Health Care Plus Option - Brochure

Welcome to the
‘I feel good policy’
Digit Health Plus Policy (Revision)
Visit us at www.godigit.com or call UIN:

1800-103-4448, anytime, for more information. GODHLGP19013V021819
Table of Contents
Follow these directions to find your way if you get lost. Just click on the chapter name to go there.
DEFINITIONS 4
COVERAGE 9
SECTION 1: HOSPITALIZATION COVER 9
SECTION 2: INFERTILITY TREATMENT COVER 17
SECTION 3: ORGAN DONOR 17
SECTION 4: ALTERNATE TREATMENT (AYUSH) COVER 18
SECTION 5: EMERGENCY AIR AMBULANCE 19
SECTION 6: LONG HOSPITALIZATION CASH BENEFIT 19
SECTION 7: MATERNITY BENEFIT & NEW BORN BABY COVER 20
SECTION 8: OUT-PATIENT (OPD) BENEFIT 21
SECTION 9: HOME (DOMICILIARY) HOSPITALIZATION 22
SECTION 10: SUM INSURED REFILL BENEFIT 23
SECTION 11: DAILY HOSPITAL CASH COVER 23
SECTION 12: CRITICAL ILLNESS BENEFIT COVER 24
SECTION 13: CRITICAL ILLNESS HOSPITALIZATION COVER 25
SECTION 14: CANCER BENEFIT COVER 33
SECTION 15: CANCER HOSPITALIZATION COVER 34
SECTION 16: WELLNESS BENEFIT PROGRAM 35
CUMULATIVE BONUS 38
NO CLAIM DISCOUNT 39
WAITING PERIODS 39
GENERAL EXCLUSIONS 41
STANDARD ONES 41
SPECIFIC ONES (CAN’T BE WAIVED) 44
Digit Health Plus Policy (Revision) (UIN: GODHLGP19013V021819) Back to Index | 2

SPECIFIC ONES (CAN BE WAIVED IN LIEU OF ADDITIONAL PREMIUM) 45
GENERAL CONDITIONS 46
CONDITIONS PRECEDENT TO THE CONTRACT 46
CONDITIONS APPLICABLE DURING THE CONTRACT 47
CONDITIONS APPLICABLE WHEN A CLAIM ARISES 49
CONDITIONS FOR RENEWAL OF THE CONTRACT 52
CUSTOMER GRIEVANCE REDRESSAL POLICY 52
Let’s get started

You’re already awesome because you decided to protect your most important asset, your health. Think of
Digit as your running or gym buddy, keeping pace with you all the way. While you’re reading this policy, if
you get confused or have a query, or if you are referring to this policy because you have a claim to make,
please call us at 1800-103-4448 or mail us at [email protected].
Based on the declaration provided by you to us, Go Digit General Insurance Limited (hereinafter called
‘the Company/DIGIT’) which forms the basis of this health policy contract, and having received your
premium, we take pleasure in issuing this policy to you.
Go Digit General Insurance Limited will cover you under this policy up to the sum insured, during the
policy period mentioned in your policy schedule / certificate of insurance. Of course, like any insurance
cover, it is governed by, and subject to certain terms, conditions and exclusions mentioned in this policy.
Note: This policy wording provides detailed terms, conditions and exclusions for all sections available under
this product. Kindly refer to the policy schedule / certificate of insurance to know exact details of sections
opted by you. Only wordings related to sections mentioned in your policy schedule / certificate of insurance
are applicable.
Disclaimer:
The Description mentioned under “Digit Simplification”/ “Examples” throughout the Insurance Policy is only
to aid Your understanding of the Coverage / Benefit Offered. In case of dispute, the Terms and Conditions
detailed in the Policy Document and Policy Schedule shall prevail.

DEFINITIONS
Digit Simplification: You didn’t think you needed to know definitions since your time in school, right? Well,
the good news is that you don’t need to learn these by heart, as long as you understand them.
Certain words and phrases used throughout the policy have specific meanings, and this section helps
to understand them.
1. Accident, Accidental means sudden, unforeseen and involuntary event caused by external,
visible and violent means.
2. Alternative/Ayush Treatment means forms of treatments other than “Allopathy”

or “modern medicine” and includes Ayurveda, Unani, Sidha and Homeopathy in the Indian context.
3. Any one illness means continuous period of illness and includes relapse within 45 days from
the date of last consultation with the hospital/nursing home where treatment was taken.
4. 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..
5. Condition Precedent means a policy term or condition upon which the insurer’s liability under
the policy is conditional upon.
6. Congenital Anomaly means a condition which is present since birth, and which is abnormal
with reference to form, structure or position.
a. Internal Congenital Anomaly means a Congenital Anomaly which is not in the visible and accessible
parts of the body.
b. External Congenital Anomaly means a Congenital Anomaly which is in the visible and accessible
parts of the body.
7. Contribution
Contribution is essentially the right of an insurer to call upon other insurers, liable to the same insured,
to share the cost of an indemnity claim on a ratable proportion of sum insured. This clause shall
not apply to any benefit offered on a fixed benefit basis.
8. 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 claims amount.
A co-payment does not reduce the sum insured. Co-payment will not be applicable to benefit
policies - Daily Hospital Cash Cover & Critical Illness Benefit, Cancer Benefit.
9. Cumulative Bonus means any increase or addition in the sum insured granted by the insurer
without an associated increase in premium.
10. Day Care Centre means any institution established for day care treatment of illness and/or
injuries or a medical setup with a hospital and which has been registered with the local authorities,
wherever applicable, and is under supervision of a registered and qualified medical practitioner
AND must comply with all minimum criterion as under –
i. has qualified nursing staff under its employment;
ii. has qualified medical practitioner/s in charge;
iii. has fully equipped operation theatre of its own where surgical procedures are carried out;
iv. maintains daily records of patients and will make these accessible to the insurance company’s
authorized personnel.

11. Day Care Treatment means medical treatment, and/or surgical procedure which is:
i. undertaken under general or local anaesthesia in a hospital/day care centre in less than 24 hrs
because of technological advancement, and
ii. which would have otherwise required hospitalization of more than 24 hours. Treatment normally
taken on an out-patient basis is not included in the scope of this definition.
12. Deductible means a cost sharing requirement under a health insurance policy that provides
that the insurer will not be liable for a specified rupee amount in case of indemnity policies and
for a specified number of days/hours in case of Daily Hospital Cash policies which will apply
before any benefits are payable by the insurer. A deductible does not reduce the sum insured.
13. Dental Treatment means a treatment related to teeth or structures supporting teeth including
examinations, fillings (where appropriate), crowns, extractions and surgery.
14. 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.
15. Domiciliary Hospitalization means medical treatment for an illness/disease/injury which in

the normal course would require care and treatment at a hospital but is actually taken while
confined at home under any of the following circumstances:
i) the condition of the patient is such that he/she is not in a condition to be moved to a hospital, or
ii) the patient takes treatment at home on account of non-availability of room in a hospital.
16. Emergency / Emergency Care means management for 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 person’s health.
17. 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 premium is received.
18. Hazardous Activities means any sport or activity, which is potentially dangerous to the insured
person whether he/she is trained or not in such sport or activity. Such sport/activity includes but not
limited to insured person whilst engaging in speed racing of any kind (other than on foot),
professional or competitive sport, bungee jumping, parasailing, ballooning, parachuting, base jumping,
skydiving, paragliding, mountain or rock climbing necessitating the use of guides or ropes, potholing,
abseiling, deep sea diving, biathlon, big game hunting, black water rafting, BMX stunt / obstacle riding,
bobsleighing / using skeletons, bouldering, boxing, canyoning, caving / spelunking / pot holing,
cave tubing, climbing / trekking / walking over 4,000 meters, cycle racing, cyclo-cross, drag racing,
endurance testing, hang gliding, harness racing, hell skiing, high diving (above 5 meters), hunting, ice
hockey, ice speedway, jousting, judo, karate, kendo, luging, marathon running, martial arts,
micro-lighting, modern pentathlon, motorcycle racing, motor rallying, parapenting, piloting aircraft,
polo, powerlifting, power boat racing, quad biking, river-boarding, river bugging, rodeo, roller hockey,
rugby, ski acrobatics, ski doo ski jumping, ski racing, sky diving, small bore target shooting, speed trials
/ time trials, triathlon, water ski jumping, weight lifting, wrestling snow and ice
sports or involving a naval military or air force operation. Flying or taking part in aerial activities except
as a fare-paying passenger in a regular schedule airline or air charter company.
19. 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 Clinical
Establishments (Registration and Regulation) Act 2010 or under enactments specified under the
Schedule of Section 56(1) and the said Act or complies with all minimum criteria as under:

i) has qualified nursing staff under its employment round the clock;
ii) 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;
iii) has qualified medical practitioner(s) in charge round-the-clock;
iv) has a fully equipped operation theatre of its own where surgical procedures are carried out;
v) maintains daily records of patients and makes these accessible to the insurance company’s
authorized personnel;
20. 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.
21. 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 - 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 disease, illness, or injury that has one or more of the following characteristics:
1. Needs ongoing or long-term monitoring through consultations, examinations, check-ups,
and /or tests
2. Needs ongoing or long-term control or relief of symptoms
3. Requires rehabilitation for the patient or for the patient to be specially trained to cope with it
4. Continues indefinitely
5. Recurs or is likely to recur
22. Injury means accidental physical bodily harm excluding illness or disease solely and directly caused
by external, violent, visible and evident means which is verified and certified by a Medical Practitioner.
23. In-patient Care means treatment for which the insured person has to stay in a hospital for more than
24 hours for a covered event.
24. 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.
25. ICU 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.
26. Maternity Expenses means:
a) medical treatment expenses traceable to childbirth (including complicated deliveries and Cesarean
sections incurred during hospitalization);
b) expenses towards lawful medical termination of pregnancy during the policy period.
27. Medical Advice means any consultation or advice from a Medical Practitioner including the issuance
of any prescription or follow-up prescription.
28. Medical Expenses means those expenses that an insured person 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 person had not been
insured and no more than other hospitals or doctors in the same locality would have charged for
the same medical treatment.
29. Medical Practitioner / Dentist means a person 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 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.
The registered practitioner should not be the insured or close member of the family.
30. Medically Necessary Treatment means any treatment, tests, medication, or stay in hospital or part
of a stay in hospital which:
i) is required for the medical management of the illness or injury suffered by the insured;
ii) must not exceed the level of care necessary to provide safe, adequate and appropriate medical care
in scope, duration, or intensity;
iii) must have been prescribed by a Medical Practitioner;
iv) must conform to the professional standards widely accepted in international medical practice or by
the medical community in India.
31. Network Provider means hospitals or healthcare providers enlisted by an insurer, TPA or jointly by an
insurer and TPA to provide medical services to an insured by a cashless facility.
32. New Born Baby means baby born during the policy period and is aged upto 90 days.
33. Non-Network Provider means any hospital, day care centre or other provider that is not part
of the network.
34. Notification of Claim means the process of intimating a claim to the insurer or TPA through any
of the recognized modes of communication.
35. OPD Treatment means the 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.
36. Policy means the proposal, the schedule / certificate of insurance (and any endorsement attaching
to or forming part thereof) and the policy wordings.
37. Policy Period means the period between the commencement date and the expiry date specified
in the schedule / certificate of insurance and includes both the commencement date as well
as the expiry date.
38. Pre-Existing Disease means any condition, ailment or injury or related condition(s) for which
there were signs or symptoms, and / or were diagnosed, and / or for which medical advice / treatment
was received within 48 months prior to the first policy issued by the insurer and renewed continuously
thereafter.
39. Pre-hospitalization Medical Expenses means medical expenses incurred during pre-defined number
of days preceding the hospitalization of the insured person, provided that:
i. Such medical expenses are for the same condition for which hospitalization was required, and
ii. The in-patient hospitalization claim for such hospitalization is admissible by the insurance company.
40. Post-hospitalization Medical Expenses means medical expenses incurred during pre-defined
number of days immediately after the insured person is discharged from the hospital provided that:
i. Such medical expenses are for the same condition for which the insured person’s hospitalization
was required, and

ii. The in-patient hospitalization claim for such hospitalization is admissible by the insurance
company.
41. Portability means transfer by an individual health insurance policyholder (including family cover)
of the credit gained for pre-existing conditions and time-bound exclusions if he/she chooses to switch
from one insurer to another.
42. 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.
43. 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.
44. 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 continuous for the purpose of gaining credit
for pre-existing diseases, time-bound exclusions and for all waiting periods.
45. Room means a single room without wall/permanent partition, dining or waiting room and with or
without following amenities: an attendant cot, one television, one sofa, a telephone, refrigerator,
wardrobe, computer with internet connection and microwave oven.
46. Room Rent means the amount charged by a hospital towards room and boarding expenses
and shall include the associated medical expenses.
47. Sum Insured means the amount as opted by you and stated in the policy schedule / certificate of
insurance against the section / cover for each insured person including cumulative bonus (if any) for
Individual Sum Insured Policy and aggregately for all insured members for a Floater Policy.
48. 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.
49. Tertiary Care constitutes of Specialized Advanced Care Unit designed to care to complex medical
condition involving super specialist consultant like Neuro Surgeon, Neurologist, Spine Surgeons
and Reconstructive Surgeons.
50. Unproven/Experimental Treatment means the treatment including drug experimental therapy
which is not based on established medical practice in India, is treatment experimental or unproven.
51. We, Us, Our, Ours, Digit, Company, Insurer means Go Digit General Insurance Limited
52. You, Your, Yours, Yourself, Policyholder, Insured Person(s) means the individual group members
who will be treated as Insured beneficiary.

COVERAGE
SECTION 1. HOSPITALIZATION COVER
Digit Simplification: Hospital stays are never fun. And the less said about hospital food, the better!
That said, it’s good to know that Digit will try and make it easy, should you need to spend some time in
hospital, before you’re back on your feet.
A. Accidental Hospitalization Cover

Digit Simplification: The day bad luck strikes.
If you have opted for this cover and you suffer an accidental injury during the policy period that requires
hospitalization as an inpatient, we’ll be there for you. We will pay You all reasonable and customary
charges that are medically necessary and incurred by you in respect of an admissible claim. The claim
can be made under the following benefits and up to the sum insured mentioned in your policy schedule /
certificate of insurance against this section.
Hospital accommodation in a ward, shared or private room subject

to a Limit Per Day as opted by you and mentioned in your policy
schedule / certificate of insurance against this cover.
Note: If You have opted for a limit on Accommodation / Room
Rent and the room rent rate exceeds the limits at the time of
hospitalization our liability will be restricted to the same proportion
admissible rate per day limit opted bears to the actual rate per
day of room rent charges except for the cost of medicines and
consumables, unless this condition is specifically waived off by Us
Accommodation/Room Rent
and mentioned in Your Policy Schedule/Certificate of Insurance.
Example: If you have opted a room rent limit of ₹1,500 per day
but you go in for a room with a rent of ₹4,500 per day which is
three times the allowed limit, when you claim, We will pay one-
third of the total bill amount and deduct the balance i.e. in the
same proportion as it increased. This is because the other charges
related to your treatment like doctor’s fees, also increase with the
room type. This deduction will not be applicable for the cost of
medicines and consumables.

ICU Intensive Care Unit
Fees for treatment by specialists, physicians, nurses, surgeons and

Professional Fees
anaesthetists.
Drugs, medicines, consumables, prescribed by a specialist or

medical practitioner. This also includes anesthesia, blood, oxygen,
Medication
patient’s diet, surgical appliances and cost of prosthetic and other
devices or equipment if implanted during the surgical procedure.
Necessary procedures such as x-rays, pathology, brain and body

Diagnostic
scans (MRI, CT scans) Etc. used to make a diagnosis for treatment.
Theatre Fees Operation Theatre Fees
ACCIDENTAL HOSPITALIZATION COVER
A1 Day Care Procedures
Digit Simplification: Why stay unnecessarily in a hospital when the required procedure
requires just a day!
If you suffer an accidental injury during the policy period, due to which you need to undergo
medical treatment and/or surgical procedure as an inpatient under general or local anesthesia in
a hospital/day care centre for a stay less than 24 hour because of technological advancement,
We will pay the medical expenses incurred for such day care procedures. Treatment normally
taken on an out-patient basis is not included in the scope of this cover.
A2 Pre-Hospitalization Expenses
Digit Simplification: We all know that sometimes you need to shell out money way before you
are actually hospitalized; smile, you’re covered.
We will pay for consultations, investigations and the cost of medicines incurred for a period
not exceeding the number of days as opted by You and mentioned in Your Policy Schedule /
Certificate of Insurance against this Cover, prior to the date of Your admission in a hospital,
provided that:
a) Such Expenses recommended by the Hospital/Medical Practitioner were in fact incurred
for the same condition for which Your subsequent hospitalization was required.
b) We have accepted an In-patient Accidental Hospitalization Claim under Section 1.A.
Accidental Hospitalization Cover of this Policy.

A3 Post-Hospitalization Expenses
Digit Simplification: This covers for expenses incurred by You after you get discharged!
Certificate of Insurance against this Cover, from the date of Your discharge from the hospital,
provided that:
a) The expenses are recommended by the Hospital/Medical Practitioner and are for the
same condition for which you were hospitalized.
b) We have accepted an In-patient Accidental Hospitalization Claim under Section1. A.
Accidental Hospitalization Cover of this Policy.
Instead, You may also choose to opt for a onetime lumpsum benefit which shall be a percentage
of the claim amount approved under Section 1.A. Accidental Hospitalization Cover towards Post
Hospitalization Expenses, after Your discharge from the Hospital. This percentage is mentioned
in Your Policy Schedule/Certificate of Insurance. If we have paid a lump sum amount, then You
won’t be eligible for any other payment under this benefit for that particular Hospitalization.
A4 Dental Treatment
Digit Simplification: Because you need to open your mouth and your wallet wide,
at the dentist’s.
We will pay for the medical expenses incurred by You for any necessary Dental Treatment
needed after an accident. A claim here is valid if the accident resulted in an admissible In-patient
Hospitalization Claim under Section 1. A. Accidental Hospitalization Cover.
A5 Road Ambulance
Digit Simplification: Emergencies will and shall always be a top priority.
We will pay for the expenses incurred on Your road transportation by a Healthcare or an
Ambulance Service Provider to a Hospital for treatment following an emergency arising out of
an accident, provided that:
a) We have accepted a claim under Section 1. A. Accidental Hospitalization Cover.
b) The maximum liability per Hospitalization is restricted to the amount as mentioned in
Your Policy Schedule / Certificate of Insurance against this Cover.
c) The Coverage also Includes Your cost of road Transportation from a Hospital to another
nearest Hospital which is prepared to admit You and provide the necessary medical
services, if such medical services cannot satisfactorily be provided at a Hospital where
You are situated. Such road Transportation has to be prescribed by a Medical
Practitioner and/or should be medically necessary.

A6 Second Medical Opinion
Digit Simplification: We want nothing but the best for You. Which is why we encourage you to
go in for a second opinion, wherever necessary!
We shall arrange and bear the cost for Second Opinion from our panel of Medical Practitioners.
This is for times when there has been a major accidental injury that requires your hospitalization
in a tertiary care facility during the Policy Period, provided that:
1. We have received Your request to arrange for a Second Opinion.
2. You have the option to choose any one of Our Panel Medical Practitioners.
3. We will not provide more than one opinion for the same Medical Condition
within a Policy Period.
All the above Covers are Subject to terms, conditions, deductible, co-payment, limitations and
exclusions mentioned in the Policy.
B. Accidental & Illness Hospitalization Cover

Digit Simplification: The day bad luck strikes.
If You have opted for this Cover and You suffer an Accidental Injury or Illness during the Policy Period that
requires Hospitalization as an in-patient, We will pay You all Reasonable and Customary Charges that
are medically necessary and incurred by You in respect of an admissible claim. The claim can be made
under the following benefits and up to the Sum Insured mentioned in Your Policy Schedule / Certificate of
Insurance against this Section.

to a Limit Per Day as opted by You and mentioned in Your Policy
Schedule / Certificate of Insurance against this Cover.
Note: If You have opted for a Limit on “Accommodation/Room
Rent” and the Room Rent Rate exceeds the limits at the time
of hospitalization, our liability will be restricted to the same
proportion Admissible Rate Per Day Limit Opted bears to the
Actual Rate Per Day of Room Rent Charges except for the cost of
medicines and consumables, unless this condition is specifically
Accommodation/Room Rent waived off and mentioned in Your Policy Schedule/Certificate of
Insurance.
but You go in for a room with a rent of ₹4,500 per day which is
three times the allowed limit, when You claim, We will pay one-
related to Your treatment like doctor’s fees, also increase with the

Professional Fees
anaesthetists.

medical practitioner. This also includes Anaesthesia, Blood, Oxygen,
Medication
Patient’s Diet, Surgical appliances & Cost of Prosthetic and other
devices or equipment if implanted during the Surgical Procedure.
Necessary Procedures such as x-rays, pathology, brain and body

Diagnostic
scans (MRI, CT scans) etc. used to make a diagnosis for treatment.
ACCIDENTAL & ILLNESS HOSPITALIZATION COVER
B1 Day Care Procedures

Digit Simplification: Why stay unnecessarily in a hospital when the required procedure
requires just a day!
If You suffer an Accidental Injury during the Policy Period, due to which You need to undergo
medical treatment and/or surgical procedure as an in-patient under General or Local
Anaesthesia in a hospital/day care centre for a stay less than 24 hour because of technological
advancement, We will pay the medical expenses incurred for such Day Care Procedures.
Treatment normally taken on an out-patient basis is not included in the scope of this Cover.
B2 Pre-Hospitalization Expenses
Digit Simplification: Before you get hospitalized, there might be some expenses. This takes care
of those!
Certificate of Insurance against this cover, prior to the date of Your admission in a hospital,
provided that:
a) Such Expenses recommended by the Hospital/Medical Practitioner were in fact incurred
for the same condition for which Your subsequent hospitalization was required.
b) We have accepted an In-patient Accidental Hospitalization Claim under Section 1.B.
Accidental & Illness Hospitalization Cover of this Policy.

B3 Post-Hospitalization Expenses
Digit Simplification: This covers expenses incurred by you after getting discharged!
We will pay for consultations, investigations and the cost of medicines incurred for a period not
exceeding the number of days as opted by you and mentioned in your policy schedule / certificate
of insurance against this cover, from the date of your discharge from the hospital, provided that:
a) The expenses are recommended by the hospital / Medical Practitioner and are for the
same condition for which you were hospitalized.
b) We have accepted an In-patient Accidental Hospitalization Claim under
Section 1.B. Accidental & Illness Hospitalization Cover
Instead, you may also choose to opt for a one-time lumpsum benefit which shall be a percentage
of the claim amount approved under Section 1.B. Accidental & Illness Hospitalization Cover
towards Post Hospitalization Expenses, after your discharge from the hospital. This percentage
is mentioned in Your Policy Schedule/Certificate of Insurance. If we have paid a lump sum
amount, then you won’t be eligible for any other payment under this benefit for that particular
hospitalization.
B4 Dental Treatment
Digit Simplification: The dentist’s chair is never fun, but we make sure you smile.
We will pay for the medical expenses incurred in respect of any necessary dental treatment
from a dentist provided the dental treatment is required as a result of an accident that results
in an admissible inpatient hospitalization claim under Section 1. B. Accidental & Illness
Hospitalization Cover.
B5 Road Ambulance
Digit Simplification: In an emergency, getting to the hospital quickly is paramount!
We will pay for the expenses incurred on your road transportation by a healthcare or an
ambulance service provider to a hospital for treatment following an emergency, provided that:
a) We have accepted a claim under Section 1. B. Accidental & Illness Hospitalization Cover.
b) The maximum liability per hospitalization is restricted to the amount as mentioned in
your policy schedule / certificate of insurance against this cover.
c) The coverage also includes your cost of road transportation from a hospital to another
nearest hospital which is prepared to admit you and provide the necessary medical services,
if such medical services cannot satisfactorily be provided at a hospital where you are
situated. Such road transportation has to be prescribed by a Medical Practitioner and / or
should be medically necessary.

Bariatric Surgery Cover
B6
Digit Simplification: Tackling obesity may require more than healthy eating and exercise.
Therefore, if you are hospitalized for a Bariatric Surgery which is medically necessary, on the
advice of a Medical Practitioner, we cover the related medical expenses subject to
the following conditions:
a) The insured person undergoing the surgery is at least 18 years old.
b) The Medical Practitioner / Bariatric Surgeon confirms that your existing Body
Mass Index (BMI) and health conditions fall within the below qualification requirements
for Bariatric Surgery:
• Class III Obesity (extreme obesity)- [Body Mass Index (BMI) ≥ 40 kg/m2)];
• Class II Obesity (Body Mass Index (BMI) 35-39.9 kg/m2) along with any of the
following co-morbidities:
• Uncontrolled Diabetes Mellitus
• Cardiovascular Disease [Example: Stroke, Myocardial Infarction, Poorly Controlled
Hypertension]
• History of Coronary Artery Disease with a surgical intervention such as
Cardiopulmonary Bypass or Percutaneous Transluminal Coronary Angioplasty;
• Cardiopulmonary Problems as a result of another disease process, including,
though not limited to, a documented severe Obstructive Sleep Apnea (OSA),
confirmed on Polysomnography.
c) A claim under this cover is acceptable only if it is under any of the below procedures:
• Gastric Bypass
• The Roux-en-Y Gastric Bypass
• Biliopancreatic Diversion with or without Duodenal Switch (BPD/DS) Gastric Bypass
• Sleeve Gastrectomy
• Laparoscopic Gastric Banding
d) This particular cover has a waiting period. Waiting period shall be as per the “Specific
Waiting Period” section stated in your schedule / certificate of insurance against this
section which shall apply from the date of inception of the first policy with us, provided
that the policy has been renewed continuously with us without break with Bariatric
Surgery cover as a benefit since inception of the first policy.
e) If you are porting an existing policy under Portability Guidelines, from some other
General or Health Insurance Company or if you are adding this cover while renewing our
health policy, a fresh waiting period as opted by you and mentioned in your policy
schedule / certificate of insurance will be applied.
f) Confirmation from Medical Practitioner / Bariatric Surgeon that the Bariatric Surgery is
not for a specific correctable cause for treating obesity. Example: Endocrine disorder
g) And we would need a documented detailed history of your obesity-related health
problems, difficulties, and treatment attempts demonstrating that a multidisciplinary
approach with dietary, other lifestyle modifications (such as exercise and behavioural
modification), and pharmacological therapy, if appropriate, have been unsuccessful, at
least for past 6 months.

h) A prior approval should be taken from us before the Bariatric Surgery is performed.
Our maximum liability under this benefit is restricted to the limit as opted by you and
mentioned in your policy schedule / certificate of insurance against this cover.
Bariatric surgery for the following reasons is not covered:
a) For cosmetic / aesthetic reasons.
b) For treating drug-induced obesity, for severe untreated hormonal imbalance, psychiatric
and eating disorders-induced obesity.
Digit Simplification: This is in such cases, treatment of the cause that has caused
obesity, will be more beneficial than treating obesity itself.
Psychiatric Illness Cover

B7
Digit Simplification: In a holistic health policy, mental health is as important as physical health.
We will pay up to the limit mentioned in your policy schedule / certificate of insurance against
this cover for the medical expenses, related to psychiatric illness which includes, though
not limited to, dementia, depression, bipolar disorder, schizophrenia, anxiety disorders and
obsessive-compulsive disorders, provided that:
a) The first diagnosis and hospitalization, as an in-patient, was during the policy period.
b) This also has a waiting period. Waiting period shall be as per the “Specific Waiting
Period” Section stated in your schedule / certificate of insurance against this cover
which shall apply from the date of inception of the first policy with us, provided that the
policy has been renewed continuously with us without break, with psychiatric as a
benefit since inception of the first policy.
c) Hospitalization under this benefit shall be subject to prior approval from us, except in
cases of emergencies.
Complimentary Health Check-up

B8
Digit Simplification: Prevention is always better than cure!
If You renew your policy with us without a break, then at every policy renewal, we will pay the
expenses incurred towards cost of health check-up up to the Limits Per Policy (excluding any
cumulative bonus) mentioned in Your Policy Schedule/Certificate of Insurance. This shall be paid,
provided that:
a. You are above 18 years of age at the time of health check-up.
b. You submit a duly filled and signed claim form along with original bills and copy
of medical reports.
Please Note: Payment under this benefit won’t be deducted from your sum insured as it is an
additional benefit.
Second Medical Opinion

B9
Digit Simplification: Any major illness (like cancer) dictates a second opinion.
When it comes to Cancer or any major Illness and you are required to get hospitalized in a
tertiary care facility during the policy period, we will arrange and bear the cost for a Second
Opinion provided that:
1. We have received your request to arrange for Second Opinion.
2. You have option to choose from any one of our panel Medical Practitioners.
3. We will not provide more than one opinion for the same medical condition within a policy period.

SECTION 2. INFERTILITY TREATMENT COVER
Digit Simplification: We make your road to parenthood easier.
If you have opted for this cover, we will pay the medical expenses if you are hospitalized on the advice of
the Medical Practitioner for Infertility/ Subfertility Treatments. This includes, though not limited to, IVF, IUI,
ZIFT, ICSI. Make sure the following conditions are met:
a) A waiting period of 48 months will apply from the date of inception of the first policy with us,
provided that the policy has been renewed continuously with this cover, without a break, with
‘Infertility Treatment Cover’ as a benefit since inception of the first policy.
b) Our maximum liability per hospitalization shall be restricted to the amount as mentioned
in your policy schedule / certificate of insurance against this section.
c) The benefit is payable only once to an insured person during the policy tenure.
This cover is subject to terms, conditions, deductible, co-payment, limitations and exclusions
mentioned in the policy.
SECTION 3. ORGAN DONOR

Digit Simplification: Organ transplantation is the gift of life itself, and we are happy to be a part of it.
If you have opted for this cover, we will pay you for the following incurred medical expenses in respect of
organ transplantation:
a) For the harvesting of the donated organ subject to availability of the sum insured under
Section 1. B. Accidental & Illness Hospitalization Cover.
b) There are strict guidelines when it comes to organ transplantation, therefore the organ
donor whose organ has been made available should be in accordance and in compliance
with the Transplantation of Human Organs Act 1994 (as amended) and the organ is donated
for your use only.
c) We will pay the donor’s Pre and Post Hospitalization expenses. This is up to 5% of the claim
amount approved in respect of harvesting expenses.
d) We will not pay any other medical treatment for the donor consequent on the harvesting.
e) This also has a waiting period. Waiting period shall be as per the “Specific Waiting Period”
section stated in your schedule / certificate of insurance against this section which
shall apply from the date of inception of the first policy with us, provided that the policy has
been renewed continuously with Us without break, with Organ Donor Cover as a benefit since
inception of the first policy.
Provided that, We have accepted a claim under Section 1. B. Accidental & Illness Hospitalization Cover.
This cover is subject to terms, conditions, deductible, co-payment, limitations and exclusions mentioned in
the policy.

SECTION 4. ALTERNATE TREATMENT (AYUSH) COVER
Digit Simplification: If you believe in the power of alternate treatments, here’s more power to you.
If You have opted for this cover, we will pay the medical expenses for your in-patient treatment, taken
under Ayurveda, Unani, Siddha or Homeopathy. This is up to the sum insured mentioned in your policy
schedule / certificate of insurance against Section 1. B. Accidental & Illness Hospitalization Cover.
This is paid provided that treatment is taken in
1. Teaching hospitals of AYUSH colleges recognised by Central Council of Indian Medicine (CCIM) and
Central Council of Homeopathy (CCH)
2. AYUSH hospitals having registration with Government authority under appropriate Act in the State/
UT and complies with the following as minimum criteria:
a) Has at least 15 in-patient beds
b) Has minimum 5 qualified and registered AYUSH Doctors;
c) Has qualified paramedical staff under its employment round the clock;
d) Has dedicated AYUSH therapy sections;
e) Maintains daily records of patients and makes these accessible to the insurance company’s
authorized personnel;
You should also be aware what we won’t pay for:
a) Pre-Hospitalisation & Post-Hospitalisation Expenses, Day Care Procedure and Outpatient
Medical Expenses.
b) All preventive and rejuvenation treatments (non-curative in nature) including, without limitation,
treatments that are not medically necessary.
This cover is subject to terms, conditions, deductible, co-payment, limitations and exclusions mentioned
in the policy.

SECTION 5. EMERGENCY AIR AMBULANCE
Digit Simplification: When every minute counts. Sometimes when you meet with an accident or have an
emergency illness, time is of a lot of importance.
If you have opted for this cover, we will pay You the expenses incurred for your transportation in an
airplane or helicopter for emergency life threatening health conditions which requires immediate and rapid
ambulance transportation to the nearest hospital.
This transportation will be from the location where the illness / accident happened the first time and
subject to availability of illness / accident mentioned in your policy schedule / certificate of insurance
against Section 1.A. Accidental Hospitalization Cover and / or Section 1.B. Accidental & Illness
Hospitalization Cover and provided that such transportation in an airplane or helicopter has been
prescribed by a Medical Practitioner and / or is medically necessary.
Provided that, we have accepted a claim under Section 1.A. Accidental Hospitalization Cover and / or
Section 1.B. Accidental & Illness Hospitalization Cover.
the policy.
SECTION 6. LONG HOSPITALIZATION CASH BENEFIT

Digit Simplification: If even ward boys seem to know you by your name, this cover is for You.
If you are hospitalized for a minimum number of consecutive days as opted by you and mentioned in the
policy schedule / certificate of insurance against this section, We will give you a lump sum amount as
mentioned in the policy schedule / certificate of insurance, provided that:
a) We have accepted a claim under Section 1.A. Accidental Hospitalization Cover and / or
Section 1.B. Accidental & Illness Hospitalization Cover, and
b) The benefit is payable only once to an insured person during the policy period.
For this cover, completion of every 24 Hours of In-patient Hospitalization from the time of Admission is
considered to be a day. This cover is subject to terms, conditions, deductible, co-payment, limitations and
exclusions mentioned in the policy.

SECTION 7. MATERNITY BENEFIT & NEW BORN BABY COVER
A. Maternity Benefit
Digit Simplification: One of the rare times when going to the hospital is for a little bundle of joy.
If you have opted for this cover, we will pay the maternity expenses incurred towards the delivery of a baby
and/or treatment related to any complication of pregnancy or medically necessary termination. This is up
to the sum insured opted by you and as mentioned in your policy schedule / certificate of insurance against
this section, during the policy period provided that:
a) Female Insured Person’s legally married spouse is also covered under this policy, unless specifically
waived by us (for example, if you are a single parent, this clause will not apply). This also has a
waiting period. Waiting period as opted by you and mentioned in your policy schedule / certificate
of insurance shall apply from the date of inception of the first policy with us, provided that
the policy has been renewed continuously with us without break, with maternity as a benefit.
b) If you are porting an existing policy under Portability Guidelines, from some other General or
Health insurance company or if you are adding this cover while renewing our health policy,
a fresh waiting period as opted by You and mentioned in your policy schedule / certificate
of insurance will be applied.
c) The maternity benefit is limited to cover up to two living children. However, there is no restriction
on the number of medically necessary and lawful termination of pregnancies.
d) If on renewal without any break in coverage, the sum insured is increased, there is a fresh waiting
period as opted by you and mentioned in your policy schedule / certificate of insurance applied
to the increased part of the sum insured.
e) Any complications arising out of or as a consequence of maternity / childbirth will also be covered
within the limit of sum insured, available under this benefit.
Digit Simplification: Sticking with us has its advantages
If we had already accepted a claim for maternity expenses for your first living child under this benefit, then
for the subsequent maternity expenses i.e. for the delivery of your second child, we shall pay up to the
percentage of the sum insured opted under this section and mentioned in your policy schedule / certificate
of insurance provided the policy is renewed with us continuously without break with Maternity Benefit &
New Born Baby Cover benefit.
We shall not pay for the following under this section:
a) Expenses for harvesting and storage of stem cells when carried out as a preventive
measure against possible future illness.
b) Medical Expenses for Ectopic Pregnancy will be covered under Section 1. B. In-patient Accidental
& Medical Treatment and not under the maternity benefit.
c) Pre-natal and post-natal medical expenses are not covered unless leading to your hospitalization.
B. New Born Baby Benefit

Digit Simplification: Your babies need all the love, care and cover they can get.
Under this cover, we will also pay the medical expenses, within the limit of the sum insured available under
the Section 7. A Maternity Benefit Section of the policy, provided that we have accepted a claim under
Section 7. A. Maternity Benefit, incurred towards:
a) The medical treatment of the insured’s new born baby while insured person is hospitalised as
an in-patient for delivery.
b) The new born baby’s hospitalisation charges as a result of any medical complications,
up to 90 days from the date of delivery.

c) Reasonable and customary charges for the vaccinations of the new born baby as per National
Immunization Schedule as defined by Government of India, up to 90 days from the date
of delivery. However, once the new born baby is added as an insured person under the policy, we
will pay the reasonable and customary charges for the vaccinations of the new born baby
as per National Immunization Schedule as defined by Government of India until the new born baby
attains 5 years of age, provided that the policy is continuously renewed with us without break and
with Maternity Benefit and New Born Baby Cover as a benefit since inception of the first policy.
d) If the policy expires before 90 days from the date of delivery, the new born baby will be covered
only if the policy is renewed, and taken in the name of new born baby as the insured person.
This is subject to our underwriting policy and payment of any additional premium.
e) After 90 days from the date of delivery, the new born baby will be covered under the existing
policy only if it is endorsed with the new born baby as the insured person. This is subject to our
underwriting policy and payment of the pro-rata additional premium for the balance period.
This cover is subject to terms, conditions, deductible, co-payment, limitations and exclusions mentioned
in the policy.
SECTION 8. OUT-PATIENT (OPD) BENEFIT

Digit Simplification: Expenses like doctor’s consultation fees, health check-ups, pharmacy bills, dental
treatment, diagnostic tests, etc. when you are not hospitalized are covered under this.
If You have opted for this cover, we will pay the reasonable and customary charges for below mentioned
expenses incurred by you as an allopathic out-patient when treatment is taken from a Network Medical
Practitioner to the extent of the sum insured opted by you and mentioned in Your your policy schedule /
certificate of insurance against this section and subject to the Co-payment Basis Opted by You
Basis 1: Co-payment of 25% in the First Year of this Section being Opted, 10% on First Renewal. From
the Second Renewal, there will be no Co-payment, provided the Policy is renewed with Us continuously
without a break with this benefit.
Basis 2: Nil Co-payment
What all is covered under this:
Fees for medically necessary consultation and examination by

Professional Fees
medical practitioners to assess your health for any illness.
Medically necessary out-patient diagnostic procedures such as

Diagnostic x-rays, pathology, brain and body scans (MRI, CT scans) etc. used
to make a diagnosis for treatment from a diagnostic centre.
Minor Surgical procedure such as POP, suturing, dressings for

Surgical Treatment accidents and animal bite related outpatient procedures etc.
carried out by a Medical Practitioner.
Medication Drugs and medicines prescribed by a Medical Practitioner.

Out-patient dental treatment for the immediate relief of dental
pain; taken by you from a dentist, provided that we will pay only
for X-rays, extractions, amalgam or composite fillings, root canal
treatments and prescribed drugs for the same, teeth alignment
Out-Patient for adolescents. We will not pay for any dental treatment that
Dental Treatment comprises cosmetic surgery, dentures, dental prosthesis, dental
implants, orthodontics, orthognathic surgery, jaw alignment or
treatment for temporomandibular (jaw), or upper and lower jaw
bone surgery and surgery related to the temporomandibular (jaw)
unless necessitated by an acute traumatic injury or cancer.
One pair of hearing aids (excluding batteries), provided that:

• These have been prescribed by an ENT specialist or Network
Medical Practitioner.
Hearing Aids
• You have continuously renewed the policy with us without
break for a period of 36 months with Out-Patient (OPD)
Benefit as a benefit, since inception of the first policy.
Specialist consultation, assessment, treatment and medication for

Psychiatric Illness
psychiatric disorders.
This cover excludes expenses incurred towards Spectacles, Contact Lenses and Physiotherapy, Cosmetic
Procedures, Ambulatory Devices like Walkers, BP Monitors, Glucometers, Thermometers, Dietician Fees,
Vitamins and Supplements.
the policy.
SECTION 9. HOME (DOMICILIARY) HOSPITALIZATION

Digit Simplification: Sometimes, admitting the patient in a hospital is not possible!
If you have opted for this cover, we will pay the medical expenses incurred by you for any illness or injury
requiring medical treatment taken at home, which would otherwise have required hospitalization, provided that:
a) The condition of the patient is such that he/she is not in a getting the patient admitted condition
to be moved to a hospital.
b) The patient takes treatment at home on account of non-availability of room in a hospital.
c) The condition for which the medical treatment is required continues for at least 3 days, in which
case we will pay the reasonable charge of any necessary medical treatment for the entire period.
d) No payment will be made if the condition for which you require medical treatment is due to:
Asthma, Bronchitis, Tonsillitis, Upper Respiratory Tract Infection including Laryngitis and
Pharyngitis, Cough and Cold, Influenza, Arthritis, Gout and Rheumatism, Chronic Nephritis and
Nephritic Syndrome, Diarrhoea and all types of Dysenteries including Gastroenteritis, Diabetes
Mellitus and Insipidus, Epilepsy, Hypertension, Psychiatric or Psychosomatic Disorders of all kinds,
Pyrexia of unknown origin.
e) Subject to availability of the sum insured under Section 1.A. Accidental Hospitalization Cover
and/or Section 1.B. Accidental & Illness Hospitalization Cover.
the policy.

SECTION 10. SUM INSURED REFILL BENEFIT
Digit Simplification: We refill your sum insured after you completely exhaust it.
If you have opted for this cover, we will refill 100% of the sum insured specified and utilized under
Section 1.A. Accidental Hospitalization Cover and/or Section 1.B. Accidental & Illness Hospitalization
Cover for that particular policy period, provided that:
a) The refilled sum insured would be triggered only if the cause of the hospitalization is not related
to / arising out of earlier hospitalization, including its complications, for which a claim has already
been availed during the same policy period for the same insured person, unless this condition is
specifically waived by us and mentioned in Your Policy Schedule / Certificate of Insurance.
b) If the first claim amount exceeds the sum insured under Section 1.A. Accidental Hospitalization
Cover and / or Section 1.B. Accidental & Illness Hospitalization Cover, the refilled sum insured
will not be applicable for the same hospitalization.
c) After the refill, the maximum amount payable for any single claim will not exceed the sum insured
mentioned under Section 1.A. Accidental Hospitalization Cover and/or Section 1.B. Accidental &
Illness Hospitalization Cover.
d) The number of times this benefit may be availed shall be as per the limit mentioned in your policy
schedule / certificate of insurance against this section during each policy period.
e) In case of Floater Policy, the refilled sum insured will be applicable on family floater basis.
the policy.
SECTION 11. DAILY HOSPITAL CASH COVER

Digit Simplification: Staying in the hospital has expenditure beyond hospital bills.
A. Accidental Hospitalization Cover

You have opted for this cover, we agree to pay a daily cash allowance, amount for this is mentioned in
your policy schedule / certificate of insurance against this section. This will be paid for each continuous
and completed period of 24 hours of Hospitalisation arising out of accident for a maximum number of
days as mentioned in your policy schedule / certificate of insurance against this section.
If You are hospitalised in the Intensive Care Unit (ICU) of a hospital for each continuous and
completed period of 24 hours, we will pay twice the Daily Cash Allowance amount mentioned in the
policy schedule / certificate of insurance against this section.
Payment of claim under this benefit is subject to the time excess as opted by you and mentioned in
your policy schedule / certificate of insurance against this section.
B. Accidental & Illness Hospitalization Cover

If you have opted for this cover, we agree to pay a Daily Cash Allowance, amount for this will be
mentioned in your policy schedule / certificate of insurance against this section. This will be paid for
each continuous and completed period of 24 hours of Hospitalization arising out of accident or illness
for a maximum number of days as mentioned in policy schedule / certificate of insurance against
this section.
If you are hospitalized in the Intensive Care Unit (ICU) of a hospital for each continuous and completed
period of 24 hours, we will pay twice the Daily Cash Allowance amount mentioned in the policy schedule
/ certificate of insurance against this section.
Payment of claim under this benefit is subject to the time excess as opted by you and mentioned in your
policy schedule / certificate of insurance against this section.

SECTION 12. CRITICAL ILLNESS BENEFIT COVER
Digit Simplification: We are with you for the best of times, and the worst of times.
If you have opted for this cover, we will pay you the sum insured as mentioned in your policy schedule /
certificate of insurance against this section. In case You are diagnosed as suffering from any of the Critical
Illnesses or undergoing covered surgical procedures as specified below provided that,
a) This Critical Illness or covered surgical procedure has happened to you for the first time in your life.
b) We will not make any payment if you are diagnosed as suffering from Critical Illness within
the number of days (i.e. Initial Waiting Period) mentioned in Your Policy Schedule/Certificate of
Insurance from the date of inception of first policy with us.
c) You survive for a minimum period of at least 30 days from the date of diagnosis of such Critical Illness
unless this condition is specifically waived by Us.
d) The Critical Illness or the surgical procedure claim is not a consequence of or arising out of
any pre-existing condition/disease.
e) Once a claim has been paid under Critical Illness and / or surgical procedure, cover under this
section shall cease and no further payment will be made for any consequent disease or any
dependent disease.
Critical Illness means the following major disease, which you have been diagnosed during the policy period
to have suffered from and which requires hospitalization and are specifically defined as below:
Sr. No. Category Critical Illness
1 Malignancy Cancer of Specified Severity
2 Myocardial Infarction
3 Open Heart Replacement or Repair of Heart Valves
4 Cardiovascular System Surgery to Aorta
5 Primary (Idiopathic) Pulmonary Hypertension
6 Open Chest CABG

7 End Stage Lung Failure
8 End Stage Liver Failure

Major Organ Transplant
9 Kidney Failure Requiring Regular Dialysis
10 Major Organ / Bone Marrow Transplant
11 Apallic Syndrome
12 Benign Brain Tumour
13 Coma of Specified Severity
14 Major Head Trauma

Nervous System
15 Permanent Paralysis of Limbs
16 Stroke Resulting in Permanent Symptoms
17 Motor Neurone Disease with Permanent Symptoms
18 Multiple Sclerosis with Persisting Symptoms
19 Loss of Independent Existence

Others
20 Aplastic Anaemia
SECTION 13. CRITICAL ILLNESS HOSPITALIZATION COVER

Digit Simplification: In times like these, you’ll need all the help you can get.
If you have opted for this cover and you are diagnosed as suffering from any of the Critical Illnesses or
undergoing covered surgical procedures as specified below, during the policy period, we will pay you
all reasonable and customary charges that are medically necessary and incurred by you in respect of
an admissible hospitalization claim, up to the sum insured mentioned in policy schedule / certificate of
insurance against this section.
Provided that,
a) This Critical Illness or covered surgical procedure has happened to you for the first time in your life.
b) We will not make any payment if you are diagnosed as suffering from Critical Illness
and hospitalized within the number of days (i.e. Initial Waiting Period) mentioned in Your Policy
Schedule/Certificate of Insurance from the date of inception of first policy with us.
c) No claim under this option shall be admissible if the Critical Illness or the surgical procedure
is a consequence of or arising out of any pre-existing condition/disease.

Hospital accommodation in a ward, shared or private room
subject to a Limit Per Day as opted by you and mentioned in policy
schedule / certificate of insurance against this section.
Note: If You have opted for a limit on “Accommodation/Room
Rent” and the room rent rate exceeds the limits at the time of
Admissible Rate Per Day limit opted bears to the Actual Rate Per
Day of Room Rent Charges except for the cost of medicines and
Accommodation/Room Rent consumables.
related to your treatment like Doctor’s fees, also increase with the

Professional Fees
anaesthetists.

medical practitioner. This also includes anaesthesia, blood, oxygen,
Medication
Necessary procedures such as X-rays, pathology, brain and body

Diagnostic
Critical Illness means the following major disease which you have been diagnosed during the policy period
to have suffered from and which requires hospitalization and are specifically defined as below:

Sr. No. Category Critical Illness
1 Malignancy Cancer of Specified Severity
2 Myocardial Infarction
3 Open Heart Replacement or Repair of Heart Valves
4 Cardiovascular System Surgery to Aorta
5 Primary (Idiopathic) Pulmonary Hypertension
6 Open Chest CABG
7 End Stage Lung Failure
8 End Stage Liver Failure

Major Organ Transplant
9 Kidney Failure Requiring Regular Dialysis
10 Major Organ / Bone Marrow Transplant
11 Apallic Syndrome
12 Benign Brain Tumour
13 Coma of Specified Severity
14 Major Head Trauma

Nervous System
15 Permanent Paralysis of Limbs
16 Stroke Resulting in Permanent Symptoms
17 Motor Neurone Disease with Permanent Symptoms
18 Multiple Sclerosis with Persisting Symptoms
19 Loss of Independent Existence

Others
20 Aplastic Anaemia

Critical Illness Definitions Applicable to Section 12 & Section 13 Above:
Digit Simplification: What all is covered and what is not. everything in black and white for you!
1 CANCER OF SPECIFIED SEVERITY

I. A malignant tumor characterized by the uncontrolled growth and spread of malignant
cells with invasion and destruction of normal tissues. This diagnosis must be supported
by histological evidence of malignancy. The term cancer includes leukemia,
lymphoma and sarcoma.
II. The following are excluded –
i. All tumors which are histologically described as carcinoma in situ, benign, pre-
malignant, borderline malignant, low malignant potential, neoplasm of unknown
behavior, or non-invasive, including but not limited to: Carcinoma in situ of breasts,
Cervical Dysplasia CIN-1, CIN-2 and CIN-3;
ii. Any non-melanoma skin carcinoma unless there is evidence of metastases to lymph
nodes or beyond;
iii. Malignant melanoma that has not caused invasion beyond the epidermis;
iv. All tumors of the prostate unless histologically classified as having a Gleason score
greater than 6 or having progressed to at least clinical TNM classification T2N0M0
v. All Thyroid cancers histologically classified as T1N0M0 (TNM Classification) or below;

vi. Chronic lymphocytic leukaemia less than RAI Stage 3;
vii. Non-invasive papillary cancer of the bladder histologically described as TaN0M0 or of
a lesser classification;
viii. All gastro-intestinal stromal tumors histologically classified as T1N0M0 (TNM
Classification) or below and with mitotic count of less than or equal to 5/50 HPFs;
ix. All tumors in the presence of HIV infection.
2 MYOCARDIAL INFARCTION
(First Heart Attack of specific severity)
I. The first occurrence of heart attack or myocardial infarction, which means the death of a
portion of the heart muscle as a result of inadequate blood supply to the relevant area.
The diagnosis for Myocardial Infarction should be evidenced by all of the following criteria:
i. A history of typical clinical symptoms consistent with the diagnosis of acute
myocardial infarction (For e.g. typical chest pain).
ii. New characteristic electrocardiogram changes.
iii. Elevation of infarction specific enzymes, Troponins or other specific biochemical markers.
II. The following are excluded:
i. Other acute coronary syndromes.
ii. Any type of angina pectoris.
iii. A rise in cardiac biomarkers or Troponin T or I in absence of overt ischemic heart
disease OR following an intra-arterial cardiac procedure.

3 OPEN HEART REPLACEMENT OR REPAIR OF HEART VALVES
The actual undergoing of open-heart valve surgery is to replace or repair one or more heart
valves, as a consequence of defects in, abnormalities of, or disease-affected cardiac valve(s).
The diagnosis of the valve abnormality must be supported by an echocardiography and the
realization of surgery has to be confirmed by a specialist medical practitioner. Catheter based
techniques including but not limited to balloon valvotomy/valvuloplasty are excluded.
4 SURGERY TO AORTA
The actual undergoing of major surgery to repair or correct an aneurysm, narrowing, obstruction
or dissection of the aorta through surgical opening of the chest or abdomen. For the purpose of
this definition, aorta shall mean the thoracic and abdominal aorta but not its branches.
5 PRIMARY (IDIOPATHIC) PULMONARY HYPERTENSION

I. An unequivocal diagnosis of Primary (Idiopathic) Pulmonary Hypertension by a Cardiologist
or specialist in respiratory medicine with evidence of right ventricular enlargement and the
pulmonary artery pressure above 30 mm of Hg on Cardiac Cauterization. There must be
permanent irreversible physical impairment to the degree of at least Class IV of the New
York Heart Association Classification of cardiac impairment.
II. The NYHA Classification of Cardiac Impairment are as follows:
i. Class III: Marked limitation of physical activity. Comfortable at rest,
but less than ordinary activity causes symptoms.
ii. Class IV: Unable to engage in any physical activity without discomfort. Symptoms may
be present even at rest.
III. Pulmonary hypertension associated with lung disease, chronic hypoventilation, pulmonary
thromboembolic disease, drugs and toxins, diseases of the left side of the heart, congenital
heart disease and any secondary cause are specifically excluded.
6 OPEN CHEST CABG

I. The actual undergoing of heart surgery to correct blockage or narrowing in one or more
coronary artery(s), by coronary artery bypass grafting done via a sternotomy (cutting
through the breast bone) or minimally invasive keyhole coronary artery bypass procedures.
The diagnosis must be supported by a coronary angiography and the realization of surgery
has to be confirmed by a cardiologist.
i. Angioplasty and / or any other intra-arterial procedures
7 END-STAGE LUNG FAILURE

End stage lung disease, causing chronic respiratory failure, as confirmed and evidenced
by all of the following:
i. FEV1 test results consistently less than 1 litre measured on 3 occasions 3 months apart; and
ii. Requiring continuous permanent supplementary oxygen therapy for hypoxemia; and
iii. Arterial blood gas analysis with partial oxygen pressure of 55mmHg or less
(PaO2 < 55mmHg); and
iv. Dyspnoea at rest.

8 END-STAGE LIVER FAILURE
I. Permanent and irreversible failure of liver function that has resulted in all three of the following:
i. Permanent jaundice; and
ii. Ascites; and
iii. Hepatic encephalopathy.
II. Liver failure secondary to drug or alcohol abuse is excluded.
9 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 (haemodialysis or peritoneal dialysis) is instituted
or renal transplantation is carried out. Diagnosis has to be confirmed by a specialist medical
practitioner.
10 MAJOR ORGAN / BONE MARROW TRANSPLANT

I. The actual undergoing of a transplant of:
i. One of the following human organs: heart, lung, liver, kidney, pancreas, that resulted
from irreversible end-stage failure of the relevant organ, or
ii. Human bone marrow using haematopoietic stem cells. The undergoing of a transplant
has to be confirmed by a specialist medical practitioner.
i. Other stem-cell transplants
ii. Where only Islets of Langerhans are transplanted
11 APALLIC SYNDROME
Universal necrosis of the brain cortex, with the brain stem intact. Diagnosis must be definitely
confirmed by a Registered Medical Practitioner who is also a Neurologist holding such an
appointment at an approved hospital. This condition must be documented for at least one (1) month.
12 BENIGN BRAIN TUMOR

I. Benign brain tumor is defined as a life threatening, non-cancerous tumor in the brain,
cranial nerves or meninges within the skull. The presence of the underlying tumor must be
confirmed by imaging studies such as CT scan or MRI.
II. This brain tumor must result in at least one of the following and must be confirmed by the
relevant medical specialist.
i. Permanent Neurological deficit with persisting clinical symptoms for a continuous period
of at least 90 consecutive days or
ii. Undergone surgical resection or radiation therapy to treat the brain tumor.
III. The following conditions are excluded:
Cysts, granulomas, malformations in the arteries or veins of the brain, hematomas,
abscesses, pituitary tumors, tumors of skull bones and tumors of the spinal cord.

13 COMA OF SPECIFIED SEVERITY
I. A state of unconsciousness with no reaction or response to external stimuli or internal needs.
This diagnosis must be supported by evidence of all of the following:
i. no response to external stimuli continuously for at least 96 hours;
ii. life support measures are necessary to sustain life; and
iii. permanent neurological deficit which must be assessed at least 30 days after the onset
of the coma.
II. The condition has to be confirmed by a specialist medical practitioner. Coma resulting directly
from alcohol or drug abuse is excluded.
14 MAJOR HEAD TRAUMA

I. Accidental head injury resulting in permanent Neurological deficit is to be assessed no sooner
than 3 months from the date of the accident. This diagnosis must be supported by unequivocal
findings on Magnetic Resonance Imaging, Computerized Tomography, or other reliable imaging
techniques. The accident must be caused solely and directly by accidental, violent, external and
visible means, and independently of all other causes.
II. The accidental head injury must result in an inability to perform at least three (3) of the
following Activities of Daily Living either with or without the use of mechanical equipment,
special devices or other aids and adaptations in use for disabled persons. For the purpose of this
benefit, the word “permanent” shall mean beyond the scope of recovery with current medical
knowledge and technology.
III. The Activities of Daily Living are:
i. Washing: the ability to wash in the bath or shower (including getting into and out of the
bath or shower) or wash satisfactorily by other means;
ii. Dressing: the ability to put on, take off, secure and unfasten all garments and, as
appropriate, any braces, artificial limbs or other surgical appliances;
iii. Transferring: the ability to move from a bed to an upright chair or wheelchair and vice
versa;
iv. Mobility: the ability to move indoors from room to room on level surfaces;
v. Toileting: the ability to use the lavatory or otherwise manage bowel and bladder functions
so as to maintain a satisfactory level of personal hygiene;
vi. Feeding: the ability to feed oneself once food has been prepared and made available.
IV. The following are excluded:
i. Spinal cord injury
15 PERMANENT PARALYSIS OF LIMBS

Total and irreversible loss of use of two or more limbs as a result of injury or disease of the brain
or spinal cord. A specialist medical practitioner must be of the opinion that the paralysis will be
permanent with no hope of recovery and must be present for more than 3 months.

16 STROKE RESULTING IN PERMANENT SYMPTOMS
I. Any cerebrovascular incident producing permanent neurological sequelae. This includes
infarction of brain tissue, thrombosis in an intracranial vessel, haemorrhage and
embolization from an extracranial source. Diagnosis has to be confirmed by a specialist
Medical Practitioner and evidenced by typical clinical symptoms as well as typical findings in
CT Scan or MRI of the brain. Evidence of permanent neurological deficit lasting for at least 3
months has to be produced.
a. Transient Ischemic Attacks (TIA)
b. Traumatic injury of the brain
c. Vascular disease affecting only the eye or optic nerve or vestibular functions
17 MOTOR NEURON DISEASE WITH PERMANENT SYMPTOMS

I. Motor neuron disease diagnosed by a specialist Medical Practitioner as spinal muscular
atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis or primary lateral sclerosis.
There must be progressive degeneration of corticospinal tracts and anterior horn cells
or bulbar efferent neurons. There must be current significant and permanent functional
neurological impairment with objective evidence of motor dysfunction that has persisted for
a continuous period of at least 3 months.
18 MULTIPLE SCLEROSIS WITH PERSISTING SYMPTOMS

I. The unequivocal diagnosis of Definite Multiple Sclerosis confirmed and evidenced by all of
the following:
i. investigations including typical MRI findings which unequivocally confirm the diagnosis
to be multiple sclerosis and
ii. there must be current clinical impairment of motor or sensory function, which must
have persisted for a continuous period of at least 6 months.
II. Other causes of neurological damage such as SLE and HIV are excluded.
19 LOSS OF INDEPENDENT EXISTENCE

I. Confirmation by a Consultant Physician of the loss of independent existence due to illness or
trauma, lasting for a minimum period of 6 months and resulting in a permanent inability to
perform at least three (3) of the following Activities of Daily Living:
i. Washing: the ability to wash in the bath or shower (including getting into and out of the
bath or shower) or wash satisfactorily by other means;
ii. Dressing: the ability to put on, take off, secure and unfasten all garments and, as
appropriate, any braces, artificial limbs or other surgical appliances;
iii. Transferring: the ability to move from a bed to an upright chair or wheelchair and vice versa;
iv. Mobility: the ability to move indoors from room to room on level surfaces;
v. Toileting: the ability to use the lavatory or otherwise manage bowel and bladder functions
so as to maintain a satisfactory level of personal hygiene;
vi. Feeding: the ability to feed oneself once food has been prepared and made available.

20 APLASTIC ANAEMIA
I. Irreversible persistent bone marrow failure which results in anaemia, neutropenia and
thrombocytopenia requiring treatment with at least two (2) of the following:
(a) Blood product transfusion;
(b) Marrow stimulating agents;
(c) Immunosuppressive agents; or
(d) Bone marrow transplantation.
II. The diagnosis of aplastic anaemia must be confirmed by a bone marrow biopsy. Two out of
the following three values should be present:
- Absolute Neutrophil count of 500 per cubic millimetre or less;
- Absolute Reticulocyte count of 20,000 per cubic millimetre or less; and
- Platelet count of 20,000 per cubic millimetre or less.
Subject to terms, conditions, limitations and exclusions mentioned in the policy.
SECTION 14. CANCER BENEFIT COVER

Digit Simplification: The big C requires another C: Cover
If you have opted for this cover, we will pay you the sum insured as mentioned in policy schedule /
certificate of insurance against this section, in case you are diagnosed as suffering from Cancer for
specified Severity for the first time in your life, provided that,
a) We will not make any payment if you are diagnosed as suffering from Cancer for specified severity
within the number of days (i.e. Initial Waiting Period) mentioned in Your Policy Schedule/
Certificate of Insurance from the date of inception of first policy with us.
b) You survive for a minimum period of at least 30 days from the date of diagnosis of such Cancer for
specified severity, unless this condition is specifically waived by Us
c) No claim under this option shall be admissible if the Cancer is a consequence of or arising out of
any pre-existing condition / disease, except for pre-existing condition / disease which were
disclosed by the Insured and accepted by Us at the time of buying the Policy with Us,
where this benefit is opted.
d) Cover under this section shall cease upon payment of the compensation on the happening of a
Cancer for specified severity and no further payment will be made for any consequent disease or
any dependent disease.
For this Cover, “CANCER OF SPECIFIED SEVERITY” means:

I. A malignant tumor characterized by the uncontrolled growth and spread of malignant cells with
invasion and destruction of normal tissues. This diagnosis must be supported by histological
evidence of malignancy. The term Cancer includes leukemia, lymphoma and sarcoma.
i. All tumors which are histologically described as carcinoma in situ, benign, pre-malignant,
borderline malignant, low malignant potential, neoplasm of unknown behavior, or non-invasive,
including but not limited to: Carcinoma in situ of breasts, Cervical Dysplasia CIN-1, CIN-2 and CIN-3.
ii. Any non-melanoma skin carcinoma unless there is evidence of metastases to lymph nodes or beyond;

iv. All tumors of the prostate unless histologically classified as having a Gleason score greater
than 6 or having progressed to at least clinical TNM classification T2N0M0;
vii. Non-invasive papillary cancer of the bladder histologically described as TaN0M0 or
of a lesser classification;
viii. All Gastro-Intestinal Stromal Tumors histologically classified as T1N0M0 (TNM Classification)
or below and with mitotic count of less than or equal to 5/50 HPFs;
SECTION 15. CANCER HOSPITALIZATION COVER

Digit Simplification: There is life after cancer. And we make sure you have quality of life.
If you have opted for this cover and you are diagnosed as suffering from Cancer for specified severity for
the first time in your life during the policy period, We will pay you all reasonable and customary charges
that are medically necessary and incurred by you in respect of an admissible hospitalization claim for
Cancer for specified severity up to the sum insured mentioned in your policy schedule / certificate of
insurance against this section.
Provided that:
a) We will not make any payment if you are diagnosed as suffering from Cancer for specified severity
and hospitalized within the number of days (i.e. Initial Waiting Period) mentioned in Your Policy
Schedule/Certificate of Insurance from the date of inception of first policy with us.
b) No claim under this option shall be admissible if Cancer is a consequence of or arising out
of any pre-existing condition/disease, except for pre-existing condition / disease which were
disclosed by the Insured and accepted by Us at the time of buying the Policy with Us,
where this benefit is opted.

to a Limit Per Day as opted by you and mentioned in your policy
schedule / certificate of insurance against this section.
Note: If You have opted for a Limit on “Accommodation/Room
Rent” and the Room Rent Rate exceeds the limits at the time of
Admissible Rate Per Day limit opted bears to the Actual Rate Per
Day of Room Rent Charges except for the cost of medicines and
Accommodation/Room Rent consumables.
Example: If You have opted a room rent limit of ₹1,500 per day
related to your treatment like Doctor’s fees, also increase with the

Professional Fees
anaesthetists.

medical practitioner. This also includes anaesthesia, blood, oxygen,
Medication

Necessary procedures such as X-rays, pathology, brain and body
Diagnostic
For this Cover, “CANCER OF SPECIFIED SEVERITY” means:

I. A malignant tumor characterized by the uncontrolled growth and spread of malignant cells with
invasion and destruction of normal tissues. This diagnosis must be supported by histological
evidence of malignancy. The term cancer includes leukemia, lymphoma and sarcoma.
i. All tumors which are histologically described as carcinoma in situ, benign, pre-malignant, borderline
malignant, low malignant potential, neoplasm of unknown behavior, or non-invasive, including but
not limited to: Carcinoma in situ of breasts, Cervical Dysplasia CIN-1, CIN-2 and CIN-3.
ii. Any non-melanoma skin carcinoma unless there is evidence of metastases to lymph nodes or beyond;
iv. All tumors of the prostate unless histologically classified as having a Gleason score greater than
6 or having progressed to at least clinical TNM classification T2N0M0;
vii. Non-invasive papillary cancer of the bladder histologically described as TaN0M0 or of a lesser
classification;
viii. All gastro-intestinal stromal tumors histologically classified as T1N0M0 (TNM Classification) or
below and with mitotic count of less than or equal to 5/50 HPFs;
SECTION 16. WELLNESS BENEFIT PROGRAM
Our Wellness Benefit Program provides the benefits listed below and shall be available to the Insured
Person as mentioned in the Policy Schedule/Certificate of Insurance. Through this Program, We intend to
incentivize the Insured Person(s) for taking care of his/her health/fitness and maintaining healthy lifestyle
through such preventative and wellness services.
There are total 12 services under Wellness Benefit Program. Services applicable for Your Policy are as
shown in Your Policy Schedule / Certificate of Insurance. Only services mentioned in your Policy Schedule/
Certificate of Insurance are available for You.
Upon Your request, We will facilitate an appointment,

through Our empanelled Service Provider, with a
Medical Practitioner who can help You by providing
Doctor on Call
round-the-clock medical helpline services through an
online portal as a chat service, a call back service or
a voice call service.

In order to educate, empower and engage You to
become more aware of Your health and proactively
manage it, We will, through periodic communications
like e-mailers, blogs and online platform provide You
information on wellness coaching in areas such as:
a) Weight Management
Wellness Coach
b) Activity and Fitness
c) Nutrition
d) Tobacco Cessation
e) Alcohol Abuse de-addiction Program
f) Information on various diseases
g) Dietary Plans
Upon Your request, We will facilitate, through Our

empanelled Service Provider, Collection of test
samples such as blood, urine, stool etc from Your
Lab Services (Home Collection)
home address for further testing and analysis. The
cost of these tests and reports will have to be borne
by You.

Empanelled Service Provider, home delivery of the
Medications Prescribed by a Registered Medical
Practitioner from the nearby Network Pharmacy,
Pharmacy (Home Delivery)
subject to copy of prescription being shared (where
ever required) and availability of the medication with
the Pharmacy. The cost of the medication will have to
be borne by You.

Empanelled Service Provider, the integration of Your
Health Device(s) such as Blood-Pressure Monitors,
Glucometers, Wireless Pedometers, Smart Watches
Vital/Physical Activity Monitoring Services
etc. to an online database that will track and asses
Your vitals as reported by the device. It can provide
periodic updates and reports of your health status.
The cost of the device will have to be borne by You.

Empanelled Service Provider, routine notification
messages via mail or a messaging portal or a follow-
Reminder Notifications
up call to You as a reminder to schedule Your medical
appointments and/or take daily dosage of Your
medicine as per the information shared by You

Upon Your request, We will arrange, through Our
Empanelled Service Provider, for a medical wallet.
This will be a digital cloud service which will allow
You to store all Your medical reports online. It will
Medical Wallet provide easy access of Medical history and reports
to the treating Medical Practitioners and to any other
person with whom You may share the login and
access codes, easing Your need to physically carry
documents with You.

Empanelled Service Provider, for regular analysis of
Your health status as per the medical records/reports
Report Aggregation shared by You. It will highlight your wellbeing or
any areas of concern or deterioration in Your health,
allowing You to take necessary calls about your
health.

Empanelled Service Provider, Home Care Services for
You in case You are in need of any of the following:
a. Home Care Nursing
b. Patient Assistant
c. Physiotherapy
Home Care Services d. Yoga Trainer
e. Psychologist
f. Palliative Care
g. Renting Medical equipment. For Example -
Wheel-Chair, Patient Bed, Oxygen Cylinder etc
The cost of the Services/Equipment will have to be
borne by You"
Upon request, We will facilitate, through Our

Empanelled Service Provider, ambulance services
for Your transportation subject to availability of
Ambulance Arrangement Services
ambulance in the area where such service needs to
be arranged. The cost of the transportation will have
to be borne by You.

Empanelled Service Provider, Pick-up and Drop
Service, for Your transportation to the Health
Pick-up and Drop Services for Consultation Care Facility for treatment/Diagnostics subject to
availability of vehicle/taxi in the area where such
service needs to be arranged. The cost of the
transportation will have to be borne by You.

Upon Your request, We will facilitate, through
Our Empanelled Service Provider, prioritization of
Your appointment, based on the urgency, with the
Prioritizing Appointments Network Providers offering the necessary treatment/
diagnostics subject to availability of the service(s).
The cost of the Consultancy/Diagnostic will have to
be borne by You.
Terms and Conditions applicable to Wellness Benefit Program

1. Any Information provided by You shall be kept confidential.
2. For services which are provided through Our Empanelled Service Provider/Medical Experts/Centres,
We are acting only as a facilitator, hence We would not be liable for any incremental costs or the
services.
3. All medical services are being provided by Empanelled Service Provider/Medical Experts/Centres
who are empanelled after full due diligence. Insured Person may however consult their Personal/
Family Doctor before availing the medical services. The decisions to utilise the services will solely be
at the discretion of the Insured Person.
4. We/Company/Us or its Group Entities, affiliates, officers, employees, agents, are not responsible for
or liable for any actions, claims, demands, losses, damages, costs, charges, and expenses which an
Insured Person/You may claim to have suffered or sustained or incurred by way of or on account of
utilization of any benefits specified herein.
5. This shall not be deemed to substitute the Insured Person’s visit or consultation to an Independent
Medical Practitioner. The Insured Person is free to choose whether or not to undergo the same and
if done whether or not to act on it.
6. We do not assume any liability towards any loss or damage arising out of or in relation to any
opinion, advice, prescription, actual or alleged errors, omissions and representations made by the
Medical Practitioner.
Cumulative Bonus
Digit Simplification: At work, and in insurance premiums, bonuses are always good.
If you’ve been safe and healthy and have had no claims made under the Section 1.A. Accidental
Hospitalization Cover and/or Section 1.B. Accidental & Illness Hospitalization Cover and/or Section 13.
Critical Illness Hospitalization Cover and/or Section 15. Cancer Hospitalization Cover in the expiring
policy period, you would be eligible for cumulative bonus at the time of renewal as mentioned in your policy
schedule / certificate of insurance against this section, provided that:
1. There is an upper limit to the Cumulative Bonus you can earn. In any policy period, the accrued
Cumulative Bonus (including any carried forward Cumulative Bonuses from the previous policy)
shall not exceed the limit mentioned in your policy schedule / certificate of insurance.
2. For a Floater Policy, the Cumulative Bonus shall be available only on Floater Basis. It shall accrue
only if no claim has been made for any of the insured members during the expiring policy period.
3. In the event of a claim in the expiring policy period, the Cumulative Bonus will reduce in the same
way as it was accrued in the policy at the time of renewal.
4. If you discontinue the policy or fail to renew the policy within the Grace Period of 30 days from the
due date of renewal, the entire Cumulative Bonus will be lost.
5. The Cumulative Bonus shall be applicable on an annual basis subject to continuation of
the policy with us.

6. The Cumulative Bonus will be calculated on the sum insured as opted by You under Section 1. A.
Accidental Hospitalization Cover and/or Section 1. B. Accidental & Illness Hospitalization Cover
and/or Section 13. Critical Illness Hospitalization Cover and/or Section 15. Cancer
Hospitalization Cover.
OR
No Claim Discount
If you’ve been safe and healthy and have had no claims made under the Section 1.A. Accidental
Hospitalization Cover and/or Section 1.B. Accidental & Illness Hospitalization Cover and/or Section 13.
Critical Illness Hospitalization Cover and/or Section 15. Cancer Hospitalization Cover in the expiring
policy period, You would be eligible for a 5% No Claim Discount in the premium against these sections (if
opted by you) at the time of renewal.
However, if there is a claim made under the Section 1.A. Accidental Hospitalization Cover and / or
Section 1.B. Accidental & Illness Hospitalization Cover and / or Section 13. Critical Illness
Hospitalization Cover and / or Section 15. Cancer Hospitalization Cover in the expiring policy period,
your premium against these sections (if opted by you) will be loaded by 10% at the time of renewal.
Note: Cumulative Bonus or No Claim Discount opted at the inception of the first policy with us can’t
be changed during the policy period and subsequent renewals.
WAITING PERIODS
Digit Simplification: Some covers have a defined period during which you cannot make claims.
We are not liable to pay for any expenses arising out of any treatment which begins during waiting periods
except if you suffer an accident.
A. Initial Waiting Period

Any disease contracted by you during the initial (first) number of days as opted by you and mentioned in
your policy schedule / certificate of insurance against this section. from the commencement date of this
policy unless:
1. You have been insured under this policy continuously and without any break in
the previous policy year, or
2. As per portability guidelines, you have been insured continuously and without interruption for
at least 1 year under any other Indian insurer’s health insurance policy for the reimbursement
of medical costs for inpatient treatment in a hospital, and you are able to submit relevant
documents to establish that you were unaware of and had not taken any advice or medication
for such Illness or treatment.
If on renewal or portability, the sum insured is increased, there is a fresh waiting period applied to the
increased part of the sum insured only.
This Waiting Period is not applicable to Section 1 - A. Accidental Hospitalization Cover
B. Pre-existing Disease
Pre-existing Disease as defined in this policy shall not be covered until the number of months of continuous
coverage as opted by you and mentioned in policy schedule / certificate of insurance have elapsed since
inception of the first policy with us.
However:
If you are presently covered and have been continuously covered without any break under:
(i) an individual health insurance plan with an Indian insurer for the reimbursement of medical costs
for in-patient treatment in a hospital, OR

(ii) any other similar health insurance plan from us,
then, pre-existing disease exclusion of the policy shall apply as below:
a) The waiting period of all pre-existing disease shall be reduced by the number of your continuous
preceding years of coverage under the previous health insurance policy.
Example, if a disease has a waiting period of 2 years and one year is already completed according to your
last policy, then when you renew with us, the Waiting Period will not be 2 years, it will only be 1 year.
b) If the proposed sum insured for you is more than the sum insured applicable under the previous
health insurance policy, then the reduced waiting period shall only apply to the extent of the
sum insured under the previous health insurance policy.
Example, if you have increased the sum insured by 2 lakhs while renewing your policy, fresh waiting
period for pre-existing disease, will be applied to this increased part of sum insured.
C. Specific Waiting Periods

Specific Illness
The illnesses and treatments listed below will be covered subject to a waiting period as opted by you and
mentioned in your policy schedule / certificate of insurance as long as the insured person has been insured
continuously under the policy without any break:
a. Non-infective Arthritis, Osteoarthritis and Osteoporosis (if age related), Systemic Connective Tissue
Disorders, Dorsopathies, Spondylopathies, Inflammatory Polyarthropathies, Arthrosis and
Intervertebral Disorders (unless due to accident)
b. Pancreatitis, Calculus disease of gall bladder/biliary tract and urogenital system, Gastric &
Duodenal Erosions/Ulcers, Varices of GI Tract, Cirrhosis of Liver, Rectal Prolapse
c. Cataract, Glaucoma and Disorder of Retina
d. Hyperplasia of Prostate, Urethral Strictures, Hydrocele/Varicocele and Spermatocele
e. All abnormal Utero-vaginal bleeding, female Genital Prolapse, Endometriosis / Adenomyosis,
Fibroids, Ovarian Cyst, Pelvic Inflammatory Disease
f. Haemorrhoids, Fissure, Fistula and Pilonidal Sinus / Cyst and Fistula
g. Hernia of all sites
h. Chronic Kidney disease and failure
i. Diabetes and its related complications
j. Ischemic heart disease and Valvular heart diseases
k. Varicose veins of lower extremities
l. Disease of middle ear and mastoid including otitis Media, Cholesteatoma, Perforation of Tympanic
Membrane, Sinusitis, Tonsillitis, Adenoid Hypertrophy, Nasal Septum Deviation, Turbinate
Hypertrophy, Nasal Polyp, Mastoiditis, Nasal Concha Bullosa
m. All internal and external benign or In Situ Neoplasms/Tumours, Cyst, Sinus, Polyp, Nodules,
Swelling, Mass or Lump including breast lumps (each of any kind unless malignant)
n. Internal Congenital Anomaly
o. Psychiatric illness
p. Neurodegenerative disorders including but not limited to Alzheimer’s disease and Parkinson’s disease

2. Joint Replacement, Bariatric Surgery and Organ Transplant
Any medical expenses incurred as a result of Joint Replacement, Bariatric Surgery and Organ Transplant
Surgery will be covered subject to a waiting period as opted by you and mentioned in your policy schedule
/ certificate of insurance as long as the insured person has been insured continuously under the policy
without any break, unless due to an accident.
If on renewal with us or on transfer from any other insurer, the sum insured is increased, there will be a
fresh waiting period applied to the increased part of sum insured.
You will be given the portability credit of the waiting period based on the number of years of continuous
and uninterrupted insurance cover.
Take Note:
• Waiting period for other sections opted by you would be as mentioned in your policy schedule /
certificate of insurance against the respective sections.
• Waiting period, wherever mentioned and applicable for different sections are applicable for each
individual insured person separately.
General Exclusions
Digit Simplification: We believe in being transparent with you, no hidden terms and conditions. So, here’s
what you are not covered for:
We shall not be liable to make any claim payment under this policy directly or indirectly caused by,
based on, arising out of or howsoever attributable to any of the following, unless specifically agreed and
mentioned elsewhere in the policy schedule / certificate of insurance.
STANDARD ONES
1 Artificial Life Maintenance

Artificial Life Maintenance, including life support machine used, where such treatment is used
to maintain the Insured / Patient in a vegetative state
2 Breach of Law with Criminal Intent, Suicide and Self-Injury

We do not cover treatment directly or indirectly arising from or contributed or aggravated or
accelerated by any of the following:
a. Suicide or attempted suicide, while sane or insane, or due to use, misuse or abuse of narcotic
or intoxicating drugs or alcohol or solvent
b. Intentional self-injury
c. Participation in any illegal or unlawful or criminal act
d. Use or consumption of narcotic or intoxicating drugs or alcohol or solvent, or taking of drugs
(except under the direction of a Medical Practitioner)

3 Cosmetic, Aesthetic and Re-Shaping Treatment & Surgeries
a. Plastic Surgery or Cosmetic Surgery or Treatments to change your appearance (example
a tummy tuck, facelift, tattoo, ear piercing), unless necessary as a part of medically
necessary treatment certified by the attending Medical Practitioner for reconstruction
following an accident, cancer or burns
b. Treatment for alopecia, baldness, wigs, or toupees and all treatment related to the same
c. Circumcision unless necessary for the treatment of a disease or necessitated by an Accident
d. Aesthetic or change-of-life treatments of any description such as sex transformation operations
4 External Congenital Anomaly

Screening, counselling or treatment related to external Congenital Anomaly
5 Geography
Any treatment received outside India is not covered under this policy
6 Hazardous Activities / Professional Sports / Defence Operation

We will not pay any claim under this policy, whilst you are:
a. Training for or taking part in sport as a professional for which you are paid or funded by
sponsorship or grant. However, you would be covered if you participate in a non-professional
capacity for any recreational sport which may be under the supervision of a trained professional
b. Involved in naval, military, air force operation
c. Involved in any hazardous activity
7 Non-Medical Expenses
Items of personal comfort and convenience including but not limited to television (wherever
specifically charged for), charges for access to telephone and telephone calls, internet, foodstuffs
(except patient’s diet), cosmetics, hygiene articles, body care products and bath additive, barber
or beauty service, guest service as well as similar incidental services and supplies including but
not limited to charges for admission, discharge, administration, registration, documentation and
filing. (Please visit our website for complete list of non-medical items).
8 Home Care Nursing

Convalescence/ recovery, cure, rest cure, sanatorium treatment, rehabilitation measures, private
duty nursing, respite care, long-term nursing care or custodial care except to the extent covered
under SECTION 9. HOME (DOMICILIARY) HOSPITALIZATION if opted by you.
9 Insufficient Document
We have tried to reduce the number of documents you need to share but we shall not be liable
to pay any claim in case all the necessary mandatory documents as mentioned in our claims
process are not submitted to us.
10 Preventive Treatment
We do not cover inoculations, vaccinations or other treatment, for example drugs or surgery,
which aims to prevent a disease or illness except:
a. For an active vaccination for dog or animal bite
b. To the extent covered under SECTION 7. MATERNITY BENEFIT & NEW BORN BABY COVER
if opted by you

11 Reproductive Medicine & Other Maternity Expenses
Any assessment or treatment method for:
a. Birth Control
Any type of contraception, sterilization, abortions, voluntary termination of pregnancy
(except under Maternity Expenses for Medical Termination of Pregnancy (MTP) as governed
by MTP Act 1971 under Section 2.7 above) or family planning
b. Infertility
Unless you have opted for SECTION 2. INFERTILITY TREATMENT COVER, we shall not be liable
to make any payment in respect of expenses incurred towards Infertility/Subfertility including but
not limited to IVF, IUI, ZIFT, ICSI procedures and similar methods of assisted conception
c. Sexual disorder and Erectile Dysfunction
Treatment of any sexual disorder including impotence (irrespective of the cause) and sex
changes or gender reassignments or erectile dysfunction
d. Any costs or expense related to pregnancy, complications arising from pregnancy or medical
termination of pregnancy unless you have specifically opted for SECTION 7. MATERNITY
BENEFIT & NEW BORN BABY COVER
12 Sexually Transmitted Infections & Disease

Screening, prevention and treatment for sexually transmitted infection or disease including but
not limited to Genital Warts, Syphilis, Gonorrhoea, Genital Herpes, Chlamydia, Pubic Lice and
Trichomoniasis is not covered.
13 Sleep Disorders and Sleep Problems

We do not cover treatment directly or indirectly related to sleep disorders and sleep problems,
such as snoring, insomnia or sleep apnoea (when breathing stops temporarily during sleep)
including but not limited to expense related to purchase of CPAP, BIPAP or similar instruments
except as mentioned by us and covered under Section1.B6. Bariatric Surgery Cover
14 Spectacles, Hearing Aids and Other Expenses

Provision or fitting of hearing aids, spectacles or contact lenses including optometric therapy,
any treatment and associated expenses for alopecia, baldness, wigs, or toupees, medical
supplies including elastic stockings, diabetic test strips, and similar products.
15 Unproven or Experimental Treatment

We do not cover any kind of Unproven or Experimental Treatment:
a. Services including device, treatment, procedure or pharmacological regimens which are
considered as experimental, investigational or unproven
b. Stem Cell Transplant: Any stem cell transplant other than for Bone Marrow Transplant
16 Unjustified or Unwarranted Hospitalization

Admission solely for physiotherapy, evaluation, investigations, diagnosis or observation service
unless a claim is accepted under Section1 - A. Accidental Hospitalization Cover and/or B.
Accidental & Illness Hospitalization Cover.

17 Vitamins / Nutritional Supplements
Vitamins, tonics, nutritional supplements unless they form part of the treatment for injury or
disease as certified by the attending Medical Practitioner, are not covered.
18 War and Hazardous Substances

We do not cover treatment directly or indirectly arising from or required as a consequence of:
a. War, invasion, acts of foreign enemy hostilities (whether or not war is declared), civil war,
rebellion, revolution, insurrection or military or usurped power, mutiny, riot, strike, martial law
or state of siege, attempted overthrow of the government or any acts of terrorism
b. Chemical contamination or contamination by radioactivity from any nuclear material
whatsoever or from the combustion of nuclear fuel
19 Legal Liability
Any legal liability due to any errors or omission or representation or consequences of any action
taken on the part of any hospital or Medical Practitioner.
20 Substance Abuse and Addictions

Expenses incurred for the treatment of any illness or injury which is a direct or indirect consequence of:
a. Use/misuse/abuse of alcohol, opioids or nicotine or drugs (whether prescribed or not)
b. Withdrawal and de-addiction
c. Cancer of oral, oropharynx and respiratory system is specifically excluded in a tobacco user
SPECIFIC ONES (CAN’T BE WAIVED)
21 Behavioural and Neurodevelopment Disorders

Medical Expenses related to behavioural and neurodevelopment delays and disorders such as:
a. Disorders of adult personality including gender related problems, gender change
b. Learning disability including but not limited to speech and language including stammering,
dyslexia, Attention Deficit Hyperactive Disorder
c. Neurodevelopmental disorders including but not limited to cerebral palsy, autism
spectrum disorder
22 Eye Sight & Optical Services

We do not cover treatment for:
d. Correction of refractive errors of the eye including but not limited to short-sight or long-sight,
such as glasses, contact lenses or laser eyesight correction surgery
e. Intravitreal injection including but not limited to Lucentis, Macugen or any other similar
treatment
23 HIV, AIDS, and related complex

We do not cover venereal disease or any other sexually transmitted diseases such as AIDS/HIV
or any other related arising out of HIV/AIDS such as ARC (AIDS related complex), Lymphomas in
brain, Kaposi’s sarcoma, tuberculosis.

24 Menopause Related Disorders
Treatment for any symptoms, illness, complications arising due to physiological conditions
associated with Menopause such as menopausal bleeding or flushing and hormonal treatment
for post-menopausal syndrome or any other similar treatments.
25 Prosthetics and Other Devices

Prosthetics and other devices NOT implanted internally by surgery.
26 Specific Treatments
We will not pay for expenses related to administration of medications or procedures including
but not limited to expense related:
a. Hyaluronic acid, Remicade or similar medications
b. Intra-articular/intra thecal or cortico-steroid injections, immunotherapy / hormonal therapy
c. Robotic surgeries however expenses will be covered up to the conventional procedure cost
d. Predictive Genome Testing
SPECIFIC ONES (CAN BE WAIVED IN LIEU OF ADDITIONAL PREMIUM)

Digit Simplification: We have tried to make the plans as customized as possible for you; therefore, you can
choose certain covers, with additional premium!
27 Dental Treatment
Treatment, procedures and preventive, diagnostic, restorative, cosmetic services related to disease,
disorder and conditions related to natural teeth and Gingiva, unless requiring hospitalization due to
accident or if you have opted for SECTION 8. OUT-PATIENT (OPD) BENEFIT.
28 Non-Allopathic Treatment
We shall not pay for any non-allopathic treatment. However, we will pay for treatments
mentioned under SECTION 4. ALTERNATE TREATMENT (AYUSH) COVER, if you have specifically
opted for it.
29 Organ Donor
Expenses incurred by you on organ donation, except for those covered under SECTION 3. ORGAN
DONOR, if opted by you.
30 Psychiatric Illness
We do not cover the medical expenses related to Psychiatric Illness including but not limited
dementia, depression, bipolar disorder, schizophrenia, anxiety disorders and obsessive-
compulsive disorders, except for those covered under Section 1 - B7. Psychiatric Illness Cover &
SECTION 8. OUT-PATIENT (OPD) BENEFIT if specifically opted.

31 Weight-loss Surgery
We do not cover treatment that is directly or indirectly related to:
Bariatric Surgery (Weight-loss Surgery), such as gastric banding or a gastric bypass, or the
removal of surplus or fat tissue, unless you have specifically opted for SECTION 1.B. Accidental &
Illness Hospitalization Cover which covers Bariatric Surgery.
General Conditions
CONDITIONS PRECEDENT TO THE CONTRACT
Digit Simplification: There are some more conditions you should be aware of that we considered before we
issued you the policy.
Zone-wise Classification
Based on your city of residence, we have classified you within three zones. In case of family floater policies, a
single zone shall be applied to all the members covered under the policy. The three zones are defined below:
Zone A Delhi/NCR, Mumbai including (Navi Mumbai, Thane and Kalyan)

Zone B Hyderabad and Secunderabad, Bangalore, Kolkata, Ahmedabad, Vadodara, Chennai, Pune and Surat
Zone C Rest of India apart from Zone A and Zone B cities are classified as Zone C
Zone opted by you is mentioned in your policy schedule / certificate of insurance.
Note:
1. If you have availed choice of Zone B at the time of policy inception and availing treatment in a
hospital which is situated in Zone A, 10% co-pay would be applicable on admissible claim amount
2. If you have availed choice of Zone C at the time of policy inception and availing treatment in a
hospital which is situated in Zone B, 10% co-pay would be applicable on admissible claim amount
3. If you have availed choice of Zone C at the time of policy inception and availing treatment in a
hospital which is situated in Zone A, 20% co-pay would be applicable on admissible claim amount
Alterations to the Policy

This policy constitutes the complete contract of insurance. This policy cannot be changed or edited by
anyone (including an insurance agent or intermediary) except us, (subject to necessary approval from the
Insurance Regulatory and Development Authority of India) and any change we make will be through a
written endorsement signed and stamped by us, only on the request from Group Manager/ Insured Member.
Condition Precedent
The adherence to the terms and conditions of this policy by you or any insured person including the
payment of premium by the due dates mentioned in the policy schedule / certificate of insurance is
necessary for us to be liable to pay you the claim money.

Non-Disclosure or Misrepresentation:
Digit Simplification: In one line, this condition means, make sure all the information you share with
us is correct!
If at the time of issuance of policy or during continuation of the policy, the information provided to us in the
proposal form either physically or electronically or otherwise, by you or the insured person or anyone acting
on behalf of you or an insured
Person is found to be incorrect, incomplete, suppressed or not disclosed, wilfully or otherwise, the policy shall be:
1. cancelled ab initio i.e. from the inception date or the renewal date (as the case may be),
2. or the policy may be modified by us, at our sole discretion, upon 30 days’ notice by sending an
endorsement to your address shown in the schedule / certificate of insurance;
3. the claim under such policy if any, shall be rejected/repudiated forthwith.
Insured Person
1. Only those persons named as an insured person in the policy schedule / certificate of insurance shall be
covered under this policy.
2. You can add more persons during the policy period but only after payment of an additional premium
and subject to acceptance of proposal by us (wherever necessary) and after we have issued an
endorsement confirming the addition of such person as an insured person.
Nominee
You can, at the inception or at any time before the expiry of the policy, make a nomination for the purpose
of payment of claims under the policy. This is paid in the event of death of the insured.
Any change of nomination should be communicated to us in writing and such change shall apply only
when an endorsement on the policy is made by us.
In case of any insured person other than you under the policy, for the purpose of payment of claims in the
event of death, the default nominee would be you.
CONDITION APPLICABLE DURING THE CONTRACT

Digit Simplification: There are some more conditions you should be aware of during the contract!
Special Conditions applicable for policies issued with premium payment on instalment basis
If you have opted for payment of premium on an instalment basis i.e. half yearly, quarterly or monthly,
as mentioned in your policy schedule / certificate of insurance the following conditions shall apply
(notwithstanding any terms contrary elsewhere in the policy).
1. Grace Period of 15 days would be given to pay the instalment premium due for the policy.
2. During such Grace Period, coverage will not be available from the instalment premium payment due
date till the date of receipt of premium by us.
3. In case of instalment premium due not received within the Grace Period the policy will get cancelled
and a fresh policy would be issued with fresh waiting periods.
Revision/Modification of the Policy

There is a possibility of revision / modification of terms, conditions, coverages and / or premiums of
this product at any time in future, with appropriate approval from IRDAI. In such an event of revision /
modification of the product, we will inform you at least 3 months prior to the date of such revision /
modification comes into effect.

Withdrawal of Product
There is possibility of withdrawal of this product at any time in future with appropriate approval from
IRDAI, as we reserve our right to do so with an intimation of 3 months to all the existing insured members.
In such an event of withdrawal of this product, at the time of your seeking extension of this policy, you can
choose, among our available similar and closely similar health insurance products. Upon choosing our new
product, you will be charged the premium as per our Underwriting Policy for such chosen new product, as
approved by IRDAI.
Cancellation
A. Cancellation by you
1. You can choose to cancel the policy, giving us a 15-day notice period by recorded delivery. This,
provided there is no claim under the policy. The insured shall be entitled for premium refund at the
company’s Short Period Scale provided in table below.
Short Period Scale
Period in Risk Premium Refund
Within 3 months 65.00%
Exceeding 3 months but less than 6 months 45.00%
Exceeding 6 months but less than 9 months 25.00%
Exceeding 9 months 0.00%
2. Free Look Period

We shall give You a Free Look Period at the inception of the first policy and:
1. You will be allowed a period of at least 15 days from the date of receipt of the policy to review
the terms and conditions of the policy and to return the same if not acceptable.
2. If you have not made any claim during the Free Look period, you shall be entitled to
a. A refund of the premium paid less any expenses incurred by us on your medical examination
and the stamp duty charges or;
b. Where the risk has already commenced and the option of return of the policy is exercised by
you, a deduction towards the proportionate risk premium for period on cover or;
c. Where only a part of the risk has commenced, such proportionate risk premium
commensurate with the risk covered during such period.
d. Free Look Period is not applicable for renewals.
B. Cancellation by Us
Policy may be cancelled by us on the grounds of misrepresentation, fraud or non-disclosure of material
facts by sending to you 15 days notice by recorded delivery at last known address/e-mail ID without refund
of premium.
Please note KYC documents (Photo ID card) shall be required at the premium refund to the Insured Member
exceeds a threshold limit of Rs. 1 Lakhs per premium refund.

CONDITIONS APPLICABLE WHEN A CLAIM ARISES
Digit Simplification: What you should know when you are about to claim.
Multiple Policies
i. If two or more policies are taken by you during the period for which you are covered under this policy
from one or more insurers, the contribution clause shall not be applicable where the cover/ benefit
offered:
- is fixed in nature i.e. Critical Illness Benefit Cover, Cancer Benefit Cover and Daily Hospital
Cash Benefit Cover,
- does not have any relation to the treatment costs;
ii. If you are covered under multiple policies providing Critical Illness Benefit, Cancer Benefit and Daily
Hospital Cash Benefits, we shall make the claim payments independent of payments received
under other similar polices in respect of the covered event.
iii. If two or more policies are taken from one or more insurers by you during the time for which you are
covered under this policy for indemnification of your hospitalization treatment costs, we shall not
apply the contribution clause and you shall have the following rights:
- You may choose to get the settlement of claim from us as long as the claim is within the
limits of and according to terms and conditions of the policy.
- If the amount to be claimed exceeds the sum insured under a single policy after consideration of
the deductible and co-pay, you shall have the right to choose any insurers including us from whom
you want to claim the balance amount .
- Except for the Critical Illness Benefit, Cancer Benefit and Daily Hospital Cash Benefits, if in case
you have taken policies from us and one or more insurers to cover the same risk on indemnity basis,
you shall only be indemnified the hospitalisation costs in accordance with the terms and condition
of the policy.
Fraudulent/Unfounded Claims
If any claim under this policy is in any respect fraudulent or unfounded, all benefits paid and/or payable in
relation to that claim shall be forfeited and (if appropriate) recovered. In addition, all covers with respect to
the insured person shall be cancelled from policy period start date without any refund of premiums.
Arbitration
If we have any differences with respect to the claim amount to be paid under this policy, it will be referred
to arbitration in accordance with the Indian Arbitration and Conciliation Act 1996, as amended. The
making of an award under such arbitration proceedings shall be a condition precedent for the company to
be liable to make any payment under this policy.
Claims Notification and Procedure

In the event of any accidental injury or illness or condition that may result in a claim under this policy, it is a
condition precedent to our liability under the policy that below procedure should be followed depending on
the type of claim:
A. Cashless Claim Process:

Cashless Facility can be availed from our network hospitals only. This is facilitated by our Service Provider /
Third Party Administrator (TPA) and we would make a direct payment to the Network Hospital to the
extent of our liability provided that:
1. We are given a notice at least 72 hours before any planned hospitalization or within 24 Hours of
hospitalization in case of an emergency situation.

2. For Cashless Facility you shall follow the below procedure:
a. Share the Health Card/Copy of E-Cards along with ID proof with the hospital authority and
obtain the Pre-Authorization Form from the hospital.
b. Submit duly filled-in and signed Pre-Authorization Form at the hospital counter.
c. Ensure that the hospital shares the duly filled-in and signed Pre-Authorization Form to Service
Provider / Third Party Administrator (TPA) for further processing.
d. Service Provider / Third Party Administrator (TPA) will inform the decision and may issue
authorization letter depending on the policy terms and conditions to the hospital directly.
e. Once the request for pre-authorization has been granted, the treatment must take place within
15 days of the Pre-Authorization Approval Date or the policy expiry date, whichever is earlier and
shall be valid only if all the details of the authorised details, hospital and location including dates
match with the details of the actual treatment received.
f. We reserve the right to modify, add or restrict any Network Provider for Cashless Facility at our
sole discretion. Before availing Cashless Facility, please check the applicable updated list of
Network Providers.
g. For any queries designated Service Provider / Third Party Administrator (TPA) may be contacted
on the contact details mentioned on the Health Card/Copy of E-Cards issued to you.
B. Reimbursement Claim Process:

Reimbursement Facility can be availed from any hospital within India of your choice wherein you will
have to make payment directly to the hospital and submit the documents to Service Provider / Third Party
Administrator (TPA) for processing the reimbursement of the claim amount provided that:
1. We or Our Service Provider / Third Party Administrator (TPA) should be intimated within 48 hours
of date of admission.
2. For Reimbursement Claim you shall follow the below procedure:

a. Within 30 days from the date of discharge, you should submit all original documents pertaining to
the hospitalization as mentioned is the List of Claim Documents.
b. On receipt of intimation from you regarding a claim under the policy, we are entitled to investigate
and obtain information on the alleged injury or illness requiring hospitalization, if required,
c. All claims shall be settled / repudiated within 30 days from the date of receipt of the last necessary
claim document subject to the policy terms and conditions. In case of any delay in payment for
all approved claims beyond 30 day from the receipt of the last necessary claim document, we shall
be liable to pay interest at a rate which is 2% above the bank rate prevalent at the beginning of
the financial year in which the claim is reviewed by you.
d. In case of your death, we shall reimburse the claim amount to your nominee as named
in your policy schedule / certificate of insurance or your legal representative holding a valid
succession certificate.
Hospitalization Out-Patient Critical Illness/ Daily Hospital

Sr. No List of Documents / Information
Claim (OPD) Claim Cancer Claim Cash Claim
Duly Filled and Signed

1 √ √ √ √
Claim Form
2 Discharge Summary √ × × √
Medical Records (Indoor Case

3 Papers, OT notes, PAC Notes √ × √ ×
etc.)

4 Original Hospital Main Bill √ × × ×
5 Original Hospital Bill Break-up √ × × ×
6 Original Pharmacy Bills √ √ × ×
Prescriptions for the medicines

purchased (except hospital
7 √ √ × ×
supply) and investigations
done outside the hospital
8 Consultation Papers √ √ √ ×
9 Investigation Reports √ √ √ ×
Digital Images/CDs of the

10 Investigation Procedures √ √ × ×
(if required)
11 MLC/FIR Report (If applicable) √ × √ ×
Original Invoice/Sticker
12 √ × × ×
(If applicable)
Post Mortem Report

13 √ × × ×
(If applicable)
Disability Certificate
14 √ × √ ×
(If applicable)
Attending Physician Certificate

15 √ × √ ×
(If applicable)
Ante-natal Record
16 √ × × ×
(If applicable)
Birth Discharge Summary

17 √ × × ×
(If applicable)
18 Death Certificate (If applicable) √ × √ ×
KYC (Photo ID card, If

19 √ √ √ √
applicable)
Bank Details with Cancelled

20 √ √ √ √
Cheque (If applicable)
Note: There are times when you or any other person who could claim on your behalf, may be in such
a state of hardship, that you or such other person is unable to give us a notice or file a claim within the
prescribed time limit. In such cases, condonation of delay can be done by waiver of conditions A.1 , B.1 and
B.2.a may be considered where the reason for delay is proved to our satisfaction.
*KYC documents shall be required at the claim settlement stage where claims pay-out to the Insured
Member exceeds a threshold limit of Rs. 1 Lakhs per claim.

CONDITIONS FOR RENEWAL OF THE CONTRACT
Renewal
i. Your policy shall ordinarily be renewable for lifetime except on grounds of fraud, moral hazard
or misrepresentation or non-cooperation by you, provided the policy is not withdrawn.
ii. We shall not deny the renewal of your policy on the ground that you had made a claim or claims in the
preceding policy years, except for benefit-based policies where the policy terminates after the payment
of sum insured under the viz Critical Illness Benefit, Cancer Benefit and Daily Hospital Cash Benefit
Section of the policy, following payment of sum insured.
iii. If you get delayed in renewing your policy, you can renew it within 30 days from the due date of
renewal . Just that the coverage will not be available for such break in period.
iv. If the policy is not renewed within the above Grace Period of 30 days from the due date of renewal, you
can still renew the policy with us. But it will then be issued as a fresh policy, subject to our underwriting
criteria and no continuing benefits shall be available from the expired policy.
Portability and Continuity Benefits

We will grant continuity of benefits which were available to the insured members under a health insurance
policy which provides similar indemnity benefits in the immediately preceding cover year provided that:
i. We shall be liable to provide continuity of only those benefits (for e.g.: initial wait period, wait period of
specific diseases pre-existing disease etc) which are applicable under this policy.
ii. Any other wait period that is applicable specific to this policy but was permanently excluded in the
previous policy will not be given any credit.
iii. Insured members covered under this policy shall have the right to migrate from this policy to an
individual health insurance policy or a family floater policy offered by our company. The credit for wait
periods would be given in the opted individual health insurance policy or a family floater policy offered
by our company. Application for this policy is made within 45 days before, but not earlier than 60 days
from the expiry of that group insurance policy.
CUSTOMER GRIEVANCE REDRESSAL POLICY

We hope that we never leave you dissatisfied. However, if you ever wish to lodge a complaint, please feel
free to call our 24 × 7 Toll free number 1800-103-4448 or email the customer service desk at
[email protected].
Senior citizens can now contact us on 1800-103-4448 or write to us at [email protected].

After investigating the matter internally and subsequent closure, we will send you our response.
If you do not get a satisfactory response from us and you wish to pursue other avenues for redressal
of grievances, you may approach Insurance Ombudsman appointed by IRDAI under the Insurance
Ombudsman Scheme.
The contact details of the Insurance Ombudsman centers are mentioned below: (Note: Address and
contact number of Governing Body of Insurance Council)
Secretary General - Governing Body Of Insurance Council, 3rd Floor, Jeevan Seva Annexe, S. V. Road,
Santacruz (W), Mumbai - 400 054. Tel.: 022 - 26106889 / 671 / 980, Fax: 022 - 26106949,
Email: [email protected], Website: http://www.ecoi.co.in/

Location Contact Details Jurisdiction of Office)
Ahmedabad Office of the Insurance Ombudsman, Jeevan Prakash Building, 6th Gujarat, Dadra & Nagar Haveli, Daman and Diu.
floor, Tilak Marg, Relief Road, Ahmedabad – 380 001. Tel.: 079-
25501201/02/05/06
Email: [email protected]
Bengaluru Office of the Insurance Ombudsman,Jeevan Soudha Building,PID Karnataka

No. 57-27-N-19,Ground Floor, 19/19, 24th Main Road,JP Nagar, Ist
Phase,Bengaluru – 560 078. Tel.: 080 - 26652048/49
Bhopal Office of the Insurance Ombudsman, Janak Vihar Complex, 2nd Madhya Pradesh, Chattisgarh
Floor, 6, Malviya Nagar, Opp. Airtel Office, Near New Market, Bho-
pal 462 003. Tel.: 0755-2769201/02, Fax: 0755-2769203
Bhubaneshwar Office of the Insurance Ombudsman, 62, Forest park, Bhubnesh- Orissa
war 751 009. Tel.: 0674-2596461 /2596455, Fax: 0674-2596429,
Chandigarh Office of the Insurance Ombudsman, S.C.O. No. 101/102/103, 2nd Punjab, Haryana, Himachal Pradesh, Jammu & Kashmir,
Floor, Batra Building, Sector 17 – D, Chandigarh 160 017. Tel.: Chandigarh.
0172-2706196/2706468, Fax: 0172-2708274
Chennai Office of the Insurance Ombudsman, Fatima Akhtar Court, 4th Tamil Nadu, Pondicherry Town and Karaikal (which are
Floor, 453, Anna Salai, Teynampet, Chennai 600 018. Tel.: 044- part of Pondicherry).
24333668/24335284, Fax: 044-24333664
Delhi Office of the Insurance Ombudsman, 2/2 A, Universal Insur- Delhi.

ance Building, Asaf Ali Road, New Delhi 110 002.Tel.: 011-
23239633/23237532, Fax: 011-23230858
Guwahati Office of the Insurance Ombudsman, Jeevan Nivesh, 5th Floor, Nr. Assam, Meghalaya, Manipur, Mizoram, Arunachal
Panbazar over bridge, S.S.Road, Guwahati 781 001. Tel.: 0361- Pradesh, Nagaland and Tripura.
2132204/2132205, Fax: 0361-2732937
Hyderabad Office of the Insurance Ombudsman,6-2-46, 1st floor, “Moin Court”, Andhra Pradesh, Telangana, Yanam and part of
Lane Opp. Saleem Function Palace, A. C. Guards, Lakdi-Ka-Pool, Territory of Pondicherry.
Hyderabad 500 004. Tel.: 040-65504123/23312122, Fax: 040-
23376599, Email: [email protected]
Jaipur Office of the Insurance Ombudsman, Jeevan Nidhi – II Bldg., Gr. Rajasthan.
Floor, Bhawani Singh Marg, Jaipur 302 005. Tel.: 0141-2740363
Ernakulam Office of the Insurance Ombudsman, 2nd Floor, Pulinat Bldg., Opp. Kerala, Lakshadweep, Mahe-a part of Pondicherry.
Cochin Shipyard, M. G. Road, Ernakulam 682 015. Tel.: 0484-
2358759/2359338, Fax: 0484-2359336
Kolkata Office of the Insurance Ombudsman, Hindustan Bldg. An- West Bengal, Sikkim, Andaman & Nicobar Islands.
nexe, 4th Floor, 4, C.R. Avenue, Kolkata 700 072. Tel.: 033-
22124339/22124340, Fax : 033-22124341

Lucknow Office of the Insurance Ombudsman, 6th Floor, Jeevan Bhawan, Districts of Uttar Pradesh: Laitpur, Jhansi, Mahoba,
Phase-II, Nawal Kishore Road, Hazratganj, Lucknow 226 001. Tel.: Hamirpur, Banda, Chitrakoot, Allahabad, Mirzapur,
0522-2231330/2231331, Fax: 0522-2231310 Sonbhabdra, Fatehpur, Pratapgarh, Jaunpur,Varanasi,
Email: [email protected] Gazipur, Jalaun, Kanpur, Lucknow, Unnao, Sitapur,
Lakhimpur, Bahraich, Barabanki, Raebareli, Sravasti,
Gonda, Faizabad, Amethi, Kaushambi, Balrampur,
Basti, Ambedkarnagar, Sultanpur, Maharajgang,
Santkabirnagar, Azamgarh, Kushinagar, Gorkhpur,
Deoria, Mau, Ghazipur, Chandauli, Ballia,
Sidharathnagar.
Mumbai Office of the Insurance Ombudsman, 3rd Floor, Jeevan Seva Goa, Mumbai Metropolitan Region excluding Navi
Annexe, S. V. Road, Santacruz (W), Mumbai - 400 054. Tel.: 022- Mumbai & Thane.
26106552/26106960, Fax: 022-26106052
Patna Office of the Insurance Ombudsman, 1st Floor, Kalpana Arcade Bihar, Jharkhand.
Building, Bazar Samiti Road, Bahadurpur, Patna 800 006. Tel.:
0612-2680952, Email: [email protected]
Noida Office of the Insurance Ombudsman, Bhagwan Sahai Palace 4th State of Uttaranchal and the following Districts of Uttar
Floor, Main Road, Naya Bans, Sector 15, Distt: Gautam Buddh Pradesh:Agra, Aligarh, Bagpat, Bareilly, Bijnor, Budaun,
Nagar, U.P 201 301. Tel.: 0120-2514250/2514252/2514253 Bulandshehar, Etah, Kanooj, Mainpuri, Mathura,
Email: [email protected] Meerut, Moradabad, Muzaffarnagar, Oraiyya, Pilibhit,
Etawah, Farrukhabad, Firozbad, Gautambodhanagar,
Ghaziabad, Hardoi, Shahjahanpur, Hapur, Shamli,
Rampur, Kashganj, Sambhal, Amroha, Hathras,
Kanshiramnagar, Saharanpur.
Pune Office of the Insurance Ombudsman, Jeevan Darshan Bldg., 3rd Maharashtra, Area of Navi Mumbai and Thane
Floor, C.T.S. No.s. 195 to 198, N.C. Kelkar Road, Narayan Peth, Pune excluding Mumbai Metropolitan Region.
411 030. Tel.: 020-41312555

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Welcome to the

‘I feel good policy’

Digit Health Plus Policy (Revision)

Visit us at www.godigit.com or call UIN:

SECTION 1: HOSPITALIZATION COVER 9

SECTION 2: INFERTILITY TREATMENT COVER 17

SECTION 3: ORGAN DONOR 17

SECTION 4: ALTERNATE TREATMENT (AYUSH) COVER 18

SECTION 5: EMERGENCY AIR AMBULANCE 19

SECTION 6: LONG HOSPITALIZATION CASH BENEFIT 19

SECTION 7: MATERNITY BENEFIT & NEW BORN BABY COVER 20

SECTION 8: OUT-PATIENT (OPD) BENEFIT 21

SECTION 9: HOME (DOMICILIARY) HOSPITALIZATION 22

SECTION 10: SUM INSURED REFILL BENEFIT 23

SECTION 11: DAILY HOSPITAL CASH COVER 23

SECTION 12: CRITICAL ILLNESS BENEFIT COVER 24

SECTION 13: CRITICAL ILLNESS HOSPITALIZATION COVER 25

SECTION 14: CANCER BENEFIT COVER 33

SECTION 15: CANCER HOSPITALIZATION COVER 34

SECTION 16: WELLNESS BENEFIT PROGRAM 35

SPECIFIC ONES (CAN’T BE WAIVED) 44

Digit Health Plus Policy (Revision) (UIN: GODHLGP19013V021819) Back to Index | 2

CONDITIONS PRECEDENT TO THE CONTRACT 46

CONDITIONS APPLICABLE DURING THE CONTRACT 47

CONDITIONS APPLICABLE WHEN A CLAIM ARISES 49

CONDITIONS FOR RENEWAL OF THE CONTRACT 52

CUSTOMER GRIEVANCE REDRESSAL POLICY 52

Let’s get started

Digit Health Plus Policy (Revision) (UIN: GODHLGP19013V021819) Back to Index | 3

2. Alternative/Ayush Treatment means forms of treatments other than “Allopathy”

i. has qualified nursing staff under its employment;

ii. has qualified medical practitioner/s in charge;

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15. Domiciliary Hospitalization means medical treatment for an illness/disease/injury which in

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iii) has qualified medical practitioner(s) in charge round-the-clock;

5. Recurs or is likely to recur

26. Maternity Expenses means:

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iii) must have been prescribed by a Medical Practitioner;

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A. Accidental Hospitalization Cover

Hospital accommodation in a ward, shared or private room subject

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Fees for treatment by specialists, physicians, nurses, surgeons and

Drugs, medicines, consumables, prescribed by a specialist or

Necessary procedures such as x-rays, pathology, brain and body

Theatre Fees Operation Theatre Fees

ACCIDENTAL HOSPITALIZATION COVER

A1 Day Care Procedures

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B. Accidental & Illness Hospitalization Cover

Hospital accommodation in a ward, shared or private room subject

ICU Intensive Care Unit

Fees for treatment by specialists, physicians, nurses, surgeons and

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Necessary Procedures such as x-rays, pathology, brain and body