Insured, limits, terms, conditions and definitions,
exclusions contained or otherwise expressed in this Policy.
SECTION A) COVERAGE
1. In-patient Hospitalization Treatment

If You are hospitalized on the advice of a Medical practitioner as defined under Policy because of Illness or Accidental Bodily Injury sustained or contracted during the
Policy Period, then We will pay You, Reasonable and Customary Medical Expenses incurred subject to
i. Room rent and Boarding expenses as provided by the Hospital/Nursing Home subject to below limits
• Silver Plan
Up to 1% of Sum Insured per day (Excluding Cumulative Bonus)
• Gold Plan and Platinum Plan

a) Sum Insured 3 lacs to 7.5 lacs- maximum eligible room is Single private Air Conditioned room
b) Sum Insured 10 Lacs and above - eligible for any room category
ii. If admitted in ICU, the Company will pay up to actual ICU expenses provided by Hospital.
iii. Nursing Expenses as provided by the hospital
iv. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees.
v. Anesthesia, Blood, Oxygen, Operation Theatre Charges, surgical appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, cost of Artificial Limbs,
cost of prosthetic devices implanted during surgical procedure like Pacemaker, orthopedic implants, infra cardiac valve replacements, vascular stents.
vi. Relevant laboratory diagnostic tests, X-ray and such similar expenses that are medically necessary prescribed by the treating Medical Practitioner.

Note:
In case of admission to a room at rates exceeding the limits as mentioned under (i), the reimbursement of all other expenses incurred at the Hospital,
with the exception of cost of Pharmacy/medicines, consumables, implants, medical devices & diagnostics, shall be payable in the same proportion as the
admissible rate per day bears to the actual rate per day of room rent charges
Proportionate deductions shall not apply in respect of the Hospitals which do not follow differential billings or for those expenses in respect of which differ-
ential billing is not adopted based on the room category
2. Pre-Hospitalization
The Medical Expenses incurred during the 60 days immediately before You were Hospitalized, provided that: Such Medical Expenses were incurred for the same
illness/injury for which subsequent Hospitalization was required, and We have accepted an inpatient Hospitalization claim under Inpatient
Hospitalization Treatment. (Section A. 1)
3. Post-Hospitalization
The Medical Expenses incurred during the 90 days immediately after You were discharged post Hospitalization provided that: Such costs are incurred in
respect of the same illness/injury for which the earlier Hospitalization was required, and We have accepted an inpatient Hospitalization claim under Inpatient Hos-
pitalization Treatment. (Section A. 1)
4. Road Ambulance
We will pay the reasonable cost to a maximum of Rs. 20,000/- per Policy Year incurred on an ambulance offered by a healthcare or ambulance service provider for
transferring You to the nearest Hospital with adequate emergency facilities for the provision of health services following an Emergency.
We will also reimburse the expenses incurred on an ambulance offered by a healthcare or ambulance service provider for transferring You from the Hospital where
You were admitted initially to another hospital with higher medical facilities.
CIN: U66010PN2000PLC015329 | UIN: BAJHLIP21227V042021 1

HEALTH GUARD
Claim under this section shall be payable by Us only when:

i. Such life threatening emergency condition is certified by the Medical Practitioner, and
ii. We have accepted Your Claim under “In-patient Hospitalization Treatment” or “Day Care Procedures” section of the Policy.
Subject otherwise to the terms, conditions and exclusions of the Policy.

This benefit will be applicable each year for policies with term more than 1 year.
5. Day Care Procedures

We will pay You the medical expenses as listed above under Section A. 1- In-patient Hospitalization Treatment for Day care procedures / Surgeries taken as an inpa-
tient in a hospital or day care center but not in the outpatient department. Refer Annexure I of Policy Wordings for list of Day Care Procedures.
6. Organ Donor Expenses:

We will pay expenses towards organ donor’s treatment for harvesting of the donated organ, provided that,
1. The organ donor is any person whose organ has been made available in accordance and in compliance with THE TRANSPLANTATION OF HUMAN
ORGANS (AMENDMENT) BILL, 2011and the organ donated is for the use of the Insured, and
2. We have accepted an inpatient Hospitalization claim for the Insured under In Patient Hospitalization Treatment (Section A.1).
7. Convalescence Benefit:
In the event of Insured Hospitalized for a disease/illness/injury for a continuous period exceeding 10 days, We will pay benefit amount as per the plan opted subject
to below limits.
 Silver Plan
Rs. 5,000 per Policy Year
 Gold and Platinum Plan
• Rs. 5,000 for Sum Insured up to Rs. 5 lacs
• Rs. 7,500 for Sum Insured 7.5 lacs and above per Policy Year.
This benefit will be triggered provided that the hospitalization claim is accepted under Section A.,1-In Patient Hospitalization Treatment.
Payment under this benefit will not reduce the base sum insured mentioned in policy Schedule.
8. Daily Cash Benefit for Accompanying an Insured Child

We will pay Daily Cash Benefit of Rs. 500 per day maximum up to 10 days during each Policy Year for reasonable accommodation expenses in respect of one parent/
legal guardian, to stay with any minor Insured (under the Age of 12), provided the hospitalization claim is paid under Section A.1-Inpatient
Hospitalization Treatment.
Payment under this benefit will not reduce the base sum insured mentioned in policy Schedule.
9. Sum Insured Reinstatement Benefit:

If Section A1. Inpatient Hospitalization Treatment Sum Insured and Cumulative Bonus or Super Cumulative Bonus (if any) is exhausted due to claims registered
and paid during the Policy Year, then it is agreed that 100% of the Base Sum Insured specified under Inpatient Hospitalization Treatment would be reinstated for the
particular Policy Year provided that:
i. The reinstated Sum Insured will be triggered only after the Inpatient Hospitalization Treatment Sum Insured inclusive of the Cumulative Bonus or Super
Cumulative Bonus (If applicable) has been completely exhausted during the Policy Year;
ii. The reinstated Sum Insured can be used for claims made by the Insured in respect of the benefits stated in Inpatient Hospitalization Treatment.
iii. If the claimed amount is higher than the Balance Sum Insured inclusive of the Cumulative Bonus or Super Cumulative Bonus (If applicable) under the policy,
then this benefit will not be triggered for the same claim, however Sum Insured reinstatement would be triggered for subsequent claims for the same mem-
ber or other insured members.
iv. This benefit is applicable only once during each Policy Year and will not be carried forward to the subsequent Policy Year/ renewals if the benefit is not utilized.
v. This benefit is applicable only once in life time of Insured covered under this Policy for claims regarding CANCER and KIDNEY FAILURE REQUIRING
REGULAR DIALYSIS as defined under the Policy, however the insured member is eligible for re-instatement benefit every year for other admissible conditions.
vi. This benefit will be applicable each year for long term policies.
vii. Additional premium would not be charged for reinstatement of the Sum Insured.
viii. In case of Family Floater policy, Reinstatement of Sum Insured will be available for all Insured Persons in the Policy
Understanding Sum Insured Reinstatement made easy-
Sum Insured at the Accumulated Sum Insured Hospitalization Reinstated Sum Payable Claim Balance Sum
beginning of the year Cumulative Bonus with CB Amount Insured Amount Insured
1st Claim 300,000 10% 330,000 350,000 0 330,000 0
2nd Claim - - - 200,000 300,000 200,000 100,000
3rd Claim - - - 200,000 0 100,000 0
10. Preventive Health Check Up

At the end of block of every continuous period as mentioned in coverage during which You have held Our Health Guard Policy, You are eligible for a free
Preventive Health checkup. We will reimburse the amount as per the plan opted, subject to below limits
- Silver Plan
1% of the Sum Insured maximum up to Rs. 2000/- for each Insured in Individual Policy during the block of 3 years

HEALTH GUARD
- Gold Plan
1% of the Sum Insured max up to Rs. 5000/- for each Insured in Individual Policy during the block of 3 years.
- Platinum Plan
1% of the Sum Insured max up to Rs. 5000/- for each Insured in Individual Policy during the block of 2 years.
This benefit can be availed by proposer & spouse only under Floater Sum Insured Policies.
You may approach Us for the arrangement of the Health Check up. For the avoidance of doubt, We shall not be liable for any other ancillary or peripheral costs or
expenses (including but not limited to those for transportation, accommodation or sustenance).
Contact Email id- [email protected].
Note: Payment under this benefit will not reduce the base sum insured mentioned in policy Schedule.
11. Bariatric Surgery Cover

If You are hospitalized on the advice of a Medical practitioner because of Conditions mentioned below which required You to undergo Bariatric Surgery during the
Policy Period, then We will pay You, Reasonable and Customary Expenses related to Bariatric Surgery
Eligibility:
For adults aged 18 years or older, presence of severe documented in contemporaneous clinical records, defined as any of the following:
Body Mass Index (BMI);
a) greater than or equal to 40 or
b) greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive methods of weight loss:
i. Obesity-related cardiomyopathy
ii. Coronary heart disease
iii. Severe Sleep Apnea
iv. Uncontrolled Type 2 Diabetes
Special Conditions applicable to Bariatric Surgery Cover

a. This benefit is subject to a waiting period of 36 months from the date of commencement of the first Health Guard Policy with Us and continuous renewal
thereof with the Company.
b. Fresh waiting period of 36 months would apply for all the policies issued with continuity from other Health Indemnity product/plans of Our Company where
Bariatric Surgery is not covered.
c. Fresh waiting period of 36 months would apply for all the policies issued with continuity under portability guidelines from any other Non-Health or Standalone
Health Insurance Company where Bariatric Surgery is not covered.
d. If the Insured is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health Insurance) Regulations then wait-
ing period for the same would be reduced to the extent of prior coverage where Insured is having policy with Bariatric Surgery Cover.
e. Our maximum liability will be restricted to
i. 25% of Sum Insured in Silver Plan
ii. 50% of Sum Insured maximum up to Rs. 5lac in Gold and Platinum Plan.
f. Bariatric surgery performed for Cosmetic reasons is excluded.
g. The indication for the procedure should be found appropriate by two qualified surgeons and the Insured shall obtain prior approval for cashless treatment
from the Company.
12. Wellness Benefits

At each renewal of Health Guard Policy with Us, You will be entitled for a wellness discount subject to below mentioned criteria being fulfilled by You during the
preceding Policy Year. The below mentioned criteria should be fulfilled each year in case of long term policies.
Sr. No Health Parameter Reading

1 Health Risk Assessment Complete the online health risk assessment
2 HbA1c (%) Up to 6.5%
3 Fasting Blood Sugar Upto 120 mg/dl
4 Systolic Diastolic
Blood Pressure (mm of Hg)
Upto 140 Upto 90
5 Body Mass Index (BMI) 18 – 25
6 Serum Cholesterol 200mg/dl
7 Steps Count 5,000 steps daily – 20 days every month
Male-13-18 g/dL
8 Hemoglobin
Female- 11-15 g/dL

HEALTH GUARD
Parameters Achieved Discount Offered

4/5 out of 8 5%
6/7 out of 8 7.5%
8 out of 8 10%
Wellness Eligibility Criteria:

1. Wellness discount is applicable for members age 25 years and above
2. If the insured member meets 4/5 out of 8 criteria, he/she is eligible for 5% discount, 6/7 out of 8 criteria he /she is eligible for 7.5% discount & meets with 8 criteria
he / she is eligible for 10% discount.
3. If an Insured meets 8 out of 8 above mentioned parameters and in addition he/she walks for 10000 steps for 20 days every month then they will be eligible for addi-
tional discount of 2.5%.
4. In Floater Policies, discount will be offered basis the average of number of Parameters Achieved by all Insured members age 25 years & above.

Total no. of parameters achieved by eligible members
Discount under Floater Policy=
Total no. of eligible members in the family

In addition to the above parameters, if the eligible members walk for 10000 steps each for 20 days every month then they will be eligible for additional discount of
2.5%.
13. Ayurvedic / Homeopathic Hospitalization Expenses (Applicable for Gold and Platinum Plan only)
If You are Hospitalized for not less than 24 hrs, in an Ayurvedic / Homeopathic Hospital which is a government hospital or in any institute recognized by
government and/or accredited by Quality Council of India/National Accreditation Board on Health on the advice of a Medical practitioner because of Illness or Acci-
dental Bodily Injury sustained or contracted during the Policy Period then We will pay You:
In-patient Treatment- Medical Expenses for Ayurvedic and Homeopathic treatment:
• Room rent, boarding expenses
• Nursing care
• Consultation fees
• Medicines, drugs and Medical consumables,
• Ayurvedic and Homeopathic treatment procedures
Our maximum liability is up to Rs. 20,000 per Policy Year.
The claim will be admissible under the Policy provided that,
(i) The illness/injury requires inpatient admission and the procedure performed on the Insured cannot be carried out on out-patient basis
14. Maternity Expenses (Applicable for Gold and Platinum Plan only)
We will pay the Medical Expenses for the delivery of a baby (including caesarean section) and/or expenses related to medically recommended and lawful termina-
tion of pregnancy, limited to maximum 2 deliveries or termination(s) or either,
a. Our maximum liability per delivery or termination shall be limited to the amount specified in the Policy Schedule as per Sum Insured opted.
b. We will pay the Medical Expenses of pre-natal and post-natal hospitalization (90 days post-delivery) per delivery or termination up to the maternity limit.
c. Waiting period of 72 months as mentioned in the Policy Schedule would apply from the date of issuance of the first Health Guard Policy with Us,
d. If the Insured is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health Insurance) Regulations then wait-
ing period for the same would be reduced to the extent of prior coverage where Insured is having policy with Maternity Expense benefit.
e. Fresh Waiting period of 72 months as mentioned in the Policy Schedule would apply for all the policies issued with continuity from other Health
Indemnity product/plans of Our Company where maternity expenses are not covered.
f. Any complications arising, within 90 days post-delivery, out of or as a consequence of maternity/child birth will be covered up to the maternity limit.
g. Payment under this benefit will not reduce the base sum insured mentioned in policy Schedule.
15. New Born Baby Cover (Applicable for Gold and Platinum Plan only)
Coverage for new born baby will be considered subject to a claim being accepted under Maternity Expenses (Section A 14). We will pay the following expenses within
the limit of the Sum Insured available under the Maternity Expenses section.
We will pay for,
a. Medical Expenses towards treatment of Your new born baby while You are Hospitalized as an inpatient for delivery for the Hospitalization,
b. Hospitalization charges incurred on the new born baby during post birth including any complications shall be covered up to a period of 90 days from the date
of birth and within limit of the Sum Insured under Maternity Expenses without payment of any additional premium
c. Mandatory Vaccinations of the new born baby up to 90 days, as recommended by the Indian Pediatric Association will be covered under the Maternity Ex-
penses Sum Insured.
COVERS APPLICABLE FOR PLATINUM PLAN ONLY
16. Super Cumulative Bonus

This benefit would be extended if You renew Your “Health Guard” with Us without any break and there has been no claim in the preceding year,
i. We will increase the Limit of Indemnity by 50% of base Sum Insured per annum for first 2 years and later 10% of base Sum Insured per annum for next 5 years.
ii. Maximum bonus will not exceed 150% of the Hospitalization Sum Insured
iii. If a claim is made in any year where a Super Cumulative Bonus has been applied, then the increased Limit of Indemnity in the Policy Period of the
subsequent “Health Guard” shall be reduced to previous slab. However the Sum Insured would not be decreased.
iv. In case of any increase or decrease of Sum Insured at renewal the Super Cumulative Bonus % would be calculated on the lesser Sum Insured.
HEALTH GUARD
Claim free Year Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7
% Increase in Limit of Indemnity 50% 50% 10% 10% 10% 10% 10%
17. Recharge Benefit

i. In event of claim amount exceeding the limit of indemnity, Sum Insured would be increased by 20% maximum up to 5 Lacs.
SUM INSURED LIMIT (INR)

5 Lacs 1 Lac
7.5 Lacs 1.5 Lacs
10 Lacs 2 Lacs
15 Lacs 3 Lacs
20 Lacs 4 Lacs
25 Lacs to 1 Crore 5 Lacs
ii. In case of Individual Sum Insured policies, this benefit will be applicable once in a policy year for each insured member.
iii. For a Floater policy, this benefit will be applicable cumulatively to all insured members, once in a policy year.
iv. The unutilized Recharge amount cannot be carried forward to the subsequent renewal.
SECTION B) DEFINITIONS
1. Accident, Accidental –
An accident is a sudden, unforeseen and involuntary event caused by external, visible and violent means.
2. Act of Terrorism:-
Means an act or thing by any person or group(s) of persons, whether acting alone or on behalf of or in connection with or in connivance with or at the instance or
instigation of any person or group(s) or organisation(s) or associations(s), who are committed or proclaimed to be committed for political, religious or ideological
purposes, whether such person or group(s) of persons or organisation(s) or association(s) are or are not banned any law, in such a manner or with intent to threaten
the unity, integrity, security or sovereignty of India or to strike terror in the people or any section of the people by using bombs, dynamite or other explosive substanc-
es or inflammable substances or firearms or other lethal weapons or poisons or noxious gases or other chemicals or by any other substances (whether biological or
otherwise) of a hazardous nature or by any other means whatsoever, with intend to cause, or likely to cause, death or, or injuries to any person or persons or loss of,
or damage to, or destruction of, property or disruption of any supplies or services essential to the life of the
community or causes damage or destruction of any property or equipment used or intended to be used for the defense of India or in connection with any other
purposes of the Government of India, any State Government or an of their agencies, or detains any person and threatens to kill or injure such person in order to
compel the Government or any other person to do or abstain from doing any act. Provided further that for the above acts appropriate criminal prosecution has been
initiated by police and charge sheet has been filed in competent court of criminal jurisdiction, either under special law or under general law.
3. Any one illness

Any one illness means continuous Period of illness and it includes relapse within 45 days from the date of last consultation with the Hospital/Nursing Home where
treatment was taken.
4. AYUSH Hospital:
An AYUSH Hospital is a healthcare facility wherein medical/surgical/para-surgical treatment procedures and interventions are carried out by AYUSH Medical Prac-
titioner(s) comprising of any of the following:
a. Central or State Government AYUSH Hospital; or
b. Teaching hospital attached to AYUSH College recognized by the Central Government/Central Council of Indian Medicine/Central Council for
Homeopathy ; or
c. AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any recognized system of medicine, registered with the local authorities,
wherever applicable, and is under the supervision of a qualified registered AYUSH Medical Practitioner and must comply with all the following criterion:
i. Having at least 5 in-patient beds;
ii. Having qualified AYUSH Medical Practitioner in charge round the clock;
iii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures are to be carried out;
iv. Maintaining daily records of the patients and making them accessible to the insurance company’s authorized representative.
5. AYUSH Day Care Centre:

AYUSH Day Care Centre means and includes Community Health Centre (CHC), Primary Health Centre (PHC), Dispensary, Clinic, Polyclinic or any such health centre
which is registered with the local authorities, wherever applicable and having facilities for carrying out treatment procedures and medical or surgical/para-surgical
interventions or both under the supervision of registered AYUSH Medical Practitioner (s) on day care basis without in-patient services and must comply with all the
following criterion:
i. Having qualified registered AYUSH Medical Practitioner(s) in charge;
ii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures are to be carried out;
iii. Maintaining daily records of the patients and making them accessible to the insurance company’s authorized representative.

HEALTH GUARD
6. Bajaj Allianz Network Hospitals / Network Hospitals/Network Providers

Bajaj Allianz Network Hospitals / Network Hospitals means the Hospitals which have been empanelled by the Insurer as per the latest version of the list of Hospitals
maintained by the Insurer, which is available to You on request. For updated list please visit Our website.
7. Bajaj Allianz Diagnostic Centre

Bajaj Allianz Diagnostic Centre means the diagnostic centers which have been empanelled by us as per the latest version of the schedule of diagnostic centers
maintained by Us, which is available to You on request.
8. Cashless facility
Cashless facility means a facility extended by the Insurer to the Insured where the payments, of the costs of treatment undergone by the Insured in accordance with
the Policy terms and conditions, are directly made to the network provider by the Insurer to the extent pre-authorization is approved.
9. Co-Payment
A co-payment means a cost-sharing requirement under a health insurance Policy that provides that the Policyholder/Insured will bear a specified percentage of the
admissible claim amount. A co-payment does not reduce the Sum Insured.
10. Condition Precedent

Condition Precedent means a Policy term or condition upon which the Insurer’s liability under the Policy is conditional upon.
11. Congenital Anomaly

Congenital Anomaly means a condition(s) which is present since birth, and which is abnormal with reference to form, structure or position.
a. Internal Congenital Anomaly- Congenital anomaly which is not in the visible and accessible parts of the body
b. External Congenital Anomaly- Congenital anomaly which is in the visible and accessible parts of the body
12. Cumulative Bonus

Cumulative Bonus means any increase or addition in the Sum Insured granted by the insurer without an associated increase in premium.
13. Day care centre

A day care centre means any institution established for day care treatment of illness and / or injuries or a medical set -up with a hospital and which has been reg-
istered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified medical practitioner AND must comply with all
minimum criteria as under:-
a. has qualified nursing staff under its employment,
b. has qualified medical practitioner (s) in charge,
c. has a fully equipped operation theatre of its own where surgical procedures are carried out
d. maintains daily records of patients and will make these accessible to the Insurance Company’s authorized personnel.
14. Day Care Treatment

Day care treatment means medical treatment, and/or surgical procedure which is:
a. undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 hrs because of technological advancement, and
b. Which would have otherwise required a hospitalization of more than 24 hours.
Treatment normally taken on an out-patient basis is not included in the scope of this definition.
15. Dental Treatment

Dental treatment means a treatment related to teeth or structures supporting teeth including examinations, fillings (where appropriate), crowns, extractions and
surgery.
16. Dependent child

A child is considered a dependent for insurance purposes until his 35th birthday (even if not enrolled in an educational institution) provided he is financially depend-
ent, on the proposal.
17. Disclosure to information norm

The Policy shall be void and all premium paid thereon shall be forfeited to the Company, in the event of misrepresentation, mis-description or non-disclosure of any
material fact.
18. Emergency Care

Emergency care means management of an illness or injury which results in symptoms which occur suddenly and unexpectedly, and requires immediate care by a
medical practitioner to prevent death or serious long term impairment of the Insured’s health.
19. Endorsement
means any writing on a Policy Schedule or Policy, in addition to its normal wording which supplements or modifies its terms. It may be added when Policy is
prepared, or subsequently. Provided however any Service Level Agreement [SLA] or Agreement/MOU laying down various service levels shall not be treated as
Endorsement.
20. Family or Family Members

For the purpose of Individual Sum Insured Policy- includes the Insured; his/her lawfully wedded spouse and dependent children, parents, Sister, Brother, Parents-in-
law, Aunt, Uncle, Grandchildren.
For the purpose of Family Floater- includes the Insured; his/her lawfully wedded spouse and dependent children. For Parents separate floater Policy can be taken.

HEALTH GUARD
21. Grace Period

Grace period means the specified period of time immediately following the premium due date during which a payment can be made to renew or continue a Policy
in force without loss of continuity benefits such as waiting periods and coverage of pre-existing diseases. Coverage is not available for the period for which no pre-
mium is received.
22. Hospital
A hospital means any institution established for in-patient care and day care treatment of illness and/or injuries and which has been registered as a hospital with the
local authorities under the Clinical Establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1)
of the said Act OR complies with all minimum criteria as under:
a. has qualified nursing staff under its employment round the clock;
b. has at least 10 in-patient beds in towns having a population of less than 10,00,000 and at least 15 in-patient beds in all other places;
c. has qualified medical practitioner(s) in charge round the clock;
d. has a fully equipped operation theatre of its own where surgical procedures are carried out;
e. maintains daily records of patients and makes these accessible to the Insurance Company’s authorized personnel.
23. Hospitalization
Hospitalization means admission in a Hospital for a minimum period of 24 consecutive In patient Care hours except for specified procedures/ treatments, where
such admission could be for a period of less than 24 consecutive hours.
24. Illness
Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function and requires medical treatment.
a. Acute condition - Acute condition is a disease, illness or injury that is likely to respond quickly to treatment which aims to return the person to his or her state
of health immediately before suffering the disease/illness/injury which leads to full recovery.
b. Chronic condition –
A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics:
a. it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /or tests
b. it needs ongoing or long-term control for relief of symptoms
c. it requires rehabilitation for the patient or for the patient to be specially trained to cope with it
d. it continues indefinitely
e. it recurs or is likely to recur.
25. Inpatient Care

Inpatient care means treatment for which the Insured has to stay in a hospital for more than 24 hours for a covered event.
26. Injury
Injury means accidental physical bodily harm excluding illness or disease solely and directly caused by external, violent and visible and evident means which is
verified and certified by a Medical Practitioner.
27. Intensive Care Unit

Intensive care unit means an identified section, ward or wing of a hospital which is under the constant supervision of a dedicated medical practitioner(s), and which
is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition, or require life support facilities and where the level of
care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards.
28. ICU Charges

ICU (Intensive Care Unit) Charges means the amount charged by a Hospital towards ICU expenses which shall include the expenses for ICU bed, general medical
support services provided to any ICU patient including monitoring devices, critical care nursing and intensivist charges.
29. Kidney Failure Requiring Regular Dialysis

End stage renal disease presenting as chronic irreversible failure of both kidneys to function, as a result of which either regular renal dialysis (hemodialysis
or peritoneal dialysis) is instituted or renal transplantation is carried out. Diagnosis has to be confirmed by a Specialist Medical Practitioner.
30. Limit of Indemnity

Limit of Indemnity represents Our maximum liability to make payment for each and every claim per person and collectively for all persons mentioned in the Sched-
ule during the Policy Period and in the aggregate for the person(s) named in the schedule during the Policy Period, and means the amount stated in the Schedule
against each Cover.
31. Maternity expenses:

Maternity expenses means;
a. medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalization);
b. expenses towards lawful medical termination of pregnancy during the Policy Period.
32. Medical Advise

Medical advise means any consultation or advice from a Medical Practitioner including the issue of any prescription or follow up prescription.
33. Medical Consumable

Medical consumables and equipment includes syringes, needles, sutures, staples, packaging, tubing, catheters, medical gloves, gowns, masks, adhesives and seal-
ants for wound dressing and a whole host of other devices and tools used with a hospital or surgical environment.
34. Medical expenses

Medical Expenses means those expenses that an Insured has necessarily and actually incurred for medical treatment on account of Illness or Accident on the advice
of a Medical Practitioner, as long as these are no more than would have been payable if the Insured had not been Insured and no more than other hospitals or
HEALTH GUARD
Medical practitioners in the same locality would have charged for the same medical treatment.
35. Medical Practitioner/Doctor/ Physician:

means a Medical Practitioner who holds a valid registration from the Medical Council of any State or Medical Council of India or Council for Indian Medicine or for
Homeopathy or Ayurvedic and or such other authorities set up by the Government of India or a State Government and is thereby entitled to practice medicine within
its jurisdiction; and is acting within its scope and jurisdiction of license and acceptable to Us.
36. A Doctor/ Physician/Medical Practitioner shall not include any member of the Insured’s family.
37. Medically Necessary Treatment

Medically necessary treatment means any treatment, tests, medication, or stay in hospital or part of a stay in hospital which
a. is required for the medical management of the illness or injury suffered by the Insured;
b. must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity;
c. must have been prescribed by a medical practitioner,
d. must conform to the professional standards widely accepted in international medical practice or by the medical community in India.
38. Migration- means, the right accorded to health insurance policyholders (including all members under family cover and members under family cover and members
of group health insurance policy), to transfer the credit gained for pre-existing conditions and time bound exclusions, with the same insurer.
39. Named Insured/ Insured/Insured Person:

Insured means the persons, or his Family Members, named in the Schedule provided that an Insured or his Family Members has attained the age of 3 months and
is not older than 65 years of age at the commencement of the Policy Period.
40. New Born Baby

Newborn baby means baby born during the Policy Period and is aged up to 90 days.
41. Network Provider :

Network Provider means hospitals or health care providers enlisted by an insurer, TPA or jointly by an Insurer and TPA to provide medical services to an insured by a
cashless facility.
42. Non- Network Provider

Non-Network provider means any hospital, day care centre or other provider that is not part of the network.
43. Notification of Claim

Notification of claim means the process of intimating a claim to the insurer or TPA through any of the recognized modes of communication.
44. OPD treatment

OPD treatment means one in which the Insured visits a clinic / hospital or associated facility like a consultation room for diagnosis and treatment based on the advice
of a Medical Practitioner. The Insured is not admitted as a day care or in-patient.
45. Obesity means abnormal or excessive fat accumulation that may impair health. Obesity is measured in Body Mass Index.
Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults. It is defined as a person’s weight
in kilograms divided by the square of his height in meters (kg/m2).
The WHO definition is:
• BMI greater than or equal to 25 is overweight
• BMI greater than or equal to 30 is obesity
46. Policy or Contract means the Proposal, the Policy Schedule, along with these Terms and Conditions issued to the Insured and any annexures and/or Endorse
ments attaching to and / or forming part thereof either at the commencement of Policy Period or during the Policy Period.
47. Policy Schedule or Schedule means the Policy Schedule and any annexure or Endorsements to it, if any, as issued by the Company, which forms part of Policy.
48. Policy Period means period from risk inception date [RID] to risk end date [RED], as mentioned in the Policy Schedule.
49. Policy Year means the period of 12 months. In case of long-term Policy for more than one year, then each year viz. 1st year, 2nd year, 3rd year etc., shall be treated
as a separate Policy Year.
50. Portability
Portability means the right accorded to an individual health insurance policyholder (including all members under family cover) to transfer the credit gained for
pre-existing conditions and time-bound exclusions from one insurer to another.
51. Pre-Existing Disease

means any condition, ailment or injury or disease
a. That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement
or
b. For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy issued
by the insurer or its reinstatement.

HEALTH GUARD
52. Pre-hospitalization Medical Expenses

Pre-hospitalization Medical Expenses means medical expenses incurred during predefined number of days preceding the hospitalization of the Insured
Person, provided that:
a. Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalization was required, and
b. The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.
53. Post-hospitalization Medical Expenses

Post-hospitalization Medical Expenses means medical expenses incurred during predefined number of days immediately after the Insured Person is discharged
from the hospital provided that:
a. Such Medical Expenses are for the same condition for which the Insured Person’s hospitalization was required, and
b. The inpatient hospitalization claim for such hospitalization is admissible by the Insurance Company.
54. Qualified Nurse

Qualified nurse means a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India.
55. Reasonable and Customary charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the
prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness / injury involved.
56. Room rent

Room Rent means the amount charged by a Hospital towards Room and Boarding expenses and shall include the associated medical expenses.
57. Single Private room

Single Private Room means a single occupancy air-conditioned room with an attached washroom/toilet. Such room must be the most economical of all accommo-
dation available as single occupancy in that hospital and excludes a suite.
58. Renewal
Renewal means the terms on which the contract of insurance can be renewed on mutual consent with a provision of grace period for treating the renewal contin-
uous for the purpose of gaining credit for pre-existing diseases, time-bound exclusions and for all waiting periods.
59. Surgery or Surgical Procedure

Surgery or Surgical Procedure means manual and / or operative procedure (s) required for treatment of an illness or injury, correction of deformities and defects,
diagnosis and cure of diseases, relief from suffering and prolongation of life, performed in a hospital or day care centre by a medical practitioner.
60. Schedule means the schedule and any annexure to it.
61. Unproven/Experimental treatment

Unproven/Experimental treatment means treatment, including drug Experimental therapy, which is not based on established medical practice in India, is treatment
experimental or unproven.
62. You, Your, Yourself, Your Family named in the Policy Schedule means the Insured or Insured’s Family Members who are beneficiaries that We insure as set out in
the Schedule.
63. We, Our, Ours means the Bajaj Allianz General Insurance Company Limited.
SECTION C) EXCLUSIONS UNDER THE POLICY
I. Waiting Period (Applicable for Silver, Gold and Platinum Plan)
1. Pre-existing Diseases waiting period (Excl01)

a) Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 36 months of
continuous coverage after the date of inception of the first Health Guard Policy with us.
b) In case of enhancement of Sum Insured the exclusion shall apply afresh to the extent of Sum Insured increase.
c) If the Insured is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health Insurance) Regulations then
waiting period for the same would be reduced to the extent of prior coverage.
d) Coverage under the Policy after the expiry of 36 months for any pre-existing disease is subject to the same being declared at the time of application and
accepted by Us.
2. Specified disease/procedure waiting period (Excl02)

a) Expenses related to the treatment of the listed Conditions, surgeries/treatments shall be excluded until the expiry of 24 months of continuous coverage after
the date of inception of the first Health Guard Policy with Us. This exclusion shall not be applicable for claims arising due to an accident.
b) In case of enhancement of Sum Insured the exclusion shall apply afresh to the extent of Sum Insured increase.
c) If any of the specified disease/procedure falls under the waiting period specified for Pre-Existing diseases, then the longer of the two waiting periods shall
apply.
d) The waiting period for listed conditions shall apply even if contracted after the Policy or declared and accepted without a specific exclusion.
e) If the Insured is continuously covered without any break as defined under the applicable norms on portability stipulated by IRDAI, then waiting period for the
same would be reduced to the extent of prior coverage.
f) List of specific diseases/procedures is as below

HEALTH GUARD
1. Any type gastrointestinal ulcers 2. Cataracts,

3. Any type of fistula 4. Macular Degeneration
5. Benign prostatic hypertrophy 6. Hernia of all types
7. All types of sinuses 8. Fissure in ano
9. Haemorrhoids, piles 10. Hydrocele
11. Dysfunctional uterine bleeding 12. Fibromyoma
13. Endometriosis 14. Hysterectomy
15. Uterine Prolapse 16. Stones in the urinary and biliary systems
17. Surgery on ears/tonsils/ adenoids/ paranasal sinuses 18. Surgery on all internal or external tumours/cysts/ nodules/polyps of any kind including
breast lumps.
19. Mental Illness 20. Diseases of gall bladder including cholecystitis
21. Pancreatitis 22. All forms of Cirrhosis
23. Gout and rheumatism 24. Tonsilitis
25. Surgery for varicose veins and varicose ulcers 26. Chronic Kidney Disease
27. Alzheimer’s Disease
3. Any Medical Expenses incurred during the first three consecutive annual periods during which You have the benefit of a Health Guard Policy with Us in connec-
tion with:
a) Joint replacement surgery,
b) Surgery for vertebral column disorders (unless necessitated due to an accident)
c) Surgery to correct deviated nasal septum
d) Hypertrophied turbinate
e) Congenital internal diseases or anomalies
f) Treatment for correction of eye sight due to refractive error recommended by Ophthalmologist for medical reasons with refractive error greater or equal to
7.5
g) Bariatric Surgery
h) Parkinson’s Disease
i) Genetic disorders
4. 30-day waiting period (Excl03)

a) Expenses related to the treatment of any illness within 30 days from the first Policy commencement date shall be excluded except claims arising due to an
accident, provided the same are covered.
b) This exclusion shall not, however apply if the Insured has Continuous Coverage for more than twelve months.
c) The within referred waiting period is made applicable to the enhanced Sum Insured in the event of granting higher Sum Insured subsequently.
II. Waiting Period for Maternity Expenses (Applicable only for Gold and Platinum Plan)
1. Any treatment arising from or traceable to pregnancy, child birth including cesarean section and/or any treatment related to pre and postnatal care and complica-
tions arising out of Pregnancy and Childbirth until 72 months continuous period has elapsed since the inception of the first Health Guard Policy with US. However
this exclusion will not apply to Ectopic Pregnancy proved by diagnostic means and certified to be life threatening by the attending medical practitioner..
III. General Exclusions (Applicable for Silver Plan)

1. Maternity ( Excl 18) : Applicable for Silver Plan only :
a. Medical Treatment Expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalization) except
ectopic pregnancy.
b. Expenses towards miscarriage (unless due to an accident) and lawful medical termination of pregnancy during the policy period.
2. Treatment for any other system other than modern medicine (allopathy)
IV. General Exclusions (Applicable for Silver, Gold and Platinum Plan)
1. Any dental treatment that comprises of cosmetic surgery, dentures, dental prosthesis, dental implants, orthodontics, surgery of any kind unless as a result of
Accidental Bodily Injury to natural teeth and also requiring hospitalization.
2. Medical expenses where Inpatient care is not warranted and does not require supervision of qualified nursing staff and qualified medical practitioner round
the clock
3. War, invasion, acts of foreign enemies, hostilities (whether war be declared or not), civil war, commotion, unrest, rebellion, revolution, insurrection, military
or usurped power or confiscation or nationalization or requisition of or damage by or under the order of any government or public local authority.
Any Medical expenses incurred due to Act of Terrorism will be covered under the Policy.
4. Investigation & Evaluation (Excl04)
a) Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded
b) Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.

HEALTH GUARD
5. Rest Cure, rehabilitation and respite care- Code- Excl05

Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:
i. Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing, dressing, moving around either
by skilled nurses or assistant or non-skilled persons.
ii. Any services for people who are terminally ill to address medical, physical, social, emotional and spiritual needs.
6. Obesity/Weight Control (Excl06)

Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:
1) Surgery to be conducted is upon the advice of the Doctor
2) The surgery/Procedure conducted should be supported by clinical protocols
3) The member has to be 18 years of age or older and
4) Body Mass Index (BMI);
a) greater than or equal to 40 or
b) greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive methods of weight loss:
i. Obesity-related cardiomyopathy
ii. Coronary heart disease
iii. Severe Sleep Apnea
iv. Uncontrolled Type2 Diabetes
7. Change-of-gender treatments (Excl07)

Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.
8. Cosmetic or plastic Surgery (Excl08)

Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident, Burn(s) or Cancer or as part of
medically necessary treatment to remove a direct and immediate health risk to the insured. For this to be considered a medical necessity, it must be certified by the
attending Medical Practitioner.
9. The cost of spectacles, contact lenses, hearing aids, crutches, dentures, artificial teeth and all other external appliances and/or devices whether for diagnosis or
treatment except for Cost of Artificial Limbs, cost of prosthetic devices implanted during surgical procedure like Pacemaker, orthopedic implants, infra cardiac
valve replacements, vascular stents etc.
10. Breach of law (Excl10)

Expenses for treatment directly arising from or consequent upon any Insure Person committing or attempting to commit a breach of law with criminal intent.
11. Excluded Providers (Excl11)

Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its web-
site / notified to the policyholders are not admissible. However, in case of life threatening situations or following an accident, expenses up to the stage of stabilization
are payable but not the complete claim.
12. Treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof. (Excl12)
13. Treatments received in heath hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing home attached to such
establishments or where admission is arranged wholly or partly for domestic reasons. (Excl13)
14. Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals and organic substances unless
prescribed by a medical practitioner as part of hospitalization claim or day care procedure. (Excl14)
15. Refractive Error (Excl15)

Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres.
16. Unproven Treatments (Excl16)

Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are treatments, procedures or
supplies that lack significant medical documentation to support their effectiveness.
17. Sterility and Infertility (Excl17)

Expenses related to sterility and infertility. This includes:
a) Any type of contraception, sterilization
b) Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
c) Gestational Surrogacy
d) Reversal of sterilization
18. External medical equipment of any kind used at home as post Hospitalization care including cost of instrument used in the treatment of Sleep Apnoea Syndrome
(C.P.A.P), Continuous Peritoneal Ambulatory Dialysis (C.P.A.D) and Oxygen concentrator for Bronchial Asthmatic condition.
19. Congenital external diseases or defects or anomalies, growth hormone therapy, stem cell implantation or surgery except for Hematopoietic stem cells for bone
marrow transplant for haematological conditions.
20. Intentional self-injury (including but not limited to the use or misuse of any intoxicating drugs or alcohol)
21. Vaccination or inoculation unless forming a part of post bite treatment or if medically necessary and forming a part of treatment recommended by the treating
HEALTH GUARD
Medical practitioner.
22. All non-medical Items as per Annexure II
23. Any treatment received outside India is not covered under this Policy.
24. Circumcision unless required for the treatment of Illness or Accidental bodily injury.
SECTION D- CONDITIONS
1. Disclosure of information
The policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of misrepresentation, mis description or non-disclosure of any
material fact by the policyholder.
2. Conditions Precedent
Where this Policy requires You to do or not to do something, then the complete satisfaction of that requirement by You or someone claiming on Your behalf is a
precondition to any obligation We have under this Policy. If You or someone claiming on Your behalf fails to completely satisfy that requirement, then We may refuse
to consider Your claim.
3. Condition Precedent to Admission of Liability

The terms and conditions of the policy must be fulfilled by the Insured Person for the Company to make any payment for claim(s) arising under the policy
4. Insured
Only those persons named as the insured in the Policy Schedule shall be covered under this Policy. Cover under this Policy shall be withdrawn from any Insured upon
such Insured giving 14 days written notice to be received by Us.
5. Communications
Any communication meant for Us must be in writing and be delivered to Our address shown in the Schedule. Any communication meant for You will be sent by Us
to Your address shown in the Schedule.
6. Premium Payment in Instalments (Wherever applicable)

If the insured person has opted for Payment of Premium on an instalment basis i.e. Annual (for long term polices only), Half Yearly, Quarterly or Monthly, as men-
tioned in the policy Schedule/Certificate of Insurance, the following Conditions shall apply (notwithstanding any terms contrary elsewhere in the policy)
i) Grace Period of 15 days would be given to pay the instalment premium due for the policy.
ii) During such grace period, coverage will not be available from the due date of instalment premium till the date of receipt of premium by Company.
iii) The insured person will get the accrued continuity benefit in respect of the “Waiting Periods”, “Specific Waiting Periods” in the event of payment of premium
within the stipulated grace Period.
iv) No interest will be charged If the instalment premium is not paid on due date.
v) In case of instalment premium due not received within the grace period, the policy will get cancelled.
vi) In the event of a claim, all subsequent premium instalments shall immediately become due and payable.
vii) The company has the right to recover and deduct all the pending installments from the claim amount due under the policy.
7. Moratorium Period:
After completion of eight continuous years under this policy no look back would be applied. This period of eight years is called as moratorium period.
The moratorium would be applicable for the sums insured of the first policy and subsequently completion of eight continuous years would be applicable from date
of enhancement of sums insured only on the enhanced limits. After the expiry of Moratorium Period no claim under this policy shall be contestable except for proven
fraud and permanent exclusions specified in the policy contract. The policies would however be subject to all limits, sub limits, co-payments, deductibles as per the
policy contract.
8. Claim Settlement. (provision for Penal interest)

i. The Company shall settle or reject a claim, as the case may be, within 30 days from the date of receipt of last necessary document.
ii. ln the case of delay in the payment of a claim, the Company shall be liable to pay interest to the policyholder from the date of receipt of last necessary docu-
ment to the date of payment of claim at a rate 2% above the bank rate.
iii. However, where the circumstances of a claim warrant an investigation in the opinion of the Company, it shall initiate and complete such investigation at the
earliest, in any case not later than 30 days from the date of receipt of last necessary document- ln such cases, the Company shall settle or reject the claim
within 45 days from the date of receipt of last necessary document.
iv. ln case of delay beyond stipulated 45 days, the Company shall be liable to pay interest to the policyholder at a rate 2% above the bank rate from the date of
receipt of last necessary document to the date of payment of claim.
9. Claims Procedure
All Claims will be settled by In house claims settlement team of the Company and no TPA is engaged. However the Company reserves to engage TPA at any time, at
the sole discretion of the Company.
If You meet with any Accidental Bodily Injury or suffer an Illness that may result in a claim, then as a condition precedent to Our liability, You must comply with the
following:
A. Cashless Claims Procedure:

Cashless treatment is only available at Network Hospitals. In order to avail of cashless treatment, the following procedure must be followed by You:
i. For planned treatment or Hospitalization, prior to taking treatment and/or incurring Medical Expenses at a Network Hospital, You or Your representa-
tive must intimate Us 48 hours before the planned Hospitalization and request pre-authorisation by way of the written form.
ii. After considering Your request and after obtaining any further information or documentation We have sought, We may, if satisfied, send You or the
HEALTH GUARD
Network Hospital, an authorisation letter. The authorisation letter, the ID card issued to You along with this Policy and any other information or docu-
mentation that We have specified must be produced to the NetworkHospital identified in the pre-authorization letter at the time of Your admission to
the same.
iii. If the procedure above is followed, You will not be required to directly pay for the bill amount in the Network Hospital that We are liable under Section
A1-In-Patient Hospitalization Treatment above and the original bills and evidence of treatment in respect of the same shall be left with the Network
Hospital. Pre-authorisation does not guarantee that all costs and expenses will be covered. We reserve the right to review each claim for Medical Ex-
penses and accordingly coverage will be determined according to the terms and conditions of this Policy.
iv. In case any treatment or procedure is to be taken on an Emergency basis, You or Your representative must intimate Us in writing immediately within
24 hours of hospitalization.
10. Reimbursement Claims Procedure:

If Pre-authorisation as per Cashless Claims Procedure above is denied by Us or if treatment is taken in a Hospital other than a Network Hospital or if You do
not wish to avail cashless facility, then:
i. You or someone claiming on Your behalf must inform Us in writing immediately within 48 hours of hospitalization in case of emergency hospitaliza-
tion and 48 hours prior to hospitalization in case of planned hospitalization
ii. You must immediately consult a Medical practitioner and follow the advice and treatment that he recommends.
iii. You must take reasonable steps or measures to minimize the quantum of any claim that may be made under this Policy.
iv. You must have Yourself examined by Our medical advisors if We ask for this, and as often as We consider this to be necessary at our cost.
v. You or someone claiming on Your behalf must promptly and in any event within 30 days of discharge from a Hospital give Us the documentation as
listed out in greater detail below and other information We ask for to investigate the claim or Our obligation to make payment for it.
vi. In the event of the death of the Insured, someone claiming on his behalf must inform Us in writing immediately and send Us a copy of the post mor-
tem report (if any) within 30 days*
vii. If the original documents are submitted with the co-insurer, the Xerox copies attested by the co-insurer should be submitted
*Note: In case You are claiming for the same event under an indemnity based Policy of another insurer and are required to submit the original documents
related to Your treatment with that particular insurer, then You may provide Us with the attested Xerox copies of such documents along with a declaration
from the particular insurer specifying the availability of the original copies of the specified treatment documents with it.
**Note: Waiver of conditions (i) and (vi) may be considered in extreme cases of hardship where it is proved to Our satisfaction that under the circumstances
in which You were placed, it was not possible for You or any other person to give notice or file claim within the prescribed time limit.
List of Claim documents:

• Claim form with NEFT details & cancelled cheque duly signed by Insured
• Original/Attested copies of Discharge Summary / Discharge Certificate / Death Summary with Surgical & anesthetics notes
• Attested copies of Indoor case papers, if available
• Original/Attested copies Final Hospital Bill with break up of surgical charges, surgeon’s fees, OT charges etc
• Original Paid Receipt against the final Hospital Bill.
• Original bills towards Investigations done / Laboratory Bills.
• Original/Attested copies of Investigation Reports against Investigations done.
• Original bills and receipts paid for the transportation from Registered Ambulance Service Provider. Treating Medical practitioner certificate to transfer the
Injured person to a higher medical centre for further treatment (if Applicable).
• Cashless settlement letter or other company settlement letter
• First consultation letter for the current ailment.
• In case of implant surgery, invoice & sticker.
Please send the documents on below address

Bajaj Allianz General Insurance Company Ltd.
2nd Floor, Bajaj Finserv Building,
Behind Weikfield IT park,
Off Nagar Road, Viman Nagar
Pune 411014| Toll free: 1800-209-5858, 1800-209-0144
11. Paying a Claim

i. You agree that We need only make payment when You or someone claiming on Your behalf has provided Us with necessary documentation and
information.
ii. If the insurer, for any reasons decides to reject the claim under the Policy the reasons regarding the rejection shall be communicated to the Insured in
writing within 30 days of the receipt of documents. The Insured may take recourse to the Grievance Redressal procedure stated under Policy.
12. Basis of Claims Payment

I. If You suffer a relapse within 45 days of the date when You last obtained medical treatment or consulted a Medical practitioner and for which a claim
has been made, then such relapse shall be deemed to be part of the same claim.
II. The day care procedures listed are subject to the exclusions, terms and conditions of the Policy and will not be treated as independent coverage under
the Policy.
III. We shall make payment in Indian Rupees only.
13. Cost Sharing and Sub limits

I. Voluntary co-payment: If opted voluntarily by you, You shall bear 10% / 20% of co-payment for each and every claim payable under the Inpatient Hos-
pitalization Treatment section and Our liability, if any, shall only be in excess of that sum.
II. Cataract Limit : Our obligation to make payment in respect of surgeries for cataracts (after the expiry of the 24 months period referred to in Exclusion
I, 2 ) above, shall be restricted to 20% of the Sum Insured for each eye, subject to maximum of Rs 1,00,000/- for each of You.
III. Bariatric Surgery Limit: Our obligation to make payment in respect of Bariatric Surgery after the expiry of the 36 months period, shall be restricted to
25% of the Sum Insured in Silver Plan and 50% of the Sum Insured subject to maximum of Rs 5 lac in Gold and Platinum Plan.
HEALTH GUARD
IV. Maternity Limit: Maternity is covered under Gold & Platinum plan only
a. For Sum Insured 3 lacs up to 7.5 lacs the limit for Normal delivery is 15000 INR & 25000 INR for caesarian delivery
b. For Sum Insured Above 7.5 lacs the limit for Normal delivery is 25000 INR & 35000 INR for caesarian delivery
V. Mental Illness: (As specified in Annexure 4)
a. For Silver plan the indemnity limit for Mental illness is of 25% of Sum Insured.
b. For Gold and Platinum Plan the indemnity limit for Mental illness is 25% of Sum Insured maximum up to 2 lacs.
VI. Modern Treatment Methods and Advancement in Technologies (as per list in Annexure III) are covered up to 50% of Sum Insured or 5 lacs whichever
is lower, subject to policy terms, conditions, coverages and exclusions
14. Cumulative Bonus for Silver and Gold Plan:

If You renew Your “ Health Guard” with Us without any break and there has been no claim in the preceding year, We will increase the Limit of Indemnity by
10% of base Sum Insured per annum, but:
i. The maximum cumulative increase in the Limit of Indemnity for Silver and Gold will be limited to 10 years and 100% of base Sum Insured of Your first
“Health Guard” with Us.
ii. This clause does not alter the annual character of this insurance
iii. If a claim is made in any year where a cumulative increase has been applied, then the increased Limit of Indemnity in the Policy Period of the subsequent
“Health Guard” shall be reduced by 10%, save that the limit of indemnity applicable to Your first “ Health Guard” with Us shall be preserved.
15. Complete Discharge

Any payment to the policyholder, insured person or his/ her nominees or his/ her legal representative or assignee or to the Hospital, as the case may be, for
any benefit under the policy shall be a valid discharge towards payment of claim by the Company to the extent of that amount for the particular claim
16. Fraud
i) If any claim made by the Insured beneficiary, is in any respect fraudulent, or if any false statement, or declaration is made or used in support thereof,
or if any fraudulent means or devices are used by the Insured beneficiary or anyone acting on his/her behalf to obtain any benefit under this policy, all
benefits under this policy and the premium paid shall be forfeited.
ii) Any amount already paid against claims made under this policy but which are found fraudulent later shall be repaid by all recipient(s)/policyholder(s),
who has made that particular claim, who shall be jointly and severally liable for such repayment to the insurer.
iii) For the purpose of this clause, the expression “fraud” means any of the following acts committed by the Insured beneficiary or by his agent or the hos-
pital/doctor/any other party acting on behalf of the Insured beneficiary, with intent to deceive the insurer or to induce the insurer to issue an insurance
policy:
a) the suggestion, as a fact of that which is not true and which the Insured beneficiary does not believe to be true;
b) the active concealment of a fact by the Insured beneficiary having knowledge or belief of the fact;
c) any other act fitted to deceive; and
d) any such actor omission as the law specially declares to be fraudulent
The Company shall not repudiate the claim and / or forfeit the policy benefits on the ground of Fraud, if the Insured beneficiary / beneficiary can prove
that the misstatement was true to the best of his knowledge and there was no deliberate intention to suppress the fact or that such misstatement of
or suppression of material fact are within the knowledge of the insurer
17. Multiple Policies

i) ln case of multiple policies taken by an insured person during a period from one or more insurers to indemnify treatment costs, the insured person shall
have the right to require a settlement of his/her claim in terms of any of his/her policies. ln all such cases the insurer chosen by the insured person shall
be obliged to settle the claim as long as the claim is within the limits of and according to the terms of the chosen policy.
ii) lnsured person having multiple policies shall also have the right to prefer claims under this policy for the amounts disallowed under any other policy /
policies even if the sum insured is not exhausted. Then the insurer shall independently settle the claim subject to the terms and conditions of this policy.
iii) lf the amount to be claimed exceeds the sum insured under a single policy, the insured person shall have the right to choose insurer from whom he/
she wants to claim the balance amount.
iv) Where an insured person has policies from more than one insurer to cover the same risk on indemnity basis, the insured person shall only be indem-
nified the treatment costs in accordance with the terms and conditions of the chosen policy.
18. Nationality:
• Indian nationals residing in India would be considered for this Policy.
• This Policy can be opted by Non-Resident Indians also and premium paid in Indian currency
19. Renewal of Policy

The policy shall ordinarily be renewable except on misrepresentation by the insured person. grounds of fraud, misrepresentation by the insured person.
i) The Company shall endeavor to give notice for renewal. However, the Company is not under obligation to give any notice for renewal.
ii) Renewal shall not be denied on the ground that the insured person had made a claim or claims in the preceding policy years.
iii) Request for renewal along with requisite premium shall be received by the Company before the end of the policy period.
iv) At the end of the policy period, the policy shall terminate and can be renewed within the Grace Period of 30 days to maintain continuity of benefits
without break in policy. Coverage is not available during the grace period.
v) No loading shall apply on renewals based on individual claims experience
20. Cancellation
i. The policyholder may cancel this policy by giving 15days’written notice and in such an event, the Company shall refund premium for the unexpired
policy period as detailed below.

HEALTH GUARD
Cancellation grid for premium received on annual basis or full premium received at policy inception are as under
Premium Refund
Period in Risk
Policy Period 1 Year Policy Period 2 Year Policy Period 3 Year
Within 15 Days As per Free Look up period Condition
Exceeding 15 days but less than or equal to 3 months 65.00% 75.00% 80.00%
Exceeding 3 months but less than or equal to 6 months 45.00% 65.00% 75.00%
Exceeding 6 months but less than or equal to 12 months 0.00% 45.00% 60.00%
Exceeding 12 months but less than or equal to 15 months 30.00% 50.00%
Exceeding 24 months but less than or equal to 27 months 20.00%
• Cancellation grid for premium received on instalment basis-The premium will be refunded as per the below table:
Period in Risk (From Latest instalment date) % of Monthly Premium % of Quarterly Premium % of Half Yearly Premium
Uptp 15 days from 1st Instalment Date As per Free Look Period Condition
Exceeding 15 days but less than or equal to 3 months 30%
No Refund
Exceeding 3 months but less than or equal to 6 months 0%
Note:
The first slab of Number of days “within 15 days” in above table is applicable only in case of new business.
In case of renewal policies, period is risk “Exceeding 15 days but less than 3 months” should be read as “within 3 months”.
Notwithstanding anything contained herein or otherwise, no refunds of premium shall be made in respect of Cancellation where, any claim has been admitted or
has been lodged or any benefit has been availed by the insured person under the policy.
ii. The Company may cancel the policy at any time on grounds of misrepresentation non-disclosure of material facts, fraud by the insured person by giving 15
days’ written notice. There would be no refund of premium on cancellation on grounds of misrepresentation, non-disclosure of material facts or fraud.
21. Free Look Period

The Free Look Period shall be applicable on new individual health insurance policies and not on renewals or at the time of porting/migrating the policy.
The insured person shall be allowed free look period of fifteen days from date of receipt of the policy document to review the terms and conditions of the policy, and
to return the same if not acceptable.
lf the insured has not made any claim during the Free Look Period, the insured shall be entitled to
i) a refund of the premium paid less any expenses incurred by the Company on medical examination of the insured person and the stamp duty charges or
ii) where the risk has already commenced and the option of return of the policy is exercised by the insured person, a deduction towards the proportionate risk
premium for period of cover or
iii) Where only a part of the insurance coverage has commenced, such proportionate premium commensurate with the insurance coverage during such period
22. Portability
The Insured beneficiary will have the option to port the policy to other insurers by applying to such insurer to port the entire policy along with all the members of
the family, if any, at least 45 days before, but not earlier than 60 days from the policy renewal date as per IRDAI guidelines related to portability. If such person is
presently covered and has been continuously covered without any lapses under any health insurance policy with an Indian General/Health insurer, the proposed
Insured beneficiary will get the accrued continuity benefits in waiting periods as per IRDAI guidelines on portability.
For Detailed Guidelines on portability, kindly refer the link https://www.irdai.gov.in/ADMINCMS/cms/Circulars_List.aspx?mid=3.2.3
23. Endorsements
This Policy constitutes the complete contract of insurance. This Policy cannot be changed by anyone (including an insurance agent or broker) except by the Insurer.
Any change that the Insurer make will be evidenced by a written Endorsement signed and stamped by the Insurer.
24. Possibility of Revision of Terms of the Policy lncluding the Premium Rates:
The Company, with prior approval of lRDAl, may revise or modify the terms of the policy including the premium rates. The insured person shall be notified three
months before the changes are effected.
25. Migration
The Insured beneficiary will have the option to migrate the policy to other health insurance products/plans offered by the company by applying for migration of the
policy atleast 30 days before the policy renewal date as per IRDAI guidelines on Migration. If such person is presently covered and has been continuously covered
without any lapses under any health insurance product/plan offered by the company, the Insured beneficiary will get the accrued continuity benefits in waiting
HEALTH GUARD
periods as per IRDAI guidelines on migration.

For Detailed Guidelines on migration, kindly refer the link https://www.irdai.gov.in/ADMINCMS/cms/Circulars_List.aspx?mid=3.2.3
26. Withdrawal of Policy

i) ln the likelihood of this product being withdrawn in future, the Company will intimate the insured person about the same 90 days prior to expiry of the policy.
ii) lnsured Person will have the option to migrate to similar health insurance product available with the Company at the time of renewal with all the accrued
continuity benefits such as cumulative bonus, waiver of waiting period. as per IRDAI guidelines, provided the policy has been maintained without a break.
27. Discounts:
i. Family Discount: 10% family discount shall be offered if 2 eligible Family Members are covered under a single Policy and 15 % if more than 2 of any of the
eligible Family Members are covered under a single Policy. Moreover, this family discount will be offered for both new policies as well as for renewal policies.
Family discount is not applicable to Health Guard Floater Policies.
ii. Employee Discount: 20% discount on published premium rates to employees of Bajaj Allianz & its group companies, this discount is applicable only if the
Policy is booked in direct code.
iii. Online/Direct Business Discount: Discount of 5% will be offered in this product for policies underwritten through direct/online channel.
Note: this discount is not applicable for Employees who get employee discount
iv. Co-pay Discount:
a. If opted voluntarily and mentioned on the Policy Schedule that a Co-payment is effective by the Insured then Insured will be eligible of additional 10%
or 20% discount on the Policy premium.
b. If a claim has been admitted under Section A 1)In-patient Hospitalization Treatment then, the Insured shall bear 10% or 20% respectively of the eligible
claim amount payable under this section and Our liability, if any, shall only be in excess of that sum and would be subject to the Sum Insured.
v. Long Term Policy Discount:
a. 4 % discount is applicable if Policy is opted for 2 years
b. 8 % discount is applicable if Policy is opted for 3 years
Note: This will not apply to policies where premium is paid in instalments.
vi. Room Rent capping discount:
If You opt for this cover You will be entitled for a per day room rent limit of 1.5% of hospitalization Sum Insured up to maximum Rs. 7,500 per day.
By opting for this cover You will be eligible for discount on premium as per below grid-
Base SI Individual Floater
300,000 and above 10% 5%
Note:
a. The room rent does not include nursing charges.
b. If the availed room category is higher than the eligible room category or if the room rent opted exceeds the eligible room rent then, a proportionate co-payment
would be applied on all the expenses of the hospitalization except for cost of Medical consumables and Medicines.
vii. Wellness Discount
As detailed in Section A. 12, depending on number of parameters met by insured during a policy year discount will be offered on subsequent renewal
premium.
Note- If an Insured meets 8 out of 8 above mentioned parameters and he/she walks for 10000 steps for 20 days every month then they will be eligible for
additional discount of 2.5%.
Parameters Achieved Discount

4 out of 8 5%
6 out of 8 7.5%
8 out of 8 10%
Note- If an Insured meets 8 out of 8 above mentioned parameters and he/she walks for 10000 steps for 20 days every month then they will be eligible for additional
discount of 2.5%.
viii. Zone Discount
a. If You opt for coverage under Zone B, then You will be eligible for 20% discount on the premium
b. If You opt for coverage under Zone C, then You will be eligible for 30% discount on the premium
28. Premium payment Zone:

Zone A
Delhi / NCR, Mumbai including (Navi Mumbai, Thane and Kalyan), Hyderabad and Secunderabad, Kolkata, Ahmedabad, Vadodara and Surat.
Zone B
Rest of India apart, from the states/UTs/cities classified under Zone A and Zone C, are classified as Zone B.
Zone C
Andaman & Nicobar Islands, Arunachal Pradesh, Bihar, Chandigarh, Chattisgarh, Goa, Himachal Pradesh, Jammu & Kashmir, Jharkhand, Manipur, Meghalaya, Mizo-
ram, Nagaland, Odisha, Punjab, Sikkim, Tripura, Uttarakhand
Note:-
• Policyholders paying Zone A premium rates can avail treatment allover India without any co-payment.
• Those, who pay Zone B premium rates and avail treatment in Zone A city will have to pay 15% co-payment on admissible claim amount.
HEALTH GUARD
• Those, who pay Zone C premium rates and avail treatment in Zone A city will have to pay 20% co-payment on admissible claim amount.
• Those, who pay Zone C premium rates and avail treatment in Zone B city will have to pay 5% co-payment on admissible claim amount
• This Co – payment will not be applicable for Accidental Hospitalization cases.
• Policyholder residing in Zone B and Zone C can choose to pay premium for Zone A and avail treatment all over India without any co-payment.
• If opted for coverage under Zone B, then insured will be eligible for 20% discount on the premium.
• If opted for coverage under Zone C, then insured will be eligible for 30% discount on the premium
29. Sum Insured Enhancement:

i. The Insured can apply for enhancement of Sum Insured at the time of renewal. You can apply for enhancement of Sum Insured by submitting a fresh proposal
form to the Company.
ii. The acceptance of enhancement of Sum Insured would be at the discretion of the Company, based on the health condition of the Insured(s) & claim history
of the Policy.
iii. All waiting periods as defined in the Policy shall apply for this enhanced Sum Insured limit from the effective date of enhancement of such Sum Insured
considering such Policy Period as the first Policy with the Company.
30. Inclusion of members under the Policy:

Where an Insured is added to this Policy, either by way of Endorsement or at the time of renewal, the pre-existing disease clause, exclusions and waiting periods will
be applicable considering such Policy Year as the first year of Policy with the Company for the Insured.
31. Territorial Limits & Governing Law

i. We cover medical expenses for treatment availed within India only. Our liability to make any payment shall be to make payment within India and in Indian
Rupees only.
ii. The Policy constitutes the complete contract of insurance. No change or alteration shall be valid or effective unless approved in writing by Us, which approval
shall be evidenced by an Endorsement on the Schedule.
iii. The construction, interpretation and meaning of the provisions of this Policy shall be determined in accordance with Indian law. The section headings of this
Policy are included for descriptive purposes only and do not form part of this Policy for the purpose of its construction or interpretation.
32. Arbitration and Reconciliation

(i) If any dispute or difference shall arise as to the quantum of claim to be paid under this Policy (liability/claim being otherwise admitted by the Insurers), such
difference shall independently of all other question be referred to the decision of a sole arbitrator to be appointed in writing by the Insurer and the Insured
who has made claim under this Policy or if they cannot agree upon a single arbitrator within 30 days of any party [the Insurer or the and the Insured who has
made claim under this Policy] invoking arbitration, the same shall be referred to a panel of three arbitrators, comprising of two arbitrators one to be appointed
by the Insured who has made claim under this Policy and the Insurer, respectively, who are the parties to the dispute/ difference and the third arbitrator to be
appointed by such two appointed arbitrators and arbitration shall be conducted under and in accordance with the provisions of the Arbitration and Concilia-
tion Act, 1996 as amended from time to time. The law of the arbitration will be Indian law.
(ii) It is clearly agreed and understood that no difference or dispute shall be referable to arbitration as herein before provided if the Insurers has disputed or not
accepted/admitted the liability/claim under the Policy.
(iii) It is hereby expressly stipulated and declared that it shall be a condition precedent to any right of action or suit read with this Policy that the award by such
arbitrator/ arbitrators of the amount of the Loss or damage shall be first obtained.
(iv) It is also hereby further expressly agreed and declared that if the Insurers shall disclaim/repudiate the liability to the Insured for any claim under the Policy,
and such claim shall not, within 12 calendar months from the date of such disclaimer/repudiation have been made the subject matter of a suit in a court of
law, then all benefits/indemnities under the Policy shall be forfeited and the rights of Insured shall stand extinguished and the liability of the Insurers shall
also stand discharged.
(v) The seat of the arbitration shall be Pune. This condition remains valid, should the Policy become void.
(vi) In the event that these arbitration provisions shall be held to be invalid then all such disputes or differences shall be referred to the exclusive jurisdiction of
the Indian Courts subject to other Terms and Conditions of this Policy.
33. Nomination
The policyholder is required at the inception of the policy to make a nomination for the purpose of payment of claims under the policy in the event of death of
the policyholder. Any change of nomination shall be communicated to the company in writing and such change shall be effective only when an endorsement on
the policy is made. ln the event of death of the policyholder, the Company will pay the nominee {as named in the Policy Schedule/Policy Certificate/Endorsement
(if any) and in case there is no subsisting nominee, to the legal heirs or legal representatives of the policyholder whose discharge shall be treated as full and final
discharge of its liability under the policy.
34. Grievance Redressal Procedure

Welcome to Bajaj Allianz and Thank You for choosing us as Your insurer.
Please read Your Policy and Policy Schedule.
The Policy and Policy Schedule set out the terms of Your contract with us. Please read Your Policy and Policy Schedule carefully to ensure that the cover meets Your
needs.

We do our best to ensure that our customers are delighted with the service they receive from Bajaj Allianz. If You are dissatisfied we would like to inform You that
we have a procedure for resolving issues. Please include Your Policy number in any communication. This will help us deal with the issue more efficiently. If You don’t
have it, please call our Branch office.

Initially, we suggest You contact the Branch Manager/ Regional Manager of the local office which has issued the Policy. The address and telephone number will be
available in the Policy. Naturally, we hope the issue can be resolved to Your satisfaction at the earlier stage itself. But if You feel dissatisfied with the suggested reso-
lution of the issue after contacting the local office, please e-mail or write to:
Bajaj Allianz General Insurance Co. Ltd

Bajaj Allianz House, Airport Road
Yerawada, Pune 411006
HEALTH GUARD
E-mail: [email protected]
Call : 1800-225858 (free calls from BSNL/MTNL lines only)
1800-1025858 ( free calls from Bharti users – mobile /landline ) or020-30305858
Grievance Redressal Cell for Senior Citizens

Senior Citizen Cellfor Insured who are Senior Citizens
‘Good things come with time’ and so for our customers who are above 60 years of age we have created special cell to address any health insurance related query.
Our senior citizen customers can reach us through the below dedicated channels to enable us to service them promptly
Health toll free number: 1800-103-2529
Exclusive Email address: [email protected]
If You are still not satisfied, You can approach the Insurance Ombudsman in the respective area for resolving the issue. The contact details of the Ombudsman offices
are mentioned below:

Office Details Jurisdiction of Office Union Territory,District)
AHMEDABAD
Office of the Insurance Ombudsman, Jeevan Prakash Building, 6th floor,
Tilak Marg, Relief Road, Ahmedabad – 380 001. Gujarat, Dadra & Nagar Haveli, Daman and Diu.
Tel.: 079 - 25501201/02/05/06
Email: [email protected]
BENGALURU
Office of the Insurance Ombudsman, Jeevan Soudha Building,PID No. 57-27-N-
19 Ground Floor, 19/19, 24th Main Road, JP Nagar, Ist Phase,
Karnataka
Bengaluru – 560 078.
Tel.: 080 - 26652048 / 26652049
BHOPAL
Office of the Insurance Ombudsman, Janak Vihar Complex, 2nd Floor, 6, Malvi-
ya Nagar, Opp. Airtel Office, Near New Market, Bhopal – 462 003. Madhya Pradesh
Tel.: 0755 - 2769201 / 2769202 Chattisgarh
Fax: 0755 - 2769203
BHUBANESHWAR
Office of the Insurance Ombudsman, 62, Forest park,
Bhubneshwar – 751 009. Orissa
Tel.: 0674 - 2596461 /2596455
Fax: 0674 - 2596429
CHANDIGARH
Dr. Dinesh Kumar Verma
Office of the Insurance Ombudsman, S.C.O. No. 101, 102 & 103, 2nd Floor,
Batra Building, Sector 17 – D, Chandigarh – 160 017. Punjab, Haryana, Himachal Pradesh, Jammu & Kashmir, Chandigarh
Tel.: 0172 - 2706196 / 2706468
Fax: 0172 - 2708274
CHENNAI
Office of the Insurance Ombudsman, Fatima Akhtar Court, 4th Floor, 453, Anna
Tamil Nadu,
Salai, Teynampet,
Pondicherry Town and
CHENNAI – 600 018.
Karaikal (which are part of Pondicherry).
Tel.: 044 - 24333668 / 24335284
Fax: 044 - 24333664
DELHI
Office of the Insurance Ombudsman, 2/2 A, Universal Insurance Building, Asaf
Ali Road, New Delhi – 110 002. Delhi.
Tel.: 011 - 23232481/23213504
GUWAHATI
Office of the Insurance Ombudsman, Jeevan Nivesh, 5th Floor,
Nr. Panbazar over bridge, S.S. Road, Guwahati – 781001(ASSAM). Assam, Meghalaya, Manipur, Mizoram, Arunachal Pradesh, Nagaland and
Tel.: 0361 - 2632204 / 2602205 Tripura

HEALTH GUARD
HYDERABAD
Office of the Insurance Ombudsman, 6-2-46, 1st floor, “Moin Court”, Lane Opp.
Andhra Pradesh,
Saleem Function Palace, A. C. Guards, Lakdi-Ka-Pool, Hyderabad - 500 004.
Telangana,
Tel.: 040 - 67504123 / 23312122
Yanam and
Fax: 040 - 23376599
part of Territory of Pondicherry.
JAIPUR
Office of the Insurance Ombudsman, Jeevan Nidhi – II Bldg., Gr. Floor, Bhawani
Singh Marg, Jaipur - 302 005. Rajasthan.
Tel.: 0141 - 2740363
ERNAKULAM
Office of the Insurance Ombudsman, 2nd Floor, Pulinat Bldg., Opp. Cochin Kerala,
Shipyard, M. G. Road, Ernakulam - 682 015. Lakshadweep,
Tel.: 0484 - 2358759 / 2359338 Mahe-a part of Pondicherry.
Fax: 0484 - 2359336
KOLKATA -
Office of the Insurance Ombudsman, Hindustan Bldg. Annexe, 4th Floor, West Bengal,
4, C.R. Avenue, KOLKATA - 700 072. Sikkim,
Tel.: 033 - 22124339 / 22124340 Andaman & Nicobar Islands.
Fax : 033 - 22124341
LUCKNOW
Office of the Insurance Ombudsman, 6th Floor, Jeevan Bhawan, Phase-II, Nawal Districts of Uttar Pradesh :
Kishore Road, Hazratganj, Lucknow - 226 001. Laitpur, Jhansi, Mahoba, Hamirpur, Banda, Chitrakoot, Allahabad, Mirzapur,
Tel.: 0522 - 2231330 / 2231331 Sonbhabdra,Fatehpur, Pratapgarh, Jaunpur,Varanasi, Gazipur, Jalaun, Kanpur,
Fax: 0522 - 2231310 Lucknow, Unnao,Sitapur, Lakhimpur, Bahraich, Barabanki, Raebareli, Sravasti,
Email: [email protected] Gonda, Faizabad, Amethi,Kaushambi, Balrampur, Basti, Ambedkarnagar,
Sultanpur, Maharajgang, Santkabirnagar,Azamgarh, Kushinagar, Gorkhpur,
Deoria, Mau, Ghazipur, Chandauli, Ballia, Sidharathnagar
MUMBAI
Office of the Insurance Ombudsman, 3rd Floor, Jeevan Seva Annexe, S. V. Road,
Goa,
Santacruz (W), Mumbai - 400 054.
Mumbai Metropolitan Region
Tel.: 022 - 26106552 / 26106960
excluding Navi Mumbai & Thane
Fax: 022 - 26106052
NOIDA State of Uttaranchal and the following Districts of Uttar Pradesh:

Office of the Insurance Ombudsman, Bhagwan Sahai Palace 4th Floor, Main Agra, Aligarh, Bagpat, Bareilly, Bijnor, Budaun, Bulandshehar, Etah, Kanooj,
Road, Naya Bans, Sector 15, Distt: Gautam Buddh Nagar, U.P-201301. Mainpuri, Mathura, Meerut, Moradabad, Muzaffarnagar, Oraiyya, Pilibhit,
Tel.: 0120-2514250 / 2514252 / 2514253 Etawah, Farrukhabad, Firozbad, Gautambodhanagar, Ghaziabad, Hardoi,
Email: [email protected] Shahjahanpur, Hapur, Shamli, Rampur, Kashganj, Sambhal, Amroha, Hathras,
Kanshiramnagar, Saharanpur.
PATNA
Office of the Insurance Ombudsman, 1st Floor,Kalpana Arcade Building, Bazar Bihar,
Samiti Road, Bahadurpur, Patna 800 006. Jharkhand
Tel.: 0612-2680952
PUNE
Office of the Insurance Ombudsman, Jeevan Darshan Bldg., 3rd Floor, C.T.S. Maharashtra,
No.s. 195 to 198, N.C. Kelkar Road, Narayan Peth, Pune – 411 030. Area of Navi Mumbai and Thane
Tel.: 020-41312555 excluding Mumbai Metropolitan Region
Note: Address and contact number of Governing Body of Insurance Council

Secretary General - Governing Body of Insurance Council
JeevanSevaAnnexe, 3rd Floor, S.V. Road, Santacruz (W), Mumbai - 400 054
Tel No: 022-2610 6889, 26106245, Fax No. : 022-26106949, 2610 6052, E-mail ID: [email protected]
Cashless facility offered through network hospitals of Bajaj Allianz only.Cashless facility at 3300+ Network hospitals PAN India. Please visit our website for list of
network hospitals and network Diagnostic Centres , Website: www.bajajallianz.com or get in touch with 24*7 helpline number: 1800-103-2529 (toll free) / 020-
30305858
HEALTH GUARD
Annexure I
ENT General Surgery
1 Stapedotomy 204 Infected Keloid Excision
2 Myringoplasty(Type I Tympanoplasty) 205 Incision of a pilonidal sinus / abscess
3 Revision stapedectomy 206 Axillary lymphadenectomy
4 Labyrinthectomy for severe Vertigo 207 Wound debridement and Cover
5 Stapedectomy under GA 208 Abscess-Decompression
6 Ossiculoplasty 209 Cervical lymphadenectomy
7 Myringotomy with Grommet Insertion 210 infected sebaceous cyst
8 Tympanoplasty (Type III) 211 Inguinal lymphadenectomy
9 Stapedectomy under LA 212 Incision and drainage of Abscess
10 Revision of the fenestration of the inner ear. 213 Suturing of lacerations
11 Tympanoplasty (Type IV) 214 Scalp Suturing
12 Endolymphatic Sac Surgery for Meniere’s Disease 215 Infected lipoma excision
13 Turbinectomy 216 Maximal anal dilatation
14 Removal of Tympanic Drain under LA 217 Piles
15 Endoscopic Stapedectomy A)Injection Sclerotherapy
16 Fenestration of the inner ear B)Piles banding
17 Incision and drainage of perichondritis 218 Liver Abscess- catheter drainage
18 Septoplasty 219 Fissure in Ano- fissurectomy
19 Vestibular Nerve section 220 Fibroadenoma breast excision
20 Thyroplasty Type I 221 OesophagealvaricesSclerotherapy
21 Pseudocyst of the Pinna - Excision 222 ERCP - pancreatic duct stone removal
22 Incision and drainage - Haematoma Auricle 223 Perianal abscess I&D
23 Tympanoplasty (Type II) 224 Perianal hematoma Evacuation
24 Keratosis removal under GA 225 Fissure in anosphincterotomy
25 Reduction of fracture of Nasal Bone 226 UGI scopy and Polypectomyoesophagus
26 Excision and destruction of lingual tonsils 227 Breast abscess I& D
27 Conchoplasty 228 Feeding Gastrostomy
28 Thyroplasty Type II 229 Oesophagoscopy and biopsy of growth oesophagus
29 Tracheostomy 230 UGI scopy and injection of adrenaline, sclerosants - bleeding ulcers
30 Excision of Angioma Septum 231 ERCP - Bile duct stone removal
31 Turbinoplasty 232 Ileostomy closure
32 Incision & Drainage of Retro Pharyngeal Abscess 233 Colonoscopy
33 UvuloPalatoPharyngoPlasty 234 Polypectomy colon
34 Palatoplasty 235 Splenic abscesses Laparoscopic Drainage
35 Tonsillectomy without adenoidectomy 236 UGI SCOPY and Polypectomy stomach
36 Adenoidectomy with Grommet insertion 237 Rigid Oesophagoscopy for FB removal
37 Adenoidectomy without Grommet insertion 238 Feeding Jejunostomy
38 Vocal Cord lateralisation Procedure 239 Colostomy
39 Incision & Drainage of Para Pharyngeal Abscess 240 Ileostomy
40 Transoral incision and drainage of a pharyngeal abscess 241 colostomy closure
41 Tonsillectomy with adenoidectomy 242 Submandibular salivary duct stone removal
42 Tracheoplasty Ophthalmology 243 Pneumatic reduction of intussusception
43 Incision of tear glands 244 Varicose veins legs - Injection sclerotherapy
44 Other operation on the tear ducts 245 Rigid Oesophagoscopy for Plummer vinson syndrome
45 Incision of diseased eyelids 246 Pancreatic Pseudocysts Endoscopic Drainage

HEALTH GUARD
46 Excision and destruction of the diseased tissue of the eyelid 247 ZADEK’s Nail bed excision
47 Removal of foreign body from the lens of the eye. 248 Subcutaneous mastectomy
48 Corrective surgery of the entropion and ectropion 249 Excision of Ranula under GA
49 Operations for pterygium 250 Rigid Oesophagoscopy for dilation of benign Strictures
50 Corrective surgery of blepharoptosis 251 Eversion of Sac
51 Removal of foreign body from conjunctiva a) Unilateral
52 Biopsy of tear gland b)Bilateral
53 Removal of Foreign body from cornea 252 Lord’s plication
54 Incision of the cornea 253 Jaboulay’s Procedure
55 Other operations on the cornea 254 Scrotoplasty
56 Operation on the canthus and epicanthus 255 Surgical treatment of varicocele
57 Removal of foreign body from the orbit and the eye ball. 256 Epididymectomy
58 Surgery for cataract 257 Circumcision for Trauma
59 Treatment of retinal lesion 258 Meatoplasty
60 Removal of foreign body from the posterior chamber of the eye 259 Intersphincteric abscess incision and drainage
Oncology 260 Psoas Abscess Incision and Drainage
61 IV Push Chemotherapy 261 Thyroid abscess Incision and Drainage
62 HBI-Hemibody Radiotherapy 262 TIPS procedure for portal hypertension
63 Infusional Targeted therapy 263 Esophageal Growth stent
64 SRT-Stereotactic Arc Therapy 264 PAIR Procedure of Hydatid Cyst liver
65 SC administration of Growth Factors 265 Tru cut liver biopsy
66 Continuous Infusional Chemotherapy 266 Photodynamic therapy or esophageal tumour and Lung tumour
67 Infusional Chemotherapy 267 Excision of Cervical RIB
68 CCRT-Concurrent Chemo + RT 268 laparoscopic reduction of intussusception
69 2D Radiotherapy 269 Microdochectomy breast
70 3D Conformal Radiotherapy 270 Surgery for fracture Penis
71 IGRT- Image Guided Radiotherapy 271 Sentinel node biopsy
72 IMRT- Step & Shoot 272 Parastomal hernia
73 Infusional Bisphosphonates 273 Revision colostomy
74 IMRT- DMLC 274 Prolapsed colostomy- Correction
75 Rotational Arc Therapy 275 Testicular biopsy
76 Tele gamma therapy 276 laparoscopic cardiomyotomy( Hellers)
77 FSRT-Fractionated SRT 277 Sentinel node biopsy malignant melanoma
78 VMAT-Volumetric Modulated Arc Therapy 278 laparoscopic pyloromyotomy( Ramstedt)
79 SBRT-Stereotactic Body Radiotherapy Orthopedics
80 Helical Tomotherapy 279 Arthroscopic Repair of ACL tear knee
81 SRS-Stereotactic Radiosurgery 280 Closed reduction of minor Fractures
82 X-Knife SRS 281 Arthroscopic repair of PCL tear knee
83 Gammaknife SRS 282 Tendon shortening
84 TBI- Total Body Radiotherapy 283 Arthroscopic Meniscectomy - Knee
85 intraluminal Brachytherapy 284 Treatment of clavicle dislocation
86 Electron Therapy 285 Arthroscopic meniscus repair
87 TSET-Total Electron Skin Therapy 286 Haemarthrosis knee- lavage
88 Extracorporeal Irradiation of Blood Products 287 Abscess knee joint drainage
89 Telecobalt Therapy 288 Carpal tunnel release
90 Telecesium Therapy 289 Closed reduction of minor dislocation
91 External mould Brachytherapy 290 Repair of knee cap tendon
92 Interstitial Brachytherapy 291 ORIF with K wire fixation- small bones

HEALTH GUARD
93 Intracavity Brachytherapy 292 Release of midfoot joint

94 3D Brachytherapy 293 ORIF with plating- Small long bones
95 Implant Brachytherapy 294 Implant removal minor
96 Intravesical Brachytherapy 295 K wire removal
97 Adjuvant Radiotherapy 296 POP application
98 Afterloading Catheter Brachytherapy 297 Closed reduction and external fixation
99 Conditioning Radiothearpy for BMT 298 Arthrotomy Hip joint
100 Extracorporeal Irradiation to the Homologous Bone grafts 299 Syme’s amputation
101 Radical chemotherapy 300 Arthroplasty
102 Neoadjuvant radiotherapy 301 Partial removal of rib
103 LDR Brachytherapy 302 Treatment of sesamoid bone fracture
104 Palliative Radiotherapy 303 Shoulder arthroscopy / surgery
105 Radical Radiotherapy 304 Elbow arthroscopy
106 Palliative chemotherapy 305 Amputation of metacarpal bone
107 Template Brachytherapy 306 Release of thumb contracture
108 Neoadjuvant chemotherapy 307 Incision of foot fascia
109 Adjuvant chemotherapy 308 calcaneum spur hydrocort injection
110 Induction chemotherapy 309 Ganglion wrist hyalase injection
111 Consolidation chemotherapy 310 Partial removal of metatarsal
112 Maintenance chemotherapy 311 Repair / graft of foot tendon
113 HDR Brachytherapy 312 Revision/Removal of Knee cap
Plastic Surgery 313 Amputation follow-up surgery
114 Construction skin pedicle flap 314 Exploration of ankle joint
115 Gluteal pressure ulcer-Excision 315 Remove/graft leg bone lesion
116 Muscle-skin graft, leg 316 Repair/graft achilles tendon
117 Removal of bone for graft 317 Remove of tissue expander
118 Muscle-skin graft duct fistula 318 Biopsy elbow joint lining
119 Removal cartilage graft 319 Removal of wrist prosthesis
120 Myocutaneous flap 320 Biopsy finger joint lining
121 Fibro myocutaneous flap 321 Tendon lengthening
122 Breast reconstruction surgery after mastectomy 322 Treatment of shoulder dislocation
123 Sling operation for facial palsy 323 Lengthening of hand tendon
124 Split Skin Grafting under RA 324 Removal of elbow bursa
125 Wolfe skin graft 325 Fixation of knee joint
126 Plastic surgery to the floor of the mouth under GA 326 Treatment of foot dislocation
Urology 327 Surgery of bunion
127 AV fistula - wrist 328 intra articular steroid injection
128 URSL with stenting 329 Tendon transfer procedure
129 URSL with lithotripsy 330 Removal of knee cap bursa
130 CystoscopicLitholapaxy 331 Treatment of fracture of ulna
131 ESWL 332 Treatment of scapula fracture
132 Haemodialysis 333 Removal of tumor of arm/ elbow under RA/GA
133 Bladder Neck Incision 334 Repair of ruptured tendon
134 Cystoscopy & Biopsy 335 Decompress forearm space
135 Cystoscopy and removal of polyp 336 Revision of neck muscle ( Torticollis release )
136 Suprapubiccystostomy 337 Lengthening of thigh tendons
137 percutaneous nephrostomy 338 Treatment fracture of radius & ulna
139 Cystoscopy and “SLING” procedure. 339 Repair of knee joint Paediatric surgery

HEALTH GUARD
140 TUNA- prostate 340 Excision Juvenile polyps rectum
141 Excision of urethral diverticulum 341 Vaginoplasty
142 Removal of urethral Stone 342 Dilatation of accidental caustic stricture oesophageal
143 Excision of urethral prolapse 343 PresacralTeratomas Excision
144 Mega-ureter reconstruction 344 Removal of vesical stone
145 Kidney renoscopy and biopsy 345 Excision Sigmoid Polyp
146 Ureter endoscopy and treatment 346 SternomastoidTenotomy
147 Vesico ureteric reflux correction 347 Infantile Hypertrophic Pyloric Stenosis pyloromyotomy
148 Surgery for pelvi ureteric junction obstruction 348 Excision of soft tissue rhabdomyosarcoma
149 Anderson hynes operation 349 Mediastinal lymph node biopsy
150 Kidney endoscopy and biopsy 350 High Orchidectomy for testis tumours
151 Paraphimosis surgery 351 Excision of cervical teratoma
152 injury prepuce- circumcision 352 Rectal-Myomectomy
153 Frenular tear repair 353 Rectal prolapse (Delorme’s procedure)
154 Meatotomy for meatal stenosis 354 Orchidopexy for undescended testis
155 surgery for fournier’s gangrene scrotum 355 Detorsion of torsion Testis
156 surgery filarial scrotum 356 lap.Abdominal exploration in cryptorchidism
157 surgery for watering can perineum 357 EUA + biopsy multiple fistula in ano
158 Repair of penile torsion 358 Cystic hygroma - Injection treatment
159 Drainage of prostate abscess 359 Excision of fistula-in-ano
160 Orchiectomy Gynaecology
161 Cystoscopy and removal of FB 360 Hysteroscopic removal of myoma
Neurology 361 D&C
162 Facial nerve physiotherapy 362 Hysteroscopic resection of septum
163 Nerve biopsy 363 thermal Cauterisation of Cervix
164 Muscle biopsy 364 MIRENA insertion
165 Epidural steroid injection 365 Hysteroscopicadhesiolysis
166 Glycerol rhizotomy 366 LEEP
167 Spinal cord stimulation 367 Cryocauterisation of Cervix
168 Motor cortex stimulation 368 Polypectomy Endometrium
169 Stereotactic Radiosurgery 369 Hysteroscopic resection of fibroid
170 Percutaneous Cordotomy 370 LLETZ
171 Intrathecal Baclofen therapy 371 Conization
172 Entrapment neuropathy Release 372 polypectomy cervix
173 Diagnostic cerebral angiography 373 Hysteroscopic resection of endometrial polyp
174 VP shunt 374 Vulval wart excision
175 Ventriculoatrial shunt 375 Laparoscopic paraovarian cyst excision
Thoracic surgery 376 uterine artery embolization
176 Thoracoscopy and Lung Biopsy 377 Bartholin Cyst excision
177 Excision of cervical sympathetic Chain Thoracoscopic 378 Laparoscopic cystectomy
178 Laser Ablation of Barrett’s oesophagus 379 Hymenectomy( imperforate Hymen)
179 Pleurodesis 380 Endometrial ablation
180 Thoracoscopy and pleural biopsy 381 vaginal wall cyst excision
181 EBUS + Biopsy 382 Vulval cyst Excision
182 Thoracoscopy ligation thoracic duct 383 Laparoscopic paratubal cyst excision
183 Thoracoscopy assisted empyaema drainage 384 Repair of vagina ( vaginal atresia )
Gastroenterology 385 Hysteroscopy, removal of myoma
184 Pancreatic pseudocyst EUS & drainage 386 TURBT

HEALTH GUARD
185 RF ablation for barrett’sOesophagus 387 Ureterocoele repair - congenital internal

186 ERCP and papillotomy 388 Vaginal mesh For POP
187 Esophagoscope and sclerosant injection 389 Laparoscopic Myomectomy
188 EUS + submucosal resection 390 Surgery for SUI
189 Construction of gastrostomy tube 391 Repair recto- vagina fistula
190 EUS + aspiration pancreatic cyst 392 Pelvic floor repair( excluding Fistula repair)
191 Small bowel endoscopy (therapeutic) 393 URS + LL
192 Colonoscopy ,lesion removal 394 Laparoscopic oophorectomy
193 ERCP Critical care
194 Colonscopy stenting of stricture 395 Insert non- tunnel CV cath
195 Percutaneous Endoscopic Gastrostomy 396 Insert PICC cath ( peripherally inserted central catheter )
196 EUS and pancreatic pseudo cyst drainage 397 Replace PICC cath ( peripherally inserted central catheter )
197 ERCP and choledochoscopy 398 Insertion catheter, intra anterior
198 Proctosigmoidoscopy volvulus detorsion 399 Insertion of Portacath
199 ERCP and sphincterotomy
200 Esophageal stent placement
201 ERCP + placement of biliary stents
202 Sigmoidoscopy w / stent
203 EUS + coeliac node biopsy
(i) The standard exclusions and waiting periods are applicable to all of the above procedures depending on the medical condition/disease under treatment. Only 24
hours hospitalization is not mandatory.
Annexure II:-
List I:
List of Non-Medical Items
SL
Item
No
1 BABY FOOD Not Payable
2 BABY UTILITIES CHARGES Not Payable
3 BEAUTY SERV ICES Not Payable
4 BELTS/ BRACES Not Payable
5 BUDS Not Payable
6 COLD PACK/HOT PACK Not Payable
7 CARRY BAGS Not Payable
8 EMAIL I INTERNET CHARGES Not Payable
9 FOOD CHARGES (OTHER THAN PATIENT’s DIET PROVIDED BY HOSPITA Not Payable
L)
10 LEGGINGS Essential in bariatric and varicose vein surgery and should be considered for these
conditions where surgery itself is payable.
11 LAUNDRY CHARGES Not Payable
12 MINERAL WATER Not Payable
13 SANITARY PAD Not Payable
14 TELEPHONE CHARGES Not Payable
15 GUEST SERVICES Not Payable
16 CREPE BANDAGE Not Payable
17 DIAPER OF ANY TYPE Not Payable
18 EYELET COLLAR Not Payable
HEALTH GUARD
19 SLINGS Not Payable

20 BLOOD GROUPING AND CROSS MATCHING OF DONORS SAMPLES Not Payable
21 SERVICE CHARGES WHERE NURSING CHARGES ALSO CHARGED Not Payable
22 Television Charges Not Payable
23 SURCHA RGES Not Payable
24 ATTENDANT CHARGES Not Payable
25 EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH FORMS PART OF Not Payable
BED CHARGE)
26 BIRTH CERTIFICATE Not Payable
27 CERTIFICATE CHARGES Not Payable
28 COURIER CHARGES Not Payable
29 CONVEYANCE CHARGES Not Payable
30 MEDICAL CERTIFICATE Not Payable
31 MEDICAL RECORDS Not Payable
32 PHOTOCOPIES CHARGES Not Payable
33 MORTUARY CHARGES Not Payable
34 WALKING AIDS CHARGES Not Payable
35 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE HOSPITAL) Not Payable
36 SPACER Not Payable
37 SPIROMETRE Not Payable
38 NEBULIZER KIT Not Payable
39 STEAM INHALER Not Payable
40 ARMSLING Not Payable
41 THERMOMETER Not Payable
42 CERVICAL COLLAR Not Payable
43 SPLINT Not Payable
44 DIABETIC FOOT WEAR Not Payable
45 KNEE BRACES (LONG/ SHORT/ HINGED) Not Payable
46 KNEE IMMOBILIZER/S HOULDER IMMOBILIZER Not Payable
47 LUMBOSACRAL BELT Not Payable
48 NIMBUS BED OR WATER OR AIR BED CHARGES Not Payable
49 AMBULANCE COLLAR Not Payable
50 AMBULANCE EQUIPMENT Not Payable
51 ABDOMINAL BINDER Not Payable
52 PRIVATE NURSES CHARGES - SPECIAL NURSING CHARGES Not Payable
53 SUGAR FREE Tablets Not Payable
54 CREAMS POWDERS LOTIONS (Toiletries are not payable, only prescribed Not Payable
medical pharmaceuticals payable)
55 ECG ELECTRODES Not Payable
56 GLOVES Not Payable
57 NEBULISATION KIT Not Payable
58 ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT, ORTHOKIT , RE- Not Payable
COVERY KIT, ETC]
59 KIDNEY TRAY Not Payable
60 MASK Not Payable
61 OUNCE GLASS Not Payable
62 OXYGEN MASK Not Payable
63 PELVIC TRACTION BELT Not Payable

HEALTH GUARD
64 PAN CAN Not Payable

65 TROLLY COVER Not Payable
66 UROMETER , URINE JUG Not Payable
68 VASOFIX SAFETY Not Payable
List ll -
ltems that are to be subsumed into Room Charges
S. No. Item
1 BABY CHARGES (UNLESS SPECIFIED /INDICATED)
2 HAND WASH
3 SHOE COVER
4 CAPS
5 CARDLE CHARGES
6 COMB
7 EAU-DE-COLOGNE/ROOM FRESHNERS
8 FOOT COVER
9 GOWN
10 SLIPPERS
11 TISSUE PAPPER
12 TOOTH PASTE
13 TOOTH BRUSH
14 BED PAN
15 FACE MASK
16 FLEXI MASK
17 HAND HOLDER
18 SPUTUM CUP
19 DISINEFCTANT LOTIONS
20 LUXURY TAX
21 HVAC
22 HOUSE KEEPING CHARGES
23 AIR CONDITIONER CHARGES
24 IM IV INJECTION CHARGES
25 CLEAN SHEET
26 BLANKET/WARMER BLANKET
27 ADMISSION KIT
28 DIABETIC CHART CHARGES
29 DOCUMENTATION CHARGES/ADMINISTRATIVE EXPENSES
30 DISCHARGE PROCEDURE CHARGES
31 DAILY CHART CHARGES
32 ENTRANCE PASS / VISITORS PASS CHARGES
33 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE
34 FILE OPENING CHARGES
35 INCTDENTAL EXPENSES / MtSC. CHARGES (NOT EXPLATNED)
36 PATIENT IDENTIFICATION BAND / NAME TAG
37 PULSEOXYMETER CHARGES

HEALTH GUARD
List lll-
ltems that are to be subsumed into Procedure Charges
S. No. Item
1 HAIR REMOVAL CREAM
2 DISPOSABLES RAZORS CHARGES(for site preparations)
3 EYE PAD
4 EYE SHEILD
5 CAMERA COVER
6 DVD ,CD CHARGES
7 GAUSE SOFT
8 GAUZE
9 WARD AND THEATRE BOOKING CHARGES
10 ARTHROSCOPE AND ENDOSCOPY INSTRUMENTS
11 MICROSCOPE COVER
12 SURGICAL BLADES,HARMONICSCALPEL,SHAVER
13 SURGICAL DRILL
14 EYE KIT
15 EYE DRAPE
16 X-RAY FILM
17 BOYLES APPARATUS CHARGES
18 COTTON
19 COTTON BANDAGE
20 SURGICAL TAPE
21 APRON
22 TORNIQUET
23 ORTHOBUNDLE, GYNAEC BUNDLE
List lV -
ltems that are to be subsumed into costs of treatment
S. No. Item
1 ADMISSION/REGISTRATION CHARGES
2 HOSPITALIZATION FOR EVALUATION/DIAGNOSTIC PURPOSE
3 URINE CONTAINER
4 BLOOD RESERVATION CHARGES AND ANTE NATAL BOOKING CHARGES
5 BIPAP MACHINE
6 CPAP/CAPD EQUIPMENTS
7 INFUSION PUMP-COST
8 HYDROGEN PERPOXIDE\SPIRIT\DISINFECTION ETC
9 NUTTRITION PLANNING CHARGES - DIETICIAN CHARGES - DIET CHARGES
10 HIV KIT
11 ANTISEPTIC MOUTHWASH
12 LOZENGES
13 MOUTH PAINT
14 VACCINATION CHARGES
15 ALCOHOL SWABES
16 SCRUB SOLUTION / STERILLIUM
17 GLUCOMETER & STRIPS
18 URINE BAG

HEALTH GUARD
Annexure III:
Modern Treatment Methods and Advancement in Technologies
A. Uterine Artery Embolization and HIFU
B. Balloon Sinuplasty
C. Deep Brain stimulation
D. Oral chemotherapy
E. Immunotherapy- Monoclonal Antibody to be given as injection
F. Intra vitreal injections
G. Robotic surgeries
H. Stereotactic radio surgeries
I. Bronchical Thermoplasty
J. Vaporisation of the prostrate (Green laser treatment or holmium laser treatment)
K. IONM -(Intra Operative Neuro Monitoring)
L. Stem cell therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered
Annexure IV:
ICD specific for Mental Illness
ICD Codes ICD Description
F00 Dementia in Alzheimer disease
F02 Dementia in other diseases classified elsewhere
F03 Unspecified dementia
F05 Delirium, not induced by alcohol and other psychoactive substances
F07 Personality and behavioural disorders due to brain disease, damage and dysfunction
F09 Unspecified organic or symptomatic mental disorder
F20 Schizophrenia
F21 Schizotypal disorder
F22 Persistent delusional disorders
F23 Acute and transient psychotic disorders
F24 Induced delusional disorder
F25 Schizoaffective disorders
F31 Bipolar affective disorder
F32 Depressive episode
F33 Recurrent depressive disorder
F40 Phobic anxiety disorders

Bajaj Allianz House, Airport Road, Yerawada, Pune - 411 006. Reg. No.: 113
For more details, log on to : www.bajajallianz.com | E-mail: [email protected] or
call at : Sales - 1800 209 0144 / Service - 1800 209 5858 (Toll Free No.)
Issuing Office :
WAIVER OF ROOM CAPPING
Optional Cover Under “Health Guard”
Whereas the Insured has made to Bajaj Allianz General Insurance Company Ltd. (hereinafter called the Company), a proposal which is hereby agreed to
be the basis of this Optional Cover and the Insured has paid the additional premium for these Optional Cover as specified in the respective Policy Sched-
ule, now the Company agrees, subject always to the following terms, conditions, exclusions, and limitations, to indemnify the Insured subject always to
the Sum Insured specified in the Policy Schedule, against such expenses, incurred by Insured within the Policy Period.
Who can opt for the Optional Cover?

Insured who opted for the Company’s “Health Guard” Policy can only buy below Optional Cover.
PART A: OPERATIVE PARTS
Waiver of Room Capping:

In consideration of payment of additional premium by the Proposer to the Company and realization thereof by the Company, it is hereby agreed to
waive off the room type restriction “up to Single Private Air Conditioned room” as stated under the “Health Guard-Gold” plan and “Health Guard-Plat-
inum” Plan.
If this Optional Cover is opted at the time of inception of the Policy or during renewal, the room rent expenses as defined under the base “Health Guard”
Policy would be provided at actuals.
• This Optional Cover can be availed with Sum Insured options of (i) INR 5,00,000/- and 7,50,000/- under “Health Guard-Gold” plan and “Health
Guard-Platinum” Plan.
• This Optional Cover would be covered within Sum Insured of Base Policy Section A 1. “In-patient Hospitalization Treatment”.

PART B: DEFINITIONS
1. “Optional Cover” means the cover mentioned in PART A Operative Clause hereinabove.
2. All other DEFINITIONS as defined in “SECTION 2: DEFINITIONS” in the Policy Wordings title “Health Guard” are applicable mutatis mutandis, to
these Optional Cover.
PART C: GENERAL EXCLUSIONS APPLICABLE TO ALL SECTIONS

1. All exclusions applicable in Base Policy title “Health Guard” shall be applicable to Optional Cover.
PART D: SPECIFIC GENERAL CONDITIONS APPLICABLE TO ALL SECTIONS

All Policy Terms and Conditions and General conditions of Base Policy title “Health Guard” read with Policy Schedule are applicable mutatis mutandis.
1. Opting Optional Cover-

i. These Optional Cover cannot be opted during mid-term of Policy.
ii. Once opted, the Optional Cover has to be continued for all renewals there on.
2. Cancellation of Optional Cover-

All the terms and conditions as to Cancellation of Base Policy shall mutatis mutandis apply to the Cancelation of Optional Cover.
3. Renewal of Optional Cover-

In case of renewal of Base Policy “Health Guard”, opted Optional Cover shall be automatically renewed subject to Company’s receipt of prescribed
premium. Once Optional Cover are opted by Insured, Company will renew Base Policy together with Optional Cover and shall not renew only Base
Policy.
4. Withdrawal of Optional Cover:

1. If Base Policy “Health Guard” is withdrawn, then these Optional Cover shall also stand withdrawn.
2. ln the likelihood of this product being withdrawn in future, the Company will intimate the Insured about the same 90 days prior to expiry of
the Base Policy.
3. lnsured will have the option to migrate to similar health insurance product available with the Company at the time of renewal with all the
accrued continuity benefits such as cumulative bonus, waiver of waiting period as per IRDAI guidelines, provided the Policy has been main-
tained without a break.
5. Grievance Redressal Procedure

Welcome to Bajaj Allianz General Insurance Company Ltd [“Bajaj Allianz”] and Thank You for choosing Us as Your insurer.
Please read Your Policy Wordings and Policy Schedule.
The Policy Wordings and Policy Schedule set out the terms of Your contract with us. Please read Your Policy Wordings and Policy Schedule care-
fully to ensure that these Optional Cover meets Your needs.
We do our best to ensure that our customers are delighted with the service they receive from Bajaj Allianz. If You are dissatisfied We would like to
inform You that We have a procedure for resolving issues. Please include Your Policy number in any communication with the Company. This will
help Us deal with the issue more efficiently. If You don’t have it, please call Our Branch office.
CIN: U66010PN2000PLC015329, UIN:BAJHLAP21577V012021 1

Initially, We suggest You contact the Branch Manager/ Regional Manager of the local office which has issued the Policy. The address and telephone
number will be available in the Policy. Naturally, We hope the issue can be resolved to Your satisfaction at the earlier stage itself. But if You feel
dissatisfied with the suggested resolution of the issue after contacting the local office, please e-mail or write to:
Bajaj Allianz General Insurance Co. Ltd.

Bajaj Allianz House, Airport Road
Yerawada, Pune 411006
E-mail: [email protected]
Call : 1800-225858 (free calls from BSNL/MTNL lines only)
1800-1025858 ( free calls from Bharti users – mobile /landline ) or020-30305858
Grievance Redressal Cell for Senior Citizens

Senior Citizen Cell for Insured who are Senior Citizens
‘Good things come with time’ and so for Our customers who are above 60 years of age We have created special cell to address any health insur-
ance related query. Our senior citizen customers can reach Us through the below dedicated channels to enable Us to service them promptly
Health toll free number: 1800-103-2529
Exclusive Email address: [email protected]
If You are still not satisfied, You can approach the Insurance Ombudsman in the respective area for resolving the issue. The contact details of the
Ombudsman offices are mentioned below:
Office Details Jurisdiction of Office Union Territory,District)

AHMEDABAD
Office of the Insurance Ombudsman,
Jeevan Prakash Building, 6th floor,
Tilak Marg, Relief Road,Ahmedabad – 380 001. Gujarat, Dadra & Nagar Haveli, Daman and Diu.
Tel.: 079 - 25501201/02/05/06
BENGALURU
Jeevan Soudha Building,PID No. 57-27-N-19
Ground Floor, 19/19, 24th Main Road,JP Nagar, Ist Phase,
Karnataka
Bengaluru – 560 078.
Tel.: 080 - 26652048 / 26652049
BHOPAL
Janak Vihar Complex, 2nd Floor, 6, Malviya Nagar, Opp. Airtel Office,
Near New Market,Bhopal – 462 003. Madhya Pradesh
Tel.: 0755 - 2769201 / 2769202 Chattisgarh
Fax: 0755 - 2769203
BHUBANESHWAR
62, Forest park,Bhubneshwar – 751 009.
Orissa
Tel.: 0674 - 2596461 /2596455
Fax: 0674 - 2596429
CHANDIGARH
Office of the Insurance Ombudsman, S.C.O. No. 101, 102 & 103, 2nd Floor,
Batra Building, Sector 17 – D, Chandigarh – 160 017.
Tel.: 0172 - 2706196 / 2706468 Punjab, Haryana, Himachal Pradesh, Jammu & Kashmir, Chandigarh
Fax: 0172 - 2708274

CHENNAI
Office of the Insurance Ombudsman, Fatima Akhtar Court, 4th Floor, 453,
Tamil Nadu,
Anna Salai, Teynampet,
Pondicherry Town and
CHENNAI – 600 018.
Karaikal (which are part of Pondicherry).
Tel.: 044 - 24333668 / 24335284
Fax: 044 - 24333664
DELHI
Office of the Insurance Ombudsman, 2/2 A, Universal Insurance Building,
Asaf Ali Road, New Delhi – 110 002. Delhi.
Tel.: 011 - 23232481/23213504
GUWAHATI
Office of the Insurance Ombudsman, Jeevan Nivesh, 5th Floor,
Nr. Panbazar over bridge, S.S. Road, Guwahati – 781001(ASSAM). Assam, Meghalaya, Manipur, Mizoram, Arunachal Pradesh, Nagaland and
Tel.: 0361 - 2632204 / 2602205 Tripura
HYDERABAD
Office of the Insurance Ombudsman, 6-2-46, 1st floor, “Moin Court”, Lane
Andhra Pradesh,
Opp. Saleem Function Palace, A. C. Guards, Lakdi-Ka-Pool, Hyderabad - 500
Telangana,
004.
Yanam and
Tel.: 040 - 67504123 / 23312122
part of Territory of Pondicherry.
Fax: 040 - 23376599
JAIPUR
Office of the Insurance Ombudsman, Jeevan Nidhi – II Bldg., Gr. Floor, Bha-
wani Singh Marg, Jaipur - 302 005. Rajasthan.
Tel.: 0141 - 2740363
ERNAKULAM
Office of the Insurance Ombudsman, 2nd Floor, Pulinat Bldg., Opp. Cochin Kerala,
Shipyard, M. G. Road, Ernakulam - 682 015. Lakshadweep,
Tel.: 0484 - 2358759 / 2359338 Mahe-a part of Pondicherry.
Fax: 0484 - 2359336
KOLKATA -
Office of the Insurance Ombudsman, Hindustan Bldg. Annexe, 4th Floor, West Bengal,
4, C.R. Avenue, KOLKATA - 700 072. Sikkim,
Tel.: 033 - 22124339 / 22124340 Andaman & Nicobar Islands.
Fax : 033 - 22124341
LUCKNOW
Office of the Insurance Ombudsman, 6th Floor, Jeevan Bhawan, Phase-II, Districts of Uttar Pradesh :
Nawal Kishore Road, Hazratganj, Lucknow - 226 001. Laitpur, Jhansi, Mahoba, Hamirpur, Banda, Chitrakoot, Allahabad, Mirzapur,
Tel.: 0522 - 2231330 / 2231331 Sonbhabdra,Fatehpur, Pratapgarh, Jaunpur,Varanasi, Gazipur, Jalaun, Kan-
Fax: 0522 - 2231310 pur, Lucknow, Unnao,Sitapur, Lakhimpur, Bahraich, Barabanki, Raebareli,
Email: [email protected] Sravasti, Gonda, Faizabad, Amethi,Kaushambi, Balrampur, Basti, Ambed-
karnagar, Sultanpur, Maharajgang, Santkabirnagar,Azamgarh, Kushinagar,
Gorkhpur, Deoria, Mau, Ghazipur, Chandauli, Ballia, Sidharathnagar
MUMBAI
Office of the Insurance Ombudsman, 3rd Floor, Jeevan Seva Annexe, S. V.
Goa,
Road, Santacruz (W), Mumbai - 400 054.
Mumbai Metropolitan Region
Tel.: 022 - 26106552 / 26106960
excluding Navi Mumbai & Thane
Fax: 022 - 26106052

NOIDA State of Uttaranchal and the following Districts of Uttar Pradesh:

Office of the Insurance Ombudsman, Bhagwan Sahai Palace 4th Floor, Main Agra, Aligarh, Bagpat, Bareilly, Bijnor, Budaun, Bulandshehar, Etah, Kanooj,
Road, Naya Bans, Sector 15, Distt: Gautam Buddh Nagar, U.P-201301. Mainpuri, Mathura, Meerut, Moradabad, Muzaffarnagar, Oraiyya, Pilibhit,
Tel.: 0120-2514250 / 2514252 / 2514253 Etawah, Farrukhabad, Firozbad, Gautambodhanagar, Ghaziabad, Hardoi,
Email: [email protected] Shahjahanpur, Hapur, Shamli, Rampur, Kashganj, Sambhal, Amroha, Hath-
ras, Kanshiramnagar, Saharanpur.
PATNA
Office of the Insurance Ombudsman, 1st Floor,Kalpana Arcade Building, Bihar,
Bazar Samiti Road, Bahadurpur, Patna 800 006. Jharkhand
Tel.: 0612-2680952
PUNE
Office of the Insurance Ombudsman, Jeevan Darshan Bldg., 3rd Floor, C.T.S. Maharashtra,
No.s. 195 to 198, N.C. Kelkar Road, Narayan Peth, Pune – 411 030. Area of Navi Mumbai and Thane
Tel.: 020-41312555 excluding Mumbai Metropolitan Region
Note: Address and contact number of Governing Body of Insurance Council

Secretary General - Governing Body of Insurance Council
JeevanSevaAnnexe, 3rd Floor, S.V. Road, Santacruz (W), Mumbai - 400 054
Tel No: 022-2610 6889, 26106245, Fax No. : 022-26106949, 2610 6052, E-mail ID: [email protected]
Cashless facility offered through network hospitals of Bajaj Allianz only.Cashless facility at 3300+ Network hospitals PAN India.
Please visit Our website for list of network hospitals and network Diagnostic Centres , Website: www.bajajallianz.com or get in touch with 24*7 helpline
number: 1800-103-2529 (toll free) / 020-30305858

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Bajaj Allianz General Insurance Company Limited

1. In-patient Hospitalization Treatment

• Gold Plan and Platinum Plan

CIN: U66010PN2000PLC015329 | UIN: BAJHLIP21227V042021 1

Claim under this section shall be payable by Us only when:

Subject otherwise to the terms, conditions and exclusions of the Policy.

5. Day Care Procedures

6. Organ Donor Expenses:

8. Daily Cash Benefit for Accompanying an Insured Child

9. Sum Insured Reinstatement Benefit:

Understanding Sum Insured Reinstatement made easy-

10. Preventive Health Check Up

11. Bariatric Surgery Cover

Special Conditions applicable to Bariatric Surgery Cover

12. Wellness Benefits

Sr. No Health Parameter Reading

CIN: U66010PN2000PLC015329 | UIN: BAJHLIP21227V042021 3

Parameters Achieved Discount Offered

Wellness Eligibility Criteria:

COVERS APPLICABLE FOR PLATINUM PLAN ONLY

16. Super Cumulative Bonus

17. Recharge Benefit

SUM INSURED LIMIT (INR)

3. Any one illness

5. AYUSH Day Care Centre:

CIN: U66010PN2000PLC015329 | UIN: BAJHLIP21227V042021 5

6. Bajaj Allianz Network Hospitals / Network Hospitals/Network Providers

7. Bajaj Allianz Diagnostic Centre

10. Condition Precedent

11. Congenital Anomaly

12. Cumulative Bonus

13. Day care centre

14. Day Care Treatment

15. Dental Treatment

16. Dependent child

17. Disclosure to information norm

18. Emergency Care

20. Family or Family Members

CIN: U66010PN2000PLC015329 | UIN: BAJHLIP21227V042021 6

21. Grace Period

25. Inpatient Care

27. Intensive Care Unit

28. ICU Charges

29. Kidney Failure Requiring Regular Dialysis

30. Limit of Indemnity

31. Maternity expenses:

32. Medical Advise

33. Medical Consumable

34. Medical expenses

35. Medical Practitioner/Doctor/ Physician:

37. Medically Necessary Treatment

39. Named Insured/ Insured/Insured Person:

40. New Born Baby

41. Network Provider :

42. Non- Network Provider

43. Notification of Claim

44. OPD treatment

51. Pre-Existing Disease

CIN: U66010PN2000PLC015329 | UIN: BAJHLIP21227V042021 8

52. Pre-hospitalization Medical Expenses