(Formerly Known As Max Bupa Health Insurance Co. LTD.) : Product Name: Reassure - Product Uin: Maxhlip21060V012021

Date: 25/08/2021
Policy Number: 31919267202100

Customer ID: 2001458365
MR. RENU SHUKLA

MS RENU SHUKLA, 1741 BADA GAON GATE BAHAR DADIYAPUR, VILAIYA KA BAAG,
JHANSI KHAS,,
JHANSI,
UTTAR PRADESH - 284002
Mobile: 08448706929
Subject : Max Bupa Health Insurance Policy No. 31919267202100
Dear MR. RENU SHUKLA,
Thank you for choosing Max Bupa as your preferred health insurance partner. At Max Bupa, we put your health first and are committed to provide
you access to the very best of healthcare, backed by the highest standards of service.
Please find enclosed your Max Bupa Policy kit which will help you understand your policy in detail and give you more information on how to access
our services easily. Your Policy kit includes the following:
• Personalized Health Card: To access our wide range of hospitals for cashless hospitalization.
• Insurance Certificate: Confirming your specific policy details like date of commencement, persons covered and specific conditions related to
your plan.
• Premium Receipt: Receipt issued for the premium paid by you.
• Policy Terms and Conditions: For a clear understanding of policy coverages and exclusions.
• Proposal Form: This is a copy of the proposal form as per the information provided by you. Do inform us immediately in case there is any change
in the details mentioned therein.
• Annexure of Policyholder Servicing Turnaround Times as prescribed by Insurance Regulatory and Development Authority (IRDA)
Do visit us online at www.maxbupa.com to view and download our updated list of network hospitals in your city, download claim forms and for other
useful information. You can register with us online using your policy number, date of birth & email id and access your policy details. In case of any
further assistance, call us at 1860-500-8888 (customer helpline number) or email us at [email protected].
We request you to read your policy terms and conditions carefully so that you are fully aware of your policy benefits. For benefits related to section
80D, please consult your tax advisor.
Assuring you of our best services and wishing you and your loved ones good health always.
Yours Sincerely,
Director - Operations & Customer Service

For and on behalf of Niva Bupa Health Insurance Co. Ltd.
(Formerly known as Max Bupa Health Insurance Co. Ltd.)
Important - Please read this document and keep in a safe place.
Product Name: ReAssure | Product UIN: MAXHLIP21060V012021

Policyholder Servicing Turnaround Times as prescribed by Insurance Regulatory and
Development Authority of India (IRDAI)
POLICY SERVICING Turnaround time*

(Calendar Days)
Processing of Proposal and Communication of decisions – from the date
of receipt of proposal form 15 Days
Providing copy of the proposal – from the date of acceptance of risk 30 Days
Post Policy issue service requests – from the date of receipt of service
10 Days
request
Proposal refund in case of cancellation – from the date of decision of
15 Days
the proposal
Request for policy cancellation with free-look period– from the date of
15 Days
receipt of service request
CLAIM SERVICING Turnaround time*

(Calendar Days)
From the date of receipt of last necessary document (no investigation) 30 Days
From the date of receipt of last necessary document (with investigation) 45 Days
GRIEVANCE HANDLING Turnaround time*

(Calendar Days)
Acknowledge a grievance – from the date of receipt of grievance 3 Days
Resolve a grievance– from the date of receipt of grievance 14 Days
*Turnaround time will start from the date of receipt of complete documents at Max Bupa Health Insurance Company Ltd.

Policy Schedule
Policyholder Name: MR. RENU SHUKLA Policy Number 31919267202100

Policyholder Address: Policy Commencement Date and Time From 25/08/2021 00:00
MS RENU SHUKLA, 1741 BADA GAON GATE BAHAR Policy Expiry Date and Time To 24/08/2022 23:59
DADIYAPUR, VILAIYA KA BAAG, JHANSI KHAS, Plan Opted Family Floater
JHANSI, Policy Period 1 Year
UTTAR PRADESH - 284002 Renewal / Payment Due Date 24/08/2022
Details of Electronic Insurance Account (eIA)

eIA Number None
Insurance Repository Name None
Cover Details
Name of the Insured Person(s) Base Sum Sum Insured Booster Benefit Sum Insured (Base Sum Personal Accident
Insured (in Safeguard (in Rs.) accrued (in Rs.) Insured + Booster opted
Rs.) Benefit + Sum Insured
Safeguard) (in Rs.)
Mr. Renu Shukla 10,00,000 0 0 10,00,000 No
Ms. Shreya Shukla No
Mr. Shaurya Shukla No
Premium Details
Net Integrated Central Goods and State/UT Goods and Gross Premium (Rs.) Gross Premium (Rs.)
Premium/Taxable Goods and Service Tax (9.00 Service Tax (9.00 %) (in words)
Value (Rs.) Service Tax %)
(18.00%)
13,164.00 0.00 1,184.76 1,184.76 15,534.00 Fifteen Thousand Five Hundred
Thirty-Four Only
Nominee Details
Nominee Name Relationship with the Policyholder
Shreya Shukla Daughter
Intermediary Details
Intermediary Name Intermediary Code Intermediary Contact No.

Directweb - Drweb0099 DRWEB0099 18605008888
Claim Administrator Servicing Branch Details
Max Bupa Health Insurance Company Limited Logix Infotech Park , Plot no D-5, Sector 59, Noida, Gautam Budh Nagar, Uttar Pradesh
201301
Optional Benefit/Feature Details
Particulars Details
Personal Accident Cover Not opted

Safeguard Not opted
Hospital Cash Not opted
Product Benefit Table1

Inpatient Care Covered up to Sum Insured
Day Care Treatment Covered up to Sum Insured
Alternative treatment Covered up to Sum Insured
Domiciliary Hospitalization Covered up to Sum Insured
Modern treatments Covered up to Sum Insured with a sub-limit of Rs. 1 Lac on few robotic surgeries
Pre-hospitalization Medical Expenses (60 Days) Covered up to Sum Insured
Post-hospitalization Medical Expenses (180 Days) Covered up to Sum Insured
Living Organ Donor Transplant Covered up to Sum Insured
Emergency Ambulance Covered upto Rs. 2,000 per hospitalization
Air Ambulance Cashless claim: Covered up to Sum Insured/Reimbursement claim: Covered up to
Rs. 2.5 Lacs
Home care treatment Covered up to Sum Insured
Booster Benefit In case of claim free year, increase of 50% of expiring Base Sum Insured in a Policy
Year; maximum up to 100% of Base Sum Insured (In case of a claim, reduction of
accumulated Cumulative Bonus by 50% of expiring Base Sum Insured)
ReAssure Unlimited reinstatement up to base Sum Insured
Shared accommodation Cash Benefit Rs. 800 per day; maximum Rs. 4,800
Health Check-up For define list of tests; up to Rs. 5,000 Per Policy
Second Medical Opinion Once for any condition for which hospitalization is triggered
Live healthy benefit Discount on renewal premium basis number of steps taken(Applicable for Insured
Persons other than son / daughter)
1
The details of the benefits will change depending upon the plan opted. All the benefits are on per Policy Year basis, if otherwise not mentioned.
Insured Person Details
Name of the Insured Person (s) Age (in Years) Insured DOB Gender Relationship Pre-existing Disease* Personal
Waiting Period#
Mr. Renu Shukla 43 03/01/1978 Male Applicant None None
Ms. Shreya Shukla 20 25/09/2000 Female Daughter None None
Mr. Shaurya Shukla 14 14/06/2007 Male Son None None
Permanent Exclusion (if any):
None
(* -Pre existing Disease as disclosed by You / Insured Person or discovered by us during medical underwriting)
(# -Please refer clause 5.4 of the Policy terms &conditions)
Pursuant to Notification no 13/2020- Central Tax and Notification no 14/2020- Central Tax both dated 21st March 2020 read with rule 54 (2) of
CGST Rules 2017, the provisions of E Invoicing & QR code are not applicable to an Insurance company, hence E Invoice number and QR code has not
been printed on this document. GST under RCM: NIL
GSTI No.: 09AAFCM7916H1Z6 SAC Code / Type of Service : 997133 / General Insurance Services
Max Bupa State Code: 9 Customer State Code / Customer GSTI No.: 9 /NA
Policy issuing office: Delhi, Consolidated Stamp Duty deposited as per the order of Government of National Capital Territory of Delhi.

Location: New Delhi Director - Operations & Customer Service
Date: 25/08/2021 For and on behalf of Max Bupa Health Insurance Company Limited

Premium Receipt
Dear MR. RENU SHUKLA
MS RENU SHUKLA, 1741 BADA GAON GATE BAHAR DADIYAPUR,
VILAIYA KA BAAG, JHANSI KHAS
JHANSI
UTTAR PRADESH - 284002
We acknowledge the receipt of payment towards the premium of the following health insurance policy:
Policyholder Name Mr. Renu Shukla Policy Number 31919267202100
Product Name ReAssure Plan Opted Family Floater Base Sum Insured 10,00,000
Policy Commencement Date # 25/08/2021 Policy Expiry Date 24/08/2022
Premium Calculation:
(A) Premium (Rs.) - Base Product 13,857.00
(B) Premium (Rs.) - Personal Accident Cover 0.00
(C) Premium (Rs.) - Safeguard 0.00
(D) Premium (Rs.) - Hospital Cash 0.00
Underwriting Loading (Rs.) 0.00
Total Discount (Rs.) 693.00
Net Premium / Taxable value (Rs.) 13,164.00
Integrated Goods and Service Tax (18.00 %) 0.00
Central Goods and Service Tax (9.00 %) 1,184.76
State/UT Goods and Service Tax (9.00 %) 1,184.76
Gross Premium (Rs.) 15,534.00

#
Issuance of policy is subject to clearance of premium paid
Details of persons Insured:

Name of Person Insured Age Gender Relationship**
Mr. Renu Shukla 43 Male Applicant
Ms. Shreya Shukla 20 Female Daughter
Mr. Shaurya Shukla 14 Male Son
Upon issuance of this receipt, all previously issued temporary receipts, if any, related to this policy are considered null and void. For the
purpose of deduction under section 80D, the benefit shall be as per the provisions of the Income Tax Act, 1961 and any amendments made
thereafter.
You may get tax benefits up to Rs. 15,534.00.subject to maximum permissible limits applicable under Income Tax Act 1961 as modified from
time to time. For more details, kindly consult your tax advisor. In the event of non-realization of premium, benefits cannot be obtained against
this premium receipt.
For your eligibility and deductions, please refer to provisions of Income Tax Act 1961 as modified and consult your tax consultant.

GSTI No.: 09AAFCM7916H1Z6 SAC Code / Type of Service : 997133 / General Insurance Services
Max Bupa State Code: 9 Customer State Code / Customer GSTI No.: 9 /NA
Policy issuing office: Delhi, Consolidated Stamp Duty deposited as per the order of Government of National Capital Territory of Delhi.
Location: New Delhi Director - Operations & Customer Service

Date: 25/08/2021 For and on behalf of Max Bupa Health Insurance Company Limited

Customer Information Sheet
Sl. No Policy Clause

Title Description
Number
1 Product’s Name ReAssure
2 What am I Base Coverage:
covered for • Hospital admission longer than 24 hrs 3.1
• Day Care Treatment would be covered if admitted for more than 2 hours and would also 3.2
cover treatment taken for Angiography, Dialysis, Radiotherapy or Chemotherapy for cancer.
• Alternative treatment covered up to Sum Insured 3.3
• Domiciliary hospitalization covered up to Sum Insured 3.4
• Modern treatments like Robotic surgeries, oral chemotherapy etc. are covered 3.5
• Related medical expenses up to Sum Insured incurred 60 days prior to hospitalization 3.6
• Related medical expenses incurred up to Sum Insured within 180 days from date of discharge 3.7
• Living organ donor transplant covered up to Sum Insured 3.8
• Emergency Ambulance covered up to Rs. 2,000 per Hospitalization 3.9
• Air Ambulance covered up to Sum Insured (for Cashless claims) and up to Rs. 2.5 Lacs (for 3.10
Reimbursement claims)
• Home care treatment covered up to Sum Insured 3.11
• Booster benefit – In case of claim free year, increase of 50% of expiring Base Sum Insured 3.12
in a Policy Year; maximum up to 100% of Base Sum Insured (In case of a claim, reduction of
• ReAssure – Unlimited reinstatement up to base Sum Insured. (Applicable for both same & 3.13
different illness)
• Shared accommodation Cash Benefit as per plan chosen by You 3.14
• Health Check-up can be availed for Diagnostic Tests as per plan chosen by You 3.15
• Coverage for Second Medical Opinion for any condition for which Hospitalization is triggered 3.16
(once in a Policy Year)
• Live healthy benefit – Discount on renewal premium basis number of steps taken 3.17
Optional Coverage:
• Personal Accident coverage against accident death, permanent total and partial disability 4.1
(for insured aged 18 years & above on individual basis)
• Hospital Cash benefit is paid as per the plan chosen for a maximum for 30 days per insured 4.2
person per policy year, provided that the Insured Person should have been Hospitalized for
a minimum period of 48 hours continuously and In-patient Care Hospitalization should have
been paid by Us.
• Safeguard – 4.3
- Claim safeguard: Non-payable items paid up to Sum Insured
- Booster Benefit safeguard: No impact on Booster Benefit if claim in a policy year is less
than Rs. 50,000
- Sum Insured safeguard: CPI linked increase in Base Sum Insured
ReAssure v1, July 2020

3 What are • Investigation & Evaluation 6.1
the major • Rest Cure, rehabilitation and respite care 6.2
exclusions in • Obesity/ Weight Control 6.3
the • Change-of-Gender treatments 6.4
policy • Cosmetic or plastic Surgery 6.5
• Hazardous or Adventure sports 6.6
• Breach of law 6.7
• Excluded Providers 6.8
• Refractive Error 6.12
• Unproven Treatments 6.13
• Sterility and Infertility 6.14
• Maternity Expenses 6.15
• Circumcision 6.17
• Conflict & Disaster 6.18
• External Congenital Anomaly 6.19
• Unrecognized Physician or Hospital 6.27
(Note: the above is a partial listing of the policy exclusions. Please refer to the policy clauses for
the full listing)
4 Waiting period • Initial waiting Period: 30 days for all illness (not applicable on renewal or for accidents) 5.3
• Specific Waiting periods: 24 months for few conditions as specified in policy clause number 5.2
5.2, unless the condition is directly caused by Cancer (covered after Initial Waiting Period of
30 days) or an Accident (covered from day 1)
• Pre-existing diseases: Covered after 36 months of continuous coverage 5.1
The aforementioned Waiting Periods shall not apply to Health Checkup, Second Medical Opinion,
Live Healthy benefit and Personal Accident Cover.
5 Payment basis • Cashless treatment or Reimbursement of covered expenses up to specified limits 7.2
• Fixed amount on the occurrence of a covered event under Shared accommodation Cash 3.14
Benefit, Personal Accident Cover and Hospital Cash 4.1, 4.2
6 Loss Sharing In case of a claim, this policy will cover up to the amount / limits mentioned below:
• Sub-limits
- Modern Treatments –sublimit of Rs. 1Lac applicable on few robotic surgeries 3.5
- Emergency Ambulance is covered up to Rs. 2,000 per Hospitalization 3.9
- Air Ambulance is covered Up to Rs. 2.5 Lacs 3.10
- Shared accommodation Cash Benefit as per plan chosen by You 3.14
- Health Check up limits as per plan chosen by you 3.15
- Hospital Cash Benefit as per plan chosen by You 4.2
7 Renewal The Policy shall ordinarily be renewable except on grounds of fraud, moral hazard, misrepresen- 8.4
Conditions tation by the Insured Person.
• The Company shall endeavor to give notice for renewal. However, the Company is not bound
to give any notice for renewal.
• Renewal shall not be denied on the ground that the Insured had made a claim or claims in
the preceding policy years.
• Request for renewal along with requisite premium shall be received by the Company before
the end of the Policy Period.
• At the end of the Policy Period, the Policy shall terminate and can be renewed within the
Grace Period to maintain continuity of benefits without Break in Policy. Coverage is not avail-
able during the Grace Period.
• If not renewed within Grace Period after due renewal date, the Policy shall terminate.
• No loading shall apply on renewals based on individual claims experience.
8 Renewal • Booster benefit – In case of claim free year, increase of 50% of expiring Base Sum Insured 3.12
Benefits in a Policy Year; maximum up to 100% of Base Sum Insured (In case of a claim, reduction of
• Live healthy benefit – Discount on renewal premium basis step taken 3.17
9 Cancellation This policy would be cancelled, and no claim or refund would be due to you if: 8.2
• you have not correctly disclosed details about current and past health status OR
• you have otherwise encouraged or participated in any fraudulent claim under the policy.

10 Claims For Cashless Service:
• Hospital Network details can be obtained from www.maxbupa.com 7.2
• We must be contacted to pre-authorize Cashless Facility for planned treatment at least 72
hours prior to the proposed treatment.
• If the Insured Person has been Hospitalized in an Emergency, We must be contacted to
pre-authorize Cashless Facility within 48 hours of the Insured Person’s Hospitalization or be-
fore discharge from the Hospital, whichever is earlier.
For Reimbursement of Claim: 7.3

• We shall be provided with the necessary information and documentation in respect of all
claims within 30 days of Insured Event giving rise to a claim or within 30 days from the date
of occurrence of an Insured Event.
11 Policy • In case of any grievance the Insured Person may contact the company through: 8.22
Servicing/ Customer Services Department
Grievances/ Max Bupa Health Insurance Company Limited
Complaints 2nd Floor, Plot No D-5, Sec-59, Noida,
Gautam Buddh Nagar, Uttar Pradesh – 201301
Contact No: 1860-500-8888
Fax No.: 011-30902010
Email ID: [email protected]
Senior citizens may write to us at: [email protected]
• If Insured person is not satisfied with the redressal of grievance through one of the above
methods, Insured Person may contact the grievance officer at:
Grievance Redressal Officer
Max Bupa Health Insurance Company Limited
2nd Floor, Plot No D-5, Sec-59, Noida,
Gautam Buddh Nagar, Uttar Pradesh – 201301
Email: [email protected] or [email protected]
For details of grievance officer, kindly refer the link https://www.maxbupa.com/custom-
er-care/health-services/grievance-redressal.aspx
• IRDAI/(IGMS/Call Centre): Email ID: www.igms.irdai.gov.in
• Ombudsman (Refer Annexure III of policy document for List of Insurance Ombudsmen)
12 Insured’s Rights • Free Look - If you do not agree to the terms and conditions of the Policy, you may cancel the 8.1
Policy, stating your reasons within 15 days (30 days if the Policy with Policy Period as 3 years
has been sold through distance marketing) of receipt of the Policy document provided no
claims have been made under any benefits. The free look provision is not applicable at the
time of Renewal of the Policy.
• Implied renewability - Your policy is ordinarily renewable for life provided the due premium 8.4
is paid on time
• Migration and Portability - You can port your policy at the time of renewal according to the 8.26 & 8.27
IRDAI guidelines. You can contact Customer Service Department (phone no. and email ID
provided above) for migration and portability.
• Increase in Sum Insured during the Policy term - You may opt for enhancement of Sum 8.9
Insured at the time of Renewal, subject to underwriting. You can contact Customer Service
Department (phone no. and email ID provided above) for increasing the Sum Insured.
• Turn Around Time (TAT) for issue of Pre-Auth – 4 hours
• Turn Around Time (TAT) for settlement of Reimbursement - We shall settle or repudiate a 7.4.b
claim within 30 days of the receipt of the last necessary information and documentation
13 Insured’s • Please disclose all pre-existing disease/s or condition/s before buying a policy. Non-disclo- 8.14
Obligations sure may result in claim not being paid.
• Disclosure of material information at the time of Renewal such as change in occupation, 8.6
address etc.
Legal Disclaimer Note:
The information must be read in conjunction with the product brochure and policy document. In case of any conflict between the CIS and the
policy document, the terms and conditions mentioned in the policy document shall prevail.
Disclaimer: Max Bupa Health Insurance Company Limited, IRDAI Registration No. 145. ‘Max’, Max logo, ‘Bupa’ and Heartbeat logo are registered trademarks of their respective owners and
are being used by Max Bupa Health Insurance Company Limited under license. CIN No. U66000DL2008PLC182918. Registered Office: C-98, Lajpat Nagar 1, Delhi-110024. Website: www.
maxbupa. com, Fax: 011-30902010, Customer Helpline No.: 1860 500 8888. Insurance is the subject matter of solicitation. Please read sales brochure carefully before concluding a sale.

Benefit Illustration
Benefit Illustration (5 Lac Sum Insured, Policy Term 1 year)
Age of the Coverage opted on Coverage opted on individual basis Coverage opted on family floater basis with overall
members individual basis covering covering multiple members of the family Sum Insured (Only one Sum Insured is available for
insured each member of the under a single policy (Sum Insured is the entire family)
family separately (at a available for each member of the family)
single point in time)
Premium Sum Premium Discount, Premium Sum Premium or Floater Premium Sum
(Rs.) Insured (Rs.) if any after Insured Consolidated discount, after Insured
(Rs.) discount (Rs.) premium for if any discount (Rs.)
(Rs.) all members (Rs.)
of family (Rs.)
Illustration 1
18 6,866.00 5,00,000 6,866.00 686.60 6,179.40 5,00,000 6,866.00 12,832.00 18,048.00 5,00,000
21 6,866.00 5,00,000 6,866.00 686.60 6,179.40 5,00,000 6,866.00
39 8,574.00 5,00,000 8,574.00 857.40 7,716.60 5,00,000 8,574.00
45 8,574.00 5,00,000 8,574.00 857.40 7,716.60 5,00,000 8,574.00
Total premium for all members of Total premium for all members of the family Total premium when the policy is opted on floater
the family is Rs.30,880, when each is Rs.27,792, when they are covered under a basis is Rs.18,048.
member is covered separately. single policy.
Sum Insured of Rs.500,000 is available for the entire
Sum Insured available for each Sum Insured available for each family family.
individual is Rs.500,000. member is Rs.500,000.
Illustration 2
55 16,176.00 5,00,000 16,176.00 1,617.60 14,558.40 5,00,000 16,176.00 7,874.00 35,910.00 5,00,000
63 27,608.00 5,00,000 27,608.00 2,760.80 24,847.20 5,00,000 27,608.00
the family is Rs.43,784, when each is Rs.39,405.60, when they are covered basis is Rs.35,910.
member is covered separately. under a single policy.
Illustration 3
65 27,608.00 5,00,000 27,608.00 2,760.80 24,847.20 5,00,000 27,608.00 15,960.00 46,379.00 5,00,000
70 34,731.00 5,00,000 34,731.00 3,473.10 31,257.90 5,00,000 34,731.00
the family is Rs.62,339, when each is Rs.56,105.10, when they are covered basis is Rs.46,379.
member is covered separately. under a single policy.
Note: Premium rates specified in the above illustration are standard premium rates without considering any loading. Also, the premium rates
are exclusive of taxes applicable.
Zone 1 premium is considered

ReAssure –
Policy Terms & Conditions
1. Preamble unless otherwise specified in the respective section. Thereafter

This ‘ReAssure’ policy is a contract of insurance between You and Us only the balance Sum Insured after payment of claim amounts
which is subject to payment of full premium in advance and the terms, admitted shall be available for future claims arising in that Policy
conditions and exclusions of this Policy. This Policy has been issued on Year.
the basis of the Disclosure of Information, including the information
provided by You in the Proposal Form and / or the Information 3.1 Inpatient Care
Summary Sheet. What is covered:
We will indemnify the Medical Expenses incurred for one or more of
Please inform Us immediately of any change in the address or any the following due to the Insured Person’s Hospitalization during the
other changes affecting You or any Insured Person which would impact Policy Period following an Illness or Injury:
the benefits, terms and conditions under this Policy. a. Room Rent;
b. Room boarding and nursing charges during Hospitalization as
In addition, please note the list of exclusions is set out in Section 6 of charged by the Hospital where the Insured Person availed medical
this Policy. treatment;
c. Medical Practitioners’ fees, excluding any charges or fees for
2. Definitions & Interpretation Standby Services;
For the purposes of interpretation and understanding of this Policy, d. Investigative tests or diagnostic procedures directly related to the
We have defined, in Section 9, some of the important words used in Insured Event which lead to the current Hospitalization;
the Policy which will have the special meaning accorded to these terms e. Medicines, drugs as prescribed by the treating Medical
for the purposes of this Policy. For the remaining language and words Practitioner related to the Insured Event that led to the current
used, the usual meaning as described in standard English language Hospitalization;
dictionaries shall apply. The words and expressions defined in the f. Intravenous fluids, blood transfusion, injection administration
Insurance Act 1938, IRDA Act 1999, regulations notified by the IRDAI charges, allowable consumables and /or enteral feedings;
and circulars and guidelines issued by the IRDAI, together with their g. Operation theatre charges;
amendment shall carry the meanings given therein. h. The cost of prosthetics and other devices or equipment, if
implanted internally during Surgery;
Note: Where the context permits, the singular will be deemed to i. Intensive Care Unit Charges.
include the plural, one gender shall be deemed to include the other
genders and references to any statute shall be deemed to refer to any Conditions: The above coverage is subject to fulfilment of following
replacement or amendment of that statute. conditions:
a. The Hospitalization is for Medically Necessary Treatment and
3. Benefits available under the Policy advised in writing by a Medical Practitioner.
The benefits available under this Policy are described below. b. We will pay the consultation charges for any Medical Practitioner
a. The Policy covers Reasonable and Customary Charges incurred visiting the Insured Person only if:
towards Medically Necessary Treatment taken by the Insured i. The Medical Practitioner’s treatment or advice has been
Person during the Policy Period for an Illness, Injury or condition specifically sought by the Hospital; and
as described in the sections below and contracted or sustained ii. The consultation charges are included in the Hospital’s bill
during the Policy Period. The benefits listed in the sections below
will be payable subject to the terms, conditions and exclusions of 3.2 Day Care Treatment
this Policy and the availability of the Sum Insured and any sub- What is covered:
limits for the benefit as maybe specified in the Policy Schedule. We will indemnify the Medical Expenses incurred on the Insured
b. The expenses that are not covered or subsumed into room charges Person’s under any Day Care Treatment during the Policy Period
/ procedure charges / costs of treatment are placed as Annexure II following an Illness or Injury.
c. All the benefits (including optional benefits) which are available
under the Policy along with the respective limits / amounts Conditions: The above coverage is subject to fulfilment of following
applicable based on the Sum Insured have been summarized in conditions:
the Product Benefit Table in Annexure I. a. The Day Care Treatment is advised in writing by a Medical
d. All claims under the Policy must be made in accordance with the Practitioner as Medically Necessary Treatment.
process defined under Section 7 (Claim Process & Requirements). b. The Day Care Treatment would be covered if the Insured Person is
e. All claims paid under any benefit except for those admitted admitted for more than 2 hours and would also cover treatment
under Section 3.14 (Shared accommodation Cash Benefit), taken for Angiography, Dialysis, Radiotherapy or Chemotherapy
Section 3.15 (Health Checkup), Section 3.16 (Second Medical for cancer.
Opinion), Section 3.17 (Live Healthy benefit), Section 4.1 c. If We have accepted a claim under this benefit, We will also
(Personal Accident Cover) and Section 4.2 (Hospital Cash) shall indemnify the Insured Person’s Pre-hospitalization Medical
reduce the Sum Insured for the Policy Year in which the Insured Expenses and Post-hospitalization Medical Expenses in accordance
Event in relation to which the claim is made has been occurred, with Sections 3.6 and 3.7.
ReAssure v1, July 2020

What is not covered: vii. Robotic surgeries
a. OPD Treatment and Diagnostic Services costs are not covered viii. Stereotactic radio surgeries
under this benefit. ix. BronchicalThermoplasty
x. Vaporisation of the prostrate (Green laser treatment or
3.3 Alternative Treatments holmium laser treatment)
What is covered: xi. IONM - (Intra Operative Neuro Monitoring)
We will indemnify the Medical Expenses incurred on the Insured Person’s xii. Stem cell therapy: Hematopoietic stem cells for bone marrow
Hospitalization for Inpatient Care during the Policy Period on treatment transplant for haematological conditions to be covered.
taken under Ayurveda, Unani, Siddha and Homeopathy. b. If We have accepted a claim under this benefit, We will also
indemnify the Insured Person’s Pre-hospitalization Medical
Conditions: The above coverage is subject to fulfilment of following Expenses and Post-hospitalization Medical Expenses in
conditions: accordance with Sections 3.6 and 3.7 within the overall benefit
a. The treatment should be taken in AYUSH Hospital. sub-limit.
b. If We have accepted a claim under this benefit, We will also Special condition applicable for robotic surgeries:
indemnify the Insured Person’s Pre-hospitalization Medical A limit of maximum INR 1 Lac will apply to all robotic surgeries, except
Expenses and Post-hospitalization Medical Expenses in accordance the following:
with Sections 3.6 and 3.7, provided that these Medical Expenses i. Robotic total radical prostatectomy
relate only to Alternative Treatments and not Allopathy. ii. Robotic cardiac surgeries
c. Any non-allopathic treatment taken by the Insured Person shall iii. Robotic partial nephrectomy
only be covered under Section 3.3 (Alternative Treatments) as per iv. Robotic surgeries for malignancies
the applicable terms and conditions.
3.6 Pre-hospitalization Medical Expenses
What is not covered: What is covered:
a. Medical Expenses incurred on treatment taken under Yoga shall We will indemnify on Reimbursement basis only, the Insured Person’s
not be covered. Pre-hospitalization Medical Expenses incurred in respect of an Illness
or Injury.
3.4 Domiciliary Hospitalization
What is covered: Conditions: The above coverage is subject to fulfilment of following
We will indemnify on Reimbursement basis only, the Medical Expenses conditions:
incurred for the Insured Person’s Domiciliary Hospitalization during a. We have accepted a claim under Section 3.1 (Inpatient Care)
the Policy Period following an Illness or Injury. or Section 3.2 (Day Care Treatment) or Section 3.3 (Alternative
Treatments) or Section 3.5 (Modern Treatments).
Conditions: The above coverage is subject to fulfilment of following b. Pre-hospitalization Medical Expenses are incurred for the same
conditions: condition for which We have accepted the Inpatient Care or Day
a. The Domiciliary Hospitalization continues for at least 3 consecutive Care Treatment or Alternative Treatments or Modern Treatments
days, wherein We will make payment under this benefit in respect claim.
of Medical Expenses incurred from the first day of Domiciliary c. The expenses are incurred after the inception of the First Policy
Hospitalization; with Us. If any portion of these expenses is incurred before the
b. The treating Medical Practitioner confirms in writing that the inception of the First Policy with Us, then We shall be liable only
Insured Person’s condition was such that the Insured Person could for those expenses incurred after the commencement date of the
not be transferred to a Hospital OR the Insured Person satisfies Us First Policy, irrespective of the initial waiting period.
that a Hospital bed was unavailable. d. Pre-hospitalization Medical Expenses incurred on physiotherapy
will also be payable provided that such physiotherapy is prescribed
What is not covered: in writing by the treating Medical Practitioner as Medically
a. Sections 3.6 (Pre-hospitalization Medical Expenses) and Section Necessary Treatment and is directly related to the same condition
3.7 (Post- hospitalization Medical Expenses) are not payable that led to Hospitalization.
under this benefit. e. Any claim admitted under this Section shall reduce the Sum
Insured for the Policy Year in which Inpatient Care or Day Care
3.5 Modern Treatments Treatment or Alternative Treatments or Modern Treatments
claim has been incurred.
What is Covered:
a. The following procedures / treatments will be covered either as Sub-limit:
Inpatient Care or as part of Day Care Treatment as per Section 3.1 a. We will pay above mentioned Pre-hospitalization Medical
and Section 3.2 respectively, in a Hospital : Expenses only for period up to 60 days immediately preceding
i. Uterine Artery Embolization and HIFU (High intensity the Insured Person’s admission for Inpatient Care or Day Care
focused ultrasound) Treatment or Alternative Treatments or Modern Treatments.
ii. Balloon Sinuplasty
iii. Deep Brain stimulation 3.7 Post-hospitalization Medical Expenses
iv. Oral chemotherapy What is covered:
v. Immunotherapy- Monoclonal Antibody to be given as We will indemnify on Reimbursement basis only, the Insured Person’s
injection Post-hospitalization Medical Expenses incurred following an Illness or
Injury.
vi. Intra vitreal injections

Conditions: The above coverage is subject to fulfilment of following Conditions: The above coverage is subject to fulfilment of following
conditions: conditions:
a. We have accepted a claim under Section 3.1 (Inpatient Care) a. The medical condition of the Insured Person requires immediate
or Section 3.2 (Day Care Treatment) or Section 3.3 (Alternative ambulance services from the place where the Insured Person is
Treatments) or Section 3.5 (Modern Treatments). injured or is ill to a Hospital where appropriate medical treatment
b. Post-hospitalization Medical Expenses are incurred for the same can be obtained or;
condition for which We have accepted the Inpatient Care or Day b. The medical condition of the Insured Person requires immediate
Care Treatment or Alternative Treatments or Modern Treatments ambulance services from the existing Hospital to another Hospital
claim. with advanced facilities as advised by the treating Medical
c. The expenses incurred shall be as advised in writing by the Practitioner for management of the current Hospitalization.
treating Medical Practitioner. c. This benefit is available for only one transfer per Hospitalization.
d. Post-hospitalization Medical Expenses incurred on physiotherapy d. The ambulance service shall be offered by a healthcare or
will also be payable provided that such physiotherapy is prescribed ambulance Service Provider.
in writing by the treating Medical Practitioner as Medically e. We have accepted a claim under Section 3.1 (Inpatient Care) or
Necessary Treatment and is directly related to the same condition Section 3.2 (Day Care Treatment).
that led to Hospitalization. f. We will cover expenses up to Rs. 2,000 per Hospitalization.
e. Any claim admitted under this Section shall reduce the Sum
Insured for the Policy Year in which Inpatient Care or Day Care What is not covered:
Treatment or Alternative Treatments or Modern Treatments The Insured Person’s transfer to any Hospital or diagnostic centre for
claim has been incurred. evaluation purposes only.
Sub-limit: 3.10 Air Ambulance

a. We will pay Post-hospitalization Medical Expenses only for up to What is covered:
180 days immediately following the Insured Person’s discharge We will indemnify the costs incurred for ambulance transportation in an
from Hospital or Day Care Treatment or Alternative Treatments airplane or helicopter, for Emergency life threatening health conditions
or Modern Treatments. which require immediate and rapid ambulance transportation to the
Hospital / medical centre that ground transportation cannot provide.
3.8 Living Organ Donor Transplant
What is covered Conditions - The above coverage is subject to fulfilment of following
We will indemnify the Medical Expenses incurred for a living organ conditions:
donor’s treatment as an Inpatient for the harvesting of the organ a. We have accepted a claim under Section 3.1 (Inpatient Care) or
donated. Section 3.2 (Day Care Treatment).
b. Medically Necessary treatment is not available at the location
Conditions: The above coverage is subject to fulfilment of following
where the Insured Person is situated at the time of Emergency.
conditions:
c. The Medical Evacuation has been prescribed by a Medical
a. The donation conforms to the Transplantation of Human Organs
Practitioner and is Medically Necessary.
Act 1994 and any amendments thereafter and the organ is for the
d. The insured person is in India and the treatment is required in
use of the Insured Person.
India only and not overseas in any condition whatsoever.
b. The organ transplant is certified in writing by a Medical Practitioner
e. The air ambulance provider is registered in India.
as Medically Necessary Treatment for the Insured Person.
c. We have accepted the recipient Insured Person’s claim under f. We will cover expenses up to the amount specified in the Policy
Section 3.1 (Inpatient Care). Schedule for transportation of the Insured Person under this
benefit.
What is not covered:
a. Stem cell donation whether or not it is Medically Necessary What is not covered:
Treatment except for Bone Marrow Transplant. a. Expenses incurred in return transportation to Insured Person’s
b. Pre-hospitalization Medical Expenses or Post-hospitalization home by air ambulance is excluded.
Medical Expenses of the organ donor.
c. Screening or any other Medical Expenses related to the organ 3.11 Home Care treatment
donor, which are not incurred during the duration of Insured What is covered:
Person’s Hospitalization for organ transplant. We will indemnify the Medical Expenses incurred on the Insured
d. Transplant of any organ/tissue where the transplant is Unproven / Person’s treatment taken at home for Chemotherapy or Dialysis.
experimental treatment or investigational in nature.
e. Expenses related to organ transportation or preservation. Conditions: The above coverage is subject to fulfilment of following
f. Any other medical treatment or complication in respect of the conditions:
donor, which is directly or indirectly consequence to harvesting. a. These services shall be offered by a registered homecare provider.
3.9 Emergency Ambulance What is not covered:

What is covered: a. Treatment taken by automation machine for peritoneal dialysis.
We will indemnify the costs incurred, on transportation of the Insured b. Sections 3.6 (Pre-hospitalization Medical Expenses) and Section
Person by road Ambulance to a Hospital for treatment in an Emergency 3.7 (Post- hospitalization Medical Expenses) are not payable
following an Illness or Injury. under this benefit.

3.12 Booster benefit 3.13 ReAssure
What is covered: What is covered:
a. If the Policy is Renewed with Us without a break or if the Policy This benefit is triggered with the first paid claim itself and is available
continues to be in force for the 2nd / 3rd Policy Year in the 2 year for all subsequent claims in a Policy Year.
/ 3 year Policy Period respectively (if applicable) and no claim
has been made in the immediately preceding Policy Year, We Conditions: The above coverage is subject to fulfilment of following
will provide Booster Benefit in the form of Cumulative Bonus by conditions:
increasing the Sum Insured applicable under the Policy by 50% a. The maximum liability under a single claim under this benefit shall
of the Base Sum Insured of the immediately preceding Policy not be more than Base Sum Insured.
Year per claim free Policy Year subject to a maximum of 100% of b. The sequence of utilization of Sum Insured will be as below:
the Base Sum Insured. There will be no change in the sub-limits i. Base Sum Insured followed by;
applicable to various benefits due to increase in Sum Insured ii. Sum Insured Safeguard (if applicable) followed by;
under this benefit. iii. Accumulated Cumulative Bonus under Booster benefit (if
any) followed by;
Conditions: The above coverage is subject to fulfilment of following
iv. ReAssure benefit
conditions:
c. Claims under this benefit will be payable only under Section
a. If the Insured Persons in the expiring Policy is covered under
3.1 (Inpatient Care) or Section 3.2 (Day Care Treatment) or
Individual Policies and has an accumulated Cumulative Bonus in
Section 3.3 (Alternative Treatments) or Section 3.4 (Domiciliary
the expiring Policies under this benefit, and such expiring Policies
are merged and Renewed with Us on a Family Floater Policy Hospitalization) or Section 3.5 (Modern Treatments) or Section
with or without an addition of a new Insured Person, then the 3.8 (Living Organ Donor Transplant) or Section 3.11 (Home
accumulated Cumulative Bonus to be carried forward to the Family Care Treatment) arising in that Policy Year for any or all Insured
Floater Policy would be the least of the accumulated Cumulative Person(s).
Bonus amongst the Insured Persons of the expiring Policy. d. For Family Floater Policies, the amount under this benefit will be
b. If the Insured Person in the expiring Policy is covered under an available on a floater basis to all Insured Persons in that Policy
Individual Policy and has an accumulated Cumulative Bonus in Year.
the expiring Policy under this benefit, and such expiring Policy
is Renewed with Us on a Family Floater Policy by addition of a 3.14 Shared accommodation Cash Benefit
new Insured Person, then the accumulated Cumulative Bonus What is covered:
to be carried forward to the Family Floater Policy would be the If We have accepted an Inpatient Care Hospitalization claim and the
accumulated Cumulative Bonus of the expiring Policy. Insured Person has occupied a shared room accommodation during
c. If the Insured Persons in the expiring Policy are covered on a such Hospitalization in a Network Hospital, We will pay a daily cash
Family Floater Policy and such Insured Persons Renew their amount as specified in the Policy Schedule for the Insured Person for
expiring Policy with Us by splitting the Floater Sum Insured stated each continuous and completed period of 24 hours of Hospitalization.
in the Policy Schedule in to two or more floater / individual Policy,
then We will provide the credit of the accumulated Cumulative Conditions: The above coverage is subject to fulfilment of following
Bonus to each of the split Policy. conditions:
d. If the Insured Persons covered on a Family Floater Policy are a. The Insured Person has been admitted in a Hospital for a minimum
reduced at the time of Renewal, the applicable accumulated period of 48 hours continuously.
Cumulative Bonus shall remain same under the Policy.
e. In case the Base Sum Insured under the Policy is reduced at the What is not covered:
time of Renewal, the applicable accumulated Cumulative Bonus a. This benefit will not be payable if the Insured Person stays in an
shall also be reduced in proportion to the Base Sum Insured. Intensive Care Unit or High Dependency Units / wards.
f. In case the Base Sum Insured under the Policy is increased at the
time of Renewal, the applicable accumulated Cumulative Bonus 3.15 Health Checkup
shall also be increased in proportion to the Base Sum Insured. What is covered:
g. This benefit is not applicable for Health Check-up, Second The Insured Person may avail a health check-up, only for Diagnostic
Medical Opinion, Personal Accident Cover and Hospital Cash. Tests, up to a sub-limit as specified in Your Policy Schedule.
Enhancement of Sum Insured due to Booster benefit cannot be
utilized for the aforementioned benefits. Conditions - The above coverage is subject to fulfilment of following
h. If a claim has been made in the immediately preceding Policy Year, conditions:
We will reduce the accumulated Cumulative Bonus by 50% of a. This benefit is available only once in a Policy Year and all tests
expiring Base Sum Insured. Whereas, if a reported claim has been must have been done on the same date.
denied by Us, the Insured Persons will be eligible for this benefit. b. The list of tests covered under this benefit will be Complete
i. If a claim has been made in the immediately preceding Policy Year blood count, Urine Routine, Erythrocyte Sedimentation Rate
under Individual Policy, the reduction in accumulated Cumulative (ESR), Fasting Blood Glucose, Electrocardiogram, S Cholesterol,
Bonus shall be applicable only to the Insured Person(s) who have Complete Physical Examination by Physician, Post prandial / lunch
claimed.
blood sugar (PPBS / PLBS), Uric Acid, Lipid Profile, Kidney function
test, Serum Vitamin D, Serum Electrolytes, HbA1C, Thyroid
profile (TSH), Liver Function Test (LFT), Treadmill test (TMT) and
Ultrasound test.

What is not covered: 3.17 Live Healthy benefit
a. Any unutilized test or amount cannot be carried forward to the What is covered:
next Policy Year. We will offer a discount on Renewal premium if the eligible Insured
Person(s) achieves the health points target on the mobile application
3.16 Second Medical Opinion provided by Us as per the grid mentioned below.
What is covered:
We will indemnify the costs incurred for availing a second medical Conditions - The above coverage is subject to fulfilment of following
opinion from any Medical Practitioner for which we have admitted a conditions:
claim of Hospitalization. a. Steps taken by the Insured Person everyday, earn ‘health points’.
Steps counted by the mobile App We provide you to use ONLY
Conditions - The above coverage is subject to fulfilment of following would be considered.
conditions: b. 1 health point would be earned for every completed 1000 steps.
a. This benefit can be availed only once during a Policy Year. c. Health points accumulated in last 3 months of the Policy Period
b. We have accepted a claim under Section 3.1 (Inpatient Care) or would not be considered for discount on premium for the first
Section 3.2 (Day Care Treatment) for which opinion is sought. renewal. The last 3 months are NOT LOST and will be considered
in the next Policy Period. All renewals thereafter, will consider
What is not covered: points gained in the Policy Period.
a. The second medical opinion under this benefit shall not be valid d. The mobile app must be downloaded within 30 days of the Policy
for any medico legal purposes. commencement to avail this benefit. The step count completed
b. We do not assume any liability and shall not be deemed to by an eligible Insured Person would be tracked on this mobile
assume any liability towards any loss or damage arising out of or application.
in relation to any opinion, advice, prescription, actual or alleged e. We reserve the right to remove or reduce any count of steps if
errors, omissions and representations made by the Medical found to be achieved in unfair manner by manipulation.
Practitioner.
Policy Period: 1 year

Policy duration End of 9 months Points at the end of Points in next Total points Discount on renewal premium (Renewal
9 months (A) 3 months (B) considered for policy start
This will be discount (A + B) date 1st Jan 2021
considered for from 2nd Policy
discount on the first Period onwards NOTE: Discount applicable on the
renewal. member’s premium in Individual
sum insured policies and on the Policy
premium in case of Floater
Individual sum Floater policies with
insured policy and more than 1 Adult
Floater policies with
1 Adult
1st Jan 2020 30th September Upto 1500 0% 0%
2020
1501 –2250 5% 2.5%
2251 – 3000 15% 7.5%
3001 – 3750 20% 10%
>=3751 30% 15%

Policy Period: 2 years
Policy duration End of 21 Points at the end of Points in next Total points Discount on renewal premium (Renewal
months 21 months (A) 3 months (B) considered for policy start date 1st Jan 2022
This will be discount (A + B)
considered for from 2nd Policy NOTE: Discount applicable on the
discount on the first Period onwards member’s premium in Individual sum
renewal. insured policies and on the Policy premium
in case of Floater
1 Adult

2021
3001 – 4500 5% 2.5%
4501 – 6000 15% 7.5%
6001 – 7500 20% 10%
>=7501 30% 15%
Policy Period: 3 years

Policy duration End of 33 Points at the end of Points in next Total points Discount on renewal premium (Renewal
months 33 months (A) 3 months (B) considered for policy start date 1st Jan 2023
This will be discount (A + B)
considered for from 2nd Policy NOTE: Discount applicable on the
discount on the first Period onwards member’s premium in Individual sum
renewal. insured policies and on the Policy premium
in case of Floater
1 Adult

2022
4501 – 6750 5% 2.5%
6751 – 9000 15% 7.5%
9001 – 11250 20% 10%
>=11251 30% 15%
4. Optional Benefits All claims for any applicable optional benefits under the Policy must be
The following optional benefits shall apply under the Policy only if it is made in accordance with the process defined under Section 7 (Claim
specified in the Policy Schedule. Optional benefits can be selected by Process & Requirements).
You only at the time of issuance of the First Policy or at Renewal, unless
specified otherwise, on payment of the corresponding additional 4.1 Personal Accident Cover
premium. What is covered:
If the Insured Person covered under this optional benefit dies or
The optional benefits ‘Personal Accident Cover’ and ‘Hospital Cash’ will sustains any Injury resulting solely and directly from an Accident
be payable (only on Reimbursement basis) if the conditions mentioned occurring during the Policy Period at any location worldwide, and
in the below sections are contracted or sustained by the Insured while the Policy is in force, We will provide the benefits described
Person covered under these optional benefits during the Policy Period. below.
The applicable optional benefits will be payable subject to the terms, a. Accident Death (AD)
conditions and exclusions of this Policy and subject always to any sub- What is covered:
limits for the optional benefit as specified in Your Policy Schedule. If the Injury due to Accident solely and directly results in the Insured
Person’s death within 365 days from the occurrence of the Accident,

We will make payment of Personal Accident Cover Sum Insured c. If the Insured Person dies before a claim has been admitted
specified in the Policy Schedule. If a claim is made under this optional under this optional benefit, no amount will be payable under
benefit, the coverage for that Insured Person under the Policy shall this optional benefit, however We will consider the claim under
immediately and automatically cease. Any claim incurred before Section 4.1.a (Accident Death) subject to terms and conditions
death of such Insured person shall be admissible subject to terms and mentioned therein; and
conditions under this Policy. d. We will not make payment under Accident Permanent Total
Disability more than once in the Insured Person’s lifetime for any
b. Accident Permanent Total Disability (APTD) and all Policy Periods.
What is covered: e. If a claim under this optional benefit is admitted, then coverage
If the Injury due to Accident solely and directly results in the Permanent for the Insured Person will immediately and automatically cease
Total Disability of the Insured Person which means that the Injury under Section 4.1(Personal Accident Cover) and this optional
results in one or more of the following conditions within 365 days benefit shall not be applied in respect of that Insured Person on
from the occurrence of an Accident, We will make payment of 125% any Renewal thereafter. However, other applicable benefits can
of the Personal Accident Cover Sum Insured as specified in the Policy be Renewed in respect of the Insured Person.
Schedule.
1. Loss of use of limbs or sight c. Accident Permanent Partial Disability (APPD)
The Insured Person suffers from total and irrecoverable loss of: What is covered:
1. The use of two limbs (including paraplegia and hemiplegia) If the Injury due to Accident solely and directly results in the Permanent
OR Partial Disability of the Insured Person which is of the nature specified in
2. The sight in both eyes OR the table below within 365 days from the occurrence of such Accident,
3. The use of one limb and the sight in one eye We will make payment under this optional benefit in accordance with
the table below:
2. Loss of independent living
The Insured Person is permanently unable to perform Conditions: The above coverage is subject to fulfilment of following
independently three or more of the following six activities of daily conditions:
living. a. The Permanent Partial Disability is proved through a disability
1. Washing: the ability to maintain an adequate level of certificate issued by a Medical Board duly constituted by the
Central and/or the State Government; and
cleanliness and personal hygiene.
b. We will admit a claim under this optional benefit only if the
2. Dressing: the ability to put on and take off all necessary
Permanent Partial Disability continues for a period of at least 6
garments, artificial limbs or other surgical appliances that are
continuous calendar months from the commencement of the
medically necessary.
Permanent Partial Disability, unless it is irreversible; and
3. Feeding: the ability to transfer food from a plate or bowl to c. If the Insured Person dies before a claim has been admitted
the mouth once food has been prepared and made available. under this optional benefit, no amount will be payable under
4. Toileting: the ability to manage bowel and bladder function, this optional benefit, however We will consider the claim under
maintaining an adequate and socially acceptable level of Section 4.1.a (Accident Death) subject to the terms and conditions
hygiene. mentioned therein.
5. Mobility: the ability to move indoors from room to room on d. If a claim under this optional benefit has been admitted, then no
level surfaces at the normal place of residence. further claim in respect of the same condition will be admitted
6. Transferring: the ability to move from a lying position in a bed under this optional benefit.
to a sitting position in an upright chair or wheel chair and e. If a claim under this optional benefit is paid and the entire Personal
vice versa. Accident Sum Insured specified in the Policy Schedule does not get
utilized, then the balance Personal Accident Cover Sum Insured
Conditions: The above coverage is subject to fulfilment of following shall be available for further claims under Section 4.1 (Personal
conditions: Accident Cover) until the entire Personal Accident Cover Sum
a. The Permanent Total Disability is proved through a disability Insured is consumed. The Personal Accident Cover Sum Insured
certificate issued by a Medical Board duly constituted by the specified in the first Policy Schedule shall be a lifetime limit for
Central and/or the State Government; and the Insured Person and once this limit is exhausted, coverage
b. We will admit a claim under this optional benefit only if the for the Insured Person will immediately and automatically cease
Permanent Total Disability continues for a period of at least 6 under Section 4.1 (Personal Accident Cover) and this optional
continuous calendar months from the commencement of the benefit shall not be applied in respect of that Insured Person on
Permanent Total Disability unless it is irreversible, such as in case any Renewal thereafter. However, other applicable benefits can
of amputation/loss of limbs etc; and be Renewed in respect of the Insured Person

Permanent Partial Disability Grid
S. % of Personal Accident
Nature of Disability
No. Cover Sum Insured payable
1 Loss or total and permanent loss of use of both the hands from the wrist joint 100%
2 Loss or total and permanent loss of use of both feet from the ankle joint 100%
3 Loss or total and permanent loss of use of one hand from the wrist joint and of one foot from the ankle 100%
joint
4 Loss or total and permanent loss of use of one hand from the wrist joint and total and permanent loss of 100%
sight in one eye
5 Loss or total and permanent loss of use of one foot from the ankle joint and total and permanent loss of 100%
sight in one eye
6 Total and permanent loss of speech and hearing in both ears 100%
7 Total and permanent loss of hearing in both ears 50%
8 Loss or total and permanent loss of use of one hand from wrist joint 50%
9 Loss or total and permanent loss of use of one foot from ankle joint 50%
10 Total and permanent loss of sight in one eye 50%
11 Total and permanent loss of speech 50%
12 Permanent total loss of use of four fingers and thumb of either hand 40%
13 Permanent total loss of use of four fingers of either hand 35%
14 Uniplegia 25%
15 Permanent total loss of use of one thumb of either hand
a. Both joints 25%
b. One joint 10%
16 Permanent total loss of use of fingers of either hand
a. Three joints 10%
b. Two joints 8%
c. One joint 5%
17 Permanent total loss of use of toes of either foot
a. All toes- one foot 20%
b. Great toe- both joints 5%
c. Great toe- one joint 2%
d. Other than great toe, one toe 1%
4.2 Hospital Cash b. Booster Benefit Safeguard: Cumulative Bonus under Section 3.12
What is covered: (Booster Benefit) will not be impacted or reduced at Renewal if
If We have accepted an Inpatient Care Hospitalization claim under any one claim or multiple claims admissible in the previous Policy
Section 3.1 (In-patient Care), We will pay the Hospital Cash amount Year does not exceed the overall amount of Rs. 50,000.
specified in the Policy Schedule up to a maximum 30 days of c. Sum Insured Safeguard: The Base Sum Insured will be increased
Hospitalization during the Policy Year for the Insured Person for each on Cumulative Basis at each Policy Year on the basis of inflation
continuous period of 24 hours of Hospitalization from the first day of rate in previous year. Inflation rate would be computed as the
Hospitalization. average Consumer Price index (CPI) of the entire calendar year
published by the Central Statistical Organisation (CSO).
Conditions - The above coverage is subject to fulfilment of following
conditions: Conditions - The coverage under ‘Sum Insured Safeguard’ is subject to
a. The Insured Person has been admitted in a Hospital for a minimum fulfilment of following conditions:
period of 48 hours continuously. a. The % increase will be applicable only on Base Sum Insured under
the Policy and not on Booster Benefit or any other benefit which
4.3 Safeguard leads to increase in Sum Insured.
What is covered: b. Consumer Price index (CPI) is a measure of inflation, changes
a. Claim Safeguard: If We have accepted a Hospitalization claim in the CPI are used to assess price changes associated with the
under Section 3, then the items which are not payable as per cost of living. It is a measure that examines the weighted average
List I – ‘Expenses not covered’ under Annexure II related to that of prices of a basket of consumer goods and services, such as
particular claim will become payable. transportation, food and medical care. It is calculated by taking

price changes for each item in the predetermined basket of goods 5.1 Pre-existing Diseases (Code–Excl01):
and averaging them. a. Expenses related to the treatment of a Pre-existing Disease
c. The Central Statistics Office (CSO) is a government agency in India (PED) and its direct complications shall be excluded until the
under the Ministry of Statistics and Programme Implementation expiry of 36 months of continuous coverage after the date of
responsible for co-ordination of statistical activities in India, and inception of the first Policy with Us.
evolving and maintaining statistical standards. b. In case of enhancement of Sum Insured the exclusion shall
d. In case of Sum Insured enhancement or reduction at the time apply afresh to the extent of Sum Insured increase.
of Renewal, any accumulated Sum Insured due to Sum Insured c. If the Insured Person is continuously covered without any
Safeguard Benefit will be added to the enhanced or reduced Sum break as defined under the portability norms of the extant
Insured opted by Insured at the time of Renewal. IRDAI (Health Insurance) Regulations, then waiting period for
e. All accumulated Sum Insured Safeguard benefit will lapse and will the same would be reduced to the extent of prior coverage.
roll back to the Base Sum Insured opted if this optional benefit is d. Coverage under the Policy after the expiry of 36 months for
not Renewed. any Pre-existing Disease is subject to the same being declared
at the time of application and accepted by Us.
Illustration of calculation of inflation rate based on CPI figures 5.2 Specified disease/procedure waiting period- Code- Excl02
Month CPI 2019 CPI 2018 a. Expenses related to the treatment of the listed conditions,
surgeries/treatments shall be excluded until the expiry of 24
January 139.6 136.9 months of continuous coverage after the date of inception of
February 139.9 136.4 the first Policy with us. This exclusion shall not be applicable
for claims arising due to an Accident (covered from day 1) or
March 140.4 136.5
Cancer (covered after 30-days waiting period).
April 141.2 137.1 b. In case of enhancement of Sum Insured the exclusion shall
May 142.0 137.8 apply afresh to the extent of Sum Insured increase.
c. If any of the specified disease/procedure falls under the
June 142.9 138.5 waiting period specified for pre-Existing diseases, then the
July 144.2 139.8 longer of the two waiting periods shall apply.
d. The waiting period for listed conditions shall apply even if
August 145.0 140.4 contracted after the Policy or declared and accepted without
September 145.8 140.2 a specific exclusion.
October 147.2 140.7 e. If the Insured Person is continuously covered without any
break as defined under the applicable norms on portability
November 148.6 140.8 stipulated by IRDAI then waiting period for the same would
December 150.4 140.1 be reduced to the extent of prior coverage.
f. List of specific diseases/procedures:
Average 143.9 138.8 i. Pancreatitis and stones in biliary and urinary system
CPI inflation rate for 3.72% ii. Cataract, glaucoma and other disorders of lens, disorders
calendar year 2019 i.e. (Average CPI for 2019 – Average CPI for of retina
2018) / Average CPI for 2018 iii. Hyperplasia of prostate, hydrocele and spermatocele
iv. Abnormal utero-vaginal bleeding, female genital
As per the table above: prolapse, endometriosis/adenomyosis, fibroids, PCOD,
• The average CPI for 2019 is 143.9, whereas the average CPI for or any condition requiring dilation and curettage or
2018 is 138.8 hysterectomy
• The increase in average CPI is calculated as: (Average CPI for 2019 v. Hemorrhoids, fissure or fistula or abscess of anal and
– Average CPI for 2018) / Average CPI for 2018 rectal region
• Hence, the average increase in Base Sum Insured applicable in vi. Hernia of all sites,
vii. Osteoarthritis, systemic connective tissue disorders,
2020 will be 3.72%.
dorsopathies, spondylopathies, inflammatory
Note: CPI figure for a particular month is recorded from the following
polyarthropathies, arthrosis such as RA, gout,
link: http://mospi.nic.in/cpi intervertebral disc disorders, arthroscopic surgeries for
ligament repair
5. Waiting Periods viii. Chronic kidney disease and failure
ix. Varicose veins of lower extremities
All the Waiting Periods shall be applicable individually for each Insured
x. All internal or external benign or in situ neoplasms/
Person and claims shall be assessed accordingly. On Renewal, if the tumours, cyst, sinus, polyp, nodules, swelling, mass or
Sum Insured or any benefit sub-limit is enhanced, the Waiting Periods lump
would apply afresh to the extent of the increased amount. The Waiting xi. Ulcer, erosion and varices of gastro intestinal tract
Periods set out below shall not apply to Section 3.15 (Health Checkup), xii. Surgical treatment for diseases of middle ear and mastoid
Section 3.16 (Second Medical Opinion), Section 3.17 (Live Healthy (including otitis media, cholesteatoma, perforation
benefit) and Section 4.1 (Personal Accident Cover). of tympanic membrane), Tonsils and adenoids, nasal
septum and nasal sinuses
We shall not be liable to make any payment under this Policy directly or xiii. Internal Congenital Anomaly
indirectly caused by, based on, arising out of or howsoever attributable xiv. Surgery of Genito-urinary system unless necessitated by
to any of the following: malignancy
xv. Spinal disorders

5.3 30-day waiting period (Code- Excl03): 1) Obesity-related cardiomyopathy
a. Expenses related to the treatment of any Illness within 30 2) Coronary heart disease
days from the first Policy commencement date shall be 3) Severe Sleep Apnea
excluded except claims arising due to an Accident, provided 4) Uncontrolled Type2 Diabetes
the same are covered. 6.4 Change-of-Gender treatments (Code-Excl07)
b. This exclusion shall not, however, apply if the Insured Person Expenses related to any treatment, including surgical management, to
has continuous coverage for more than twelve months change characteristics of the body to those of the opposite sex.
c. The within referred waiting period is made applicable to the
enhanced Sum Insured in the event of granting higher Sum 6.5 Cosmetic or plastic Surgery (Code-Excl08)
Insured subsequently. Expenses for cosmetic or plastic surgery or any treatment to change
appearance unless for reconstruction following an Accident, Burn(s) or
5.4 Personal Waiting Periods: Cancer or as part of medically necessary treatment to remove a direct
Conditions specified for an Insured Person under Personal Waiting and immediate health risk to the insured. For this to be considered
Period in the Policy Schedule will be subject to a Waiting Period of 24 a medical necessity, it must be certified by the attending Medical
months from the inception of the First Policy with Us for that Insured Practitioner.
Person and will be covered from the commencement of the third
Policy Year for that Insured Person as long as the Insured Person has 6.6 Hazardous or Adventure sports (Code-Excl09)
been insured continuously under the Policy without any break. Expenses related to any treatment necessitated due to participation
as a professional in hazardous or adventure sports, including but
6. Permanent Exclusions
not limited to, para-jumping, rock climbing, mountaineering, rafting,
A permanent exclusion will be applied on any medical or physical
motor racing, horse racing or scuba diving, hand gliding, sky diving,
condition or treatment of an Insured Person, if specifically mentioned
deep-sea diving.
in the Policy Schedule and has been accepted by You. This option as
per company’s underwriting policy, will be used for such condition(s)
or treatment(s) that otherwise would have resulted in rejection of
6.7 Breach of law (Code-Excl10)
Expenses for treatment directly arising from or consequent upon any
insurance coverage under this Policy to such Insured Person.
Insured Person committing or attempting to commit a breach of law
We shall not be liable to make any payment under this Policy directly or with criminal intent.
indirectly caused by, based on, arising out of or howsoever attributable
to any of the following unless specifically mentioned elsewhere in the 6.8 Excluded Providers (Code-Excl11)
Policy. Sections 6.1 to 6.33 are not applicable to Section 4.1 (Personal Expenses incurred towards treatment in any Hospital or by any
Accident Cover). Medical Practitioner or any other provider specifically excluded by Us
and disclosed in Our website / notified to the Policyholders are not
The permanent exclusions applicable to Section 4.1 (Personal Accident admissible. However, in case of life threatening situations or following
Cover) have been specified separately under Section 6.34. an Accident, expenses up to the stage of stabilization are payable but
not the complete claim.
6.1 Investigation & Evaluation (Code-Excl04)
a. Expenses related to any admission primarily for diagnostics and 6.9 Treatment for, alcoholism, drug or substance abuse or any
evaluation purposes only are excluded. addictive condition and consequences thereof. (Code-Excl12)
b. Any diagnostic expenses which are not related or not incidental to
the current diagnosis and treatment are excluded. 6.10 Treatments received in heath hydros, nature cure clinics,
spas or similar establishments or private beds registered as a nursing
6.2 Rest Cure, rehabilitation and respite care (Code-Excl05) home attached to such establishments or where admission is
Expenses related to any admission primarily for enforced bed rest and arranged wholly or partly for domestic reasons. (Code-Excl13)
not for receiving treatment. This also includes:
a. Custodial care either at home or in a nursing facility for personal 6.11 Dietary supplements and substances that can be purchased
care such as help with activities of daily living such as bathing, without prescription, including but not limited to vitamins, minerals
dressing, moving around either by skilled nurses or assistant or and organic substances unless prescribed by a Medical Practitioner as
non-skilled persons. part of Hospitalization claim or Day Care procedure (Code-Excl14)
b. Any services for people who are terminally ill to address physical,
social, emotional and spiritual needs. 6.12 Refractive Error (Code-Excl15)
Expenses related to the treatment for correction of eye sight due to
refractive error less than 7.5 dioptres.
6.3 Obesity/ Weight Control (Code-Excl06)
Expenses related to the surgical treatment of obesity that does not
fulfil all the below conditions:
6.13 Unproven Treatments (Code-Excl16)
Expenses related to any unproven treatment, services and supplies
a. Surgery to be conducted is upon the advice of the Doctor.
for or in connection with any treatment. Unproven treatments are
b. The surgery/Procedure conducted should be supported by clinical
treatments, procedures or supplies that lack significant medical
protocols.
documentation to support their effectiveness.
c. The member has to be 18 years of age or older and;
d. Body Mass Index (BMI);
6.14 Sterility and Infertility (Code-Excl17)
i. greater than or equal to 40 or
Expenses related to sterility and infertility. This includes:
ii. greater than or equal to 35 in conjunction with any of the
a. Any type of contraception, sterilization
following severe co-morbidities following failure of less
b. Assisted Reproduction services including artificial insemination
invasive methods of weight loss:

and advanced reproductive technologies such as IVF, ZIFT, c. Treatment provided by Hospital or health facility that is not
GIFT, ICSI recognized by the relevant authorities in India.
c. Gestational Surrogacy
d. Reversal of sterilization 6.28 The condition which is not clinically significant or is related
to anxiety, bereavement, relationship or academic problems,
6.15 Maternity Expenses (Code-Excl18) acculturation difficulties or work pressure.
a. Medical treatment expenses traceable to childbirth (including
complicated deliveries and caesarean sections incurred during 6.29 Treatment related to intentional self inflicted Injury or
Hospitalization) except ectopic pregnancy; attempted suicide by any means.
b. Expenses towards miscarriage (unless due to an Accident) and
lawful medical termination of pregnancy during the Policy Period. 6.30 Any neuro-developmental delays and disorders.
6.16 Charges related to a Hospital stay not expressly mentioned 6.31 Mental retardation which is a condition of arrested or
as being covered. This will include charges for RMO charges , incomplete development of mind of a person, specially characterized
surcharges and service charges levied by the Hospital. by subnormality of intelligence.
6.17 Circumcision: 6.32 Artificial life maintenance for the Insured Person who has
Circumcision unless necessary for the treatment of a disease or been declared brain dead or in vegetative state as demonstrated by:
necessitated by an Accident. a. Deep coma and unresponsiveness to all forms of stimulation; or
b. Absent pupillary light reaction; or
6.18 Conflict & Disaster: c. Absent oculovestibular and corneal reflexes; or
Treatment for any Injury or Illness resulting directly or indirectly from d. Complete apnea.
nuclear, radiological emissions, war or war like situations (whether war
is declared or not), rebellion (act of armed resistance to an established 6.33 If as per any or all of the medical references herein below
government or leader), acts of terrorism. containing guidelines and protocols for evidence based medicines,
the Hospitalization for treatment under claim is not necessary or the
6.19 External Congenital Anomaly: stay at the Hospital is found unduly long:
Screening, counseling or treatment related to external Congenital a. Medical text books,
Anomaly. b. Standard treatment guidelines as stated in clinical establishment
act of Government of India,
6.20 Dental/oral treatment: c. World Health Organisation (WHO) protocols,
Treatment, procedures and preventive, diagnostic, restorative, d. Published guidelines by healthcare providers,
cosmetic services related to disease, disorder and conditions related e. Guidelines set by medical societies like cardiological society of
to natural teeth and gingiva except if required by an Insured Person India, neurological society of India etc.
while Hospitalized due to an Accident.
6.34 Permanent Exclusions for Personal Accident Cover
6.21 Hormone Replacement Therapy: We shall not be liable to make any payment under any benefits under
Treatment for any condition / illness which requires hormone Section 4.1 (Personal Accident Cover) if the claim is attributable to, or
replacement therapy. based on, or arises out of, or is directly or indirectly connected to any
of the following:
6.22 Multifocal Lens and ambulatory devices such as walkers, a. Suicide or self inflicted Injury, whether the Insured Person is
crutches, splints, stockings of any kind and also any medical medically sane or insane.
equipment which is subsequently used at home. b. Treatment for any Injury or Illness resulting directly or indirectly
from nuclear, radiological emissions, war or war like situations
6.23 Sexually transmitted Infections & diseases (other than HIV (whether war is declared or not), rebellion (act of armed resistance
/ AIDS): Screening, prevention and treatment for sexually related to an established government or leader), acts of terrorism.
infection or disease (other than HIV / AIDS). c. Service in the armed forces, or any police organization, of
any country at war or at peace or service in any force of an
6.24 Sleep disorders: international body or participation in any of the naval, military or
Treatment for any conditions related to disturbance of normal sleep air force operation during peace time.
patterns or behaviors. d. Any change of profession after inception of the Policy or any
Renewal which results in the enhancement of Our risk, if not
6.25 Any treatment or medical services received outside the accepted and endorsed by Us on the Policy Schedule.
geographical limits of India. e. Committing an assault, a criminal offence or any breach of law
with criminal intent.
6.26 Any expenses incurred on OPD treatment. f. Taking or absorbing, accidentally or otherwise, any intoxicating
liquor, drug, narcotic, medicine, sedative or poison, except as
6.27 Unrecognized Physician or Hospital: prescribed by a Medical Practitioner other than the Policyholder
a. Treatment or Medical Advice provided by a Medical Practitioner or an Insured Person.
not recognized by the Medical Council of India or by Central g. Participation in aviation/marine activities (including crew) other
Council of Indian Medicine or by Central council of Homeopathy. than as a passenger in an aircraft/water craft that is authorized
b. Treatment provided by anyone with the same residence as by the relevant regulations to carry such passengers between
an Insured Person or who is a member of the Insured Person’s established airports or ports.
immediate family or relatives. h. Engaging in or taking part in professional/adventure sports

or any hazardous pursuits, speed contest or racing of any kind Hospitalization or before discharge from the Hospital,
(other than on foot), bungee jumping, parasailing, ballooning, whichever is earlier.
parachuting, skydiving, paragliding, hang gliding, mountain or
rock climbing necessitating the use of guides or ropes, potholing, All final authorization requests, if required, shall be sent at
abseiling, deep sea diving, polo, snow and ice sports, hunting. least six hours prior to the Insured Person’s discharge from
i. Body or mental infirmity or any Illness except where such the Hospital.
condition arises directly as a result of an Accident during the
Policy Period. However this exclusion is not applicable to claims Each request for pre-authorization must be accompanied
made under Section 4.1(c) (Permanent Partial Disability). with completely filled and duly signed pre-authorization
form including all of the following details:
7. Claims Process & Requirements i) The health card We have issued to the Insured
The fulfillment of the terms and conditions of this Policy (including Person at the time of inception of the Policy (if
payment of full premium in advance by the due dates mentioned in available) supported with KYC document;
the Policy Schedule) in so far as they relate to anything to be done ii) The Policy Number;
or complied with by You or any Insured Person, including complying
iii) Name of the Policyholder;
with the following in relation to claims, shall be Condition Precedent
iv) Name and address of Insured Person in respect of
to Admission of Liability under this Policy.
whom the request is being made;
7.1 Claims Administration: v) Nature of the Illness/Injury and the treatment/
On the occurrence or discovery of any Illness or Injury that may give Surgery required;
rise to a claim under this Policy, the Claims Procedure set out below vi) Name and address of the attending Medical
shall be followed: Practitioner;
a. We advise You to submit all claims related documents, including vii) Hospital where treatment/Surgery is proposed to be
documents for claims within the Deductible amount, once the taken;
Deductible limit has been exhausted. viii) Date of admission;
b. We/Our Service Provider must be permitted to inspect the medical ix) First and any subsequent consultation paper /
and Hospitalization records pertaining to the Insured Person’s Medical Record since beginning of diagnosis of that
treatment and to investigate the circumstances pertaining to the treatment/Surgery;
claim. x) Admission note;
c. We and Our Service Provider must be given all reasonable co- xi) Treating Medical Practitioner certificate for
operation in investigating the claim in order to assess Our liability Illness / Insured Event history with justification of
and quantum in respect of the claim. Hospitalization.
d. It is hereby agreed and understood that no change in the Medical
Record provided under the Medical Advice information, by the If these details are not provided in full or are insufficient
Hospital or the Insured Person to Us or Our Service Provider for Us to consider the request, We will request additional
during the period of Hospitalization or after discharge by any information or documentation in respect of that request.
means of request will be accepted by Us. Any decision on request
for acceptance of such change will be considered on merits
When We have obtained sufficient details to assess the
where the change has been proven to be for reasons beyond the
request, We will issue the authorization letter specifying
claimant’s control.
the sanctioned amount, any specific limitation on the claim,
applicable Deductibles / Co-payment and non-payable items,
7.2 Claims Procedure: On the occurrence or the discovery of
if applicable, or reject the request for pre-authorisation
any Illness or Injury that may give rise to a claim under this Policy,
specifying reasons for the rejection.
then as a Condition Precedent to Admission of Liability under the
Policy the following procedure shall be complied with:
In case of preauthorization request where chronicity of
a. For Availing Cashless Facility: Cashless Facility can be availed only condition is not established as per clinical evidence based
at Our Network Providers or Service Providers (as applicable). The information, We may reject the request for preauthorization
complete list of Network Providers are available on Our website and ask the claimant to claim as Reimbursement. Claim
and at Our branches and can also be obtained by contacting document submission for Reimbursement shall not be
Us over the telephone. In order to avail Cashless Facility, the deemed as an admission of Our liability.
following process must be followed:
Once the request for pre-authorisation has been granted,
i. Process for Obtaining Pre-Authorization the treatment must take place within 15 days of the pre-
A) For Planned Treatment: authorization date and pre-authorization shall be valid
We must be contacted to pre-authorize Cashless only if all the details of the authorized treatment, including
Facility for planned treatment at least 72 hours prior dates, Hospital, locations, indications and disease details,
to the proposed treatment. Once the request for pre- match with the details of the actual treatment received. For
authorisation has been granted, the treatment must take Hospitalization on a Cashless Facility basis, We will make the
place within 15 days of the pre-authorization date at a payment of the amount assessed to be due, directly to the
Network Provider. Network Provider / Service Provider.
B) In Emergencies:
If the Insured Person has been Hospitalized in an We reserve the right to modify, add or restrict any Network
Emergency, We must be contacted to pre-authorize Provider or Service Provider for Cashless Facility at Our sole
Cashless Facility within 48 hours of the Insured Person’s discretion.

ii. Reauthorization (In case You are unable to submit such document, then We shall
Cashless Facility will be provided subject to re-authorization consider the Reasonable and Customary Charges of the Insured
if requested for either change in the line of treatment or Person’s eligible room category of Our Network Provider within
in the diagnosis or for any procedure carried out on the the same geographical area for identical or similar services.)
incidental diagnosis/finding prior to the discharge from the i. Original bills of pharmacy/medicines purchased, or of any other
Hospital. investigation done outside Hospital with reports and requisite
prescriptions.
b. For Reimbursement Claims: j. For Medico-legal cases (MLC) or in case of Accident
For all claims for which Cashless Facility has not been pre-authorized i. MLC/ Panchnama / First Information Report (FIR) copy
or for which treatment has not been taken at a Network Provider/ attested by the concerned Hospital / police station (if
Service Provider or for which Cashless Facility is not available, We shall applicable);
be given written notice of the claim along with the following details ii. Original self-narration of incident in absence of MLC /
within 48 hours of admission to the Hospital or before discharge from FIR.
the Hospital, whichever is earlier: k. Original laboratory investigation, diagnostic, radiological &
i. The Policy Number; pathological reports with supporting prescriptions.
ii. Name of the Policyholder;
iii. Name and address of the Insured Person in respect of whom In the event of the Insured Person’s death during Hospitalization,
the request is being made; written notice accompanied by a copy of the post mortem report (if
iv. Nature of Illness or Injury and the treatment/Surgery taken; any) shall be given to Us regardless of whether any other notice has
v. Name and address of the attending Medical Practitioner; been given to Us.
vi. Hospital where treatment/Surgery was taken;
vii. Date of admission and date of discharge; For Personal Accident claims
viii. Any other information that may be relevant to the Illness/ Additional claim documentation for Personal Accident Cover under
Injury/ Hospitalization. Section 4.1:
a. Accident Death
7.3 Claims Documentation: i. Copy of death certificate (issued by the office of Registrar
For medical claims – Reimbursement Facility: of Births and Deaths or any other authorized legal
We shall be provided with the following necessary information and institution)
documentation in respect of all claims at Your/Insured Person’s ii. Copy of post mortem report wherever applicable
expense within 30 days of the Insured Event giving rise to a claim or
within 30 days from the date of occurrence of an Insured Event. b. Accident Permanent Total Disability or Accident Permanent
Partial Disability
For medical claims – Cashless Facility: i. Certificate of disability issued by a Medical Board duly
constituted by the Central and/or the State Government.
We will be provided these documents by the Network Provider
immediately following the Insured Person’s discharge from Hospital 7.4 Claims Assessment & Repudiation:
a. At Our discretion, We may investigate claims to determine the
Necessary information and documentation for medical claims validity of a claim. All costs of investigation will be borne by Us
a. Claim form duly completed and signed by the claimant. and all investigations will be carried out by those individuals/
b. Details of past medical history record, first and subsequent entities that are authorized by Us in writing.
consultation. b. Complete discharge: Any payment to the Insured Person or his/
c. Age / Identity proof document of Insured Person in case of claim her nominees or his/ her legal representative or to the Hospital/
approved under Cashless Facility (not required if submitted at the Nursing Home or assignee, as the case may be, for any benefit
time of pre-authorization request) and Policyholder in case of under the Policy shall in all cases be a full, valid and an effectual
Reimbursement claim. discharge towards payment of claim by the Company to the
i. Self attested copy of valid age proof (passport / driving extent of that amount for the particular claim.
license / PAN card / class X certificate / birth certificate); c. All admissible claims under this Policy shall be assessed by Us in
ii. Self attested copy of identity proof (passport / driving the following progressive order:-
license / PAN card / voter identity card); i. If a room has been opted in a Hospital for which the room
iii. Recent passport size photograph category is higher than the eligible limit as applicable for that
Insured Person as specified in the Policy Schedule, then the
d. Cancelled cheque/ bank statement / copy of passbook mentioning Associated Medical Expenses payable shall be pro-rated as
account holder’s name, IFSC code and account number printed per the applicable limits in accordance with Section 3.1.
on it of Policyholder / nominee ( in case of death of Policyholder). ii. The Deductible (if applicable) shall be applied to the aggregate
e. Original discharge summary. of all claims that are either paid or payable under this Policy.
f. Bar code sticker and invoice for implants and prosthesis (if used Our liability to make payment shall commence only once the
and only in case of Surgery/Surgical Procedure). aggregate amount of all eligible claims as per policy terms
g. Original final bill from Hospital with detailed break-up and paid and conditions exceeds the Deductible limit within the same
receipt. Policy Year.
h. Room tariff of the entitled room category (in case of a Non- iii. Co-payment (if applicable) as specified in the Policy Schedule
Network provider and if room tariff is not a part of Hospital bill): shall be applicable on the amount payable by Us.
duly signed and stamped by the Hospital in which treatment is d. The claim amount assessed in Section 7.4 d above would be
taken.

deducted from the amount / sub-limit mentioned against each 7.8 Claim process for Section 3.16 (Second Medical Opinion), if
benefit or treatment as per terms and conditions and Sum availed on Cashless Facility:
Insured as specified in the Policy Schedule. The amount provided a. In the event of submission of request for Second Medical Opinion,
under ReAssure benefit will be applied only once the Sum Insured Our Service Provider shall be contacted on the helpline number.
is exhausted in the Policy Year. b. Our Service Provider will evaluate the information of the Insured
7.5 Delay in Claim Intimation or Claim Documentation: Person and if the request for Second Medical Opinion is approved,
If the claim is not notified to Us or claim documents are not submitted the Service Provider will facilitate arrangement as per conditions
within the stipulated time as mentioned in the above sections, then specified in the Section 3.16.
We shall be provided the reasons for the delay, in writing. We will
condone such delay on merits where the delay has been proved to be 8. General Terms and Conditions
for reasons beyond the claimant’s control.
8.1 Free Look Provision
7.6 Claims process for Section 3.10 (Air Ambulance), if availed on The Free Look Period shall be applicable at the inception of the Policy
Cashless Facility: and not on renewals or at the time of porting the Policy.
a. In the event of an Emergency, Our Service Provider shall be
contacted immediately on the helpline number. The Insured Person shall be allowed a period of fifteen days (30 days if
b. Our Service Provider will evaluate the necessity for evacuation of the Policy with Policy Period as 3 years has been sold through distance
the Insured Person and if the request for Medical Evacuation is marketing) from date of receipt of the Policy document to review
approved by Us, the Service Provider shall pre-authorise the type the terms and conditions of the Policy, and to return the same if not
of travel that can be utilized to transport the Insured Person and acceptable.
provide information on the Hospital that may be approached for
medical treatment of the Insured Person. If the Insured has not made any claim during the Free Look Period, the
c. If the Service Provider pre-authorises the Medical Evacuation of Insured shall be entitled to:
the Insured Person by means of Air Transportation through an a. a refund of the premium paid less any expenses incurred by the
air ambulance or commercial flight whichever is best suited, the Company on medical examination of the Insured Person and the
Service Provider shall also arrange for the same to be provided to stamp duty charges or
the Insured Person unless there are any logistical constraints or b. where the risk has already commenced and the option of return
the medical condition of the Insured Person prevents Emergency of the Policy is exercised by the Insured, a deduction towards the
Medical Evacuation. proportionate risk premium for period of cover or
c. Where only a part of the insurance coverage has commenced,
7.7 Claims process for Section 3.15 (Health Checkup), if availed such proportionate premium commensurate with the insurance
on Cashless Facility: coverage during such period.
a. The Insured Person shall seek appointment by contacting Our
Service Provider. 8.2 Cancellation
b. Our Service Provider will facilitate Your appointment. a. The Insured Person may cancel this Policy by giving 15days written
c. Reports of the medical tests can be collected directly from the notice and in such an event, the Company shall refund premium
Service Provider. on short term rates for the unexpired Policy Period as per the
rates detailed below.
1 year 2 years 3 years
Policy in-force up to Refund of Premium (%) Policy in-force up to Refund of Premium (%) Policy in-force up to Refund of Premium (%)
Up to 30 days 75% Up to 30 days 87.5% Up to 30 days 90%
31 to 90 days 50% 31 to 90 days 75% 31 to 90 days 87.5%
91 to 180 days 25% 91 to 180 days 62.5% 91 to 180 days 75%
exceeding 180 days 0% 181 to 365 days 50% 181 to 365 days 60%
366 to 455 days 25% 366 to 455 days 50%
456 to 545 days 12% 456 to 545 days 25%
Exceeding 545 days 0% 545 to 720 days 12%
Exceeding 720 days 0%
The above grid shall be applicable for ‘Yearly / Annual’ premium payment frequency. For Half Yearly or Quarterly premium payment frequencies,
the Company shall refund premium as per below grid:
No. of completed months at Refund % No. of completed months at Refund %
the time of cancellation Half Yearly Quarterly the time of cancellation Half Yearly Quarterly
0 62.5% 50% 6 62.5% 50%
1 33.3% 16.7% 7 33.3% 16.7%
2 25% 0% 8 25% 0%
3 8.3% 50% 9 8.3% 50%
4 4.2% 16.7% 10 4.2% 16.7%
5 0% 0% 11 0% 0%
For monthly premium payment frequency, no refund shall be applicable for cancellation of the Policy

Notwithstanding anything contained herein or otherwise, no 8.8 Addition of Insured Persons on Renewal:
refunds of premium shall be made in respect of cancellation Where an individual is added to this Policy, either by way of endorsement
where, any claim has been admitted or has been lodged or any or at the time of Renewal, the Pre-existing Disease clause, exclusions,
Benefit has been availed by the Insured Person under the Policy. loading (if any) and Waiting Periods will be applicable considering such
b. The Company may cancel the Policy at any time on grounds of Policy Year as the first year of the Policy with Us for that Insured Person.
mis-representation, non-disclosure of material facts, fraud by
the Insured Person by giving 15 days written notice. There would 8.9 Changes to Sum Insured on Renewal:
be no refund of premium on cancellation on grounds of mis- You may opt for enhancement of Sum Insured at the time of Renewal,
representation, non-disclosure of material facts or fraud. subject to underwriting. All Waiting Periods as defined in the Policy
shall apply afresh for this enhanced limit or any benefit’s enhanced
8.3 Loading on Premium sub-limit from the effective date of such enhancement.
a. Upon the disclosure of the health status of the persons proposed
for insurance and declarations made in the Proposal or Insurance 8.10 Change of Policyholder
Summary Sheet, We may apply a risk loading on the premium a. The Policyholder may be changed only at the time of Renewal.
payable (excluding statutory levies and taxes) or Special The new Policyholder must be a member of the Insured Person’s
Conditions on the Policy. The maximum risk loading applicable immediate family. Such change would be solely subject to Our
shall not exceed more than 100% of the premium per diagnosis discretion and payment of premium by You. The Renewed Policy
/ medical condition and an overall risk loading shall not exceed shall be treated as having been Renewed without break. The
more than 150% of the premium per Insured Person. Policyholder may be changed upon request in case of Your death,
b. These loadings will be applied from inception date of the First Your emigration from India or in case of Your divorce during the
Policy including subsequent Renewal(s) with Us. Policy Period.
c. We may apply a specific personal Waiting Period on a medical b. Any alteration in the Policy due to unavoidable circumstances as
condition/ailment depending on the past history or additional in case of the Policyholder’s death, emigration or divorce during
Waiting Periods on Pre-existing Diseases as part of the special the Policy Period should be reported to Us immediately.
conditions on the Policy. c. Renewal of such Policies will be according to terms and conditions
of existing Policy.
8.4 Renewal of Policy
The policy shall ordinarily be renewable except on grounds of fraud, 8.11 Nomination
misrepresentation by the insured person. The policyholder is required at the inception of the policy to make a
nomination for the purpose of payment of claims under the policy in
I. The Company shall endeavor to give notice for renewal. However,
the event of death of the policyholder. Any change of nomination shall
the Company is not under obligation to give any notice for
be communicated to the company in writing and such change shall
renewal.
be effective only when an endorsement on the policy is made. ln the
II. Renewal shall not be denied on the ground that the insured
event of death of the policyholder, the Company will pay the nominee
person had made a claim or claims in the preceding policy years.
{as named in the Policy Schedule/Policy Certificate/Endorsement (if
III. Request for renewal along with requisite premium shall be
any)} and in case there is no subsisting nominee, to the legal heirs
received by the Company before the end of the policy period.
IV. At the end of the policy period, the policy shall terminate and or legal representatives of the policyholder whose discharge shall be
can be renewed within the Grace Period of 30 days to maintain treated as full and final discharge of its liability under the policy.
continuity of benefits without break in policy. Coverage is not
available during the grace period. 8.12 Obligations in case of a minor
V. No loading shall apply on renewals based on individual claims If an Insured Person is less than 18 years of Age, You or another adult
experience. Insured Person or legal guardian (in case of Your and all other adult
Insured Person’s demise) shall be completely responsible for ensuring
8.5 Renewal Premium: compliance with all the terms and conditions of this Policy on behalf of
Renewal premium will alter based on Age. The reference of age for that minor Insured Person.
calculating the premium for Family Floater Policies shall be the age of
the eldest Insured Person. 8.13 Authorization to obtain all pertinent records or information:
As a Condition Precedent to Admission of Liability for payment of
8.6 Disclosures on Renewal: benefits, We and/or Our Service Provider shall have the authority
You shall make a full disclosure to Us in writing of any material change to obtain all pertinent records or information from any Medical
in the health condition or geographical location of any Insured Person Practitioner, Hospital, clinic, insurer, individual or institution to assess
at the time of seeking Renewal of this Policy, irrespective of any claim the validity of a claim submitted by or on behalf of any Insured Person.
arising or made. The terms and condition of the existing Policy will not
be altered. 8.14 Fraud
If any claim made by the insured person, is in any respect fraudulent, or
8.7 Renewal for Insured Persons who have achieved Age 31: if any false statement, or declaration is made or used in support thereof,
If any Insured Person who is a child and has completed Age 31 years or if any fraudulent means or devices are used by the insured person or
at the time of Renewal in a Family Floater Policy, then such Insured anyone acting on his/her behalf to obtain any benefit under this policy,
Person will have to take a separate policy based on Our underwriting all benefits under this policy and the premium paid shall be forfeited.
guidelines, as per Our Board approved underwriting policy as he/she
will no longer be eligible to be covered under such Policy. In such cases, Any amount already paid against claims made under this policy but
the credit of the Waiting Periods served under the Policy will be passed which are found fraudulent later shall be repaid by all recipient(s)/
on to the separate policy taken by such Insured Person. policyholder(s), who has made that particular claim, who shall be
jointly and severally liable for such repayment to the insurer.

For the purpose of this clause, the expression “fraud” means any of 8.21 Withdrawal of Policy
the following acts committed by the insured person or by his agent or ln the likelihood of this product being withdrawn in future, the
the hospital/doctor/any other party acting on behalf of the insured Company will intimate the insured person about the same 90 days
person, with intent to deceive the insurer or to induce the insurer to prior to expiry of the policy.
issue an insurance policy: a) the suggestion, as a fact of that which is not
true and which the insured person does not believe to be true; b) the lnsured Person will have the option to migrate to similar health
active concealment of a fact by the insured person having knowledge insurance product available with the Company at the time of renewal
or belief of the fact; c) any other act fitted to deceive; and d) any such with all the accrued continuity benefits such as cumulative bonus,
act or omission as the law specially declares to be fraudulent. waiver of waiting period as per IRDAI guidelines, provided the policy
has been maintained without a break.
The Company shall not repudiate the claim and / or forfeit the policy
benefits on the ground of Fraud, if the insured person / beneficiary 8.22 Redressal of Grievance:
can prove that the misstatement was true to the best of his knowledge In case of any grievance the Insured Person may contact the
and there was no deliberate intention to suppress the fact or that
company through:
such misstatement of or suppression of material fact are within the
Website: www.maxbupa.com
knowledge of the insurer.
Toll free: 1860-500-8888
8.15 Policy Disputes E-mail: [email protected]
Any dispute concerning the interpretation of the terms, conditions, (Senior citizens may write to us at:
limitations and/or exclusions contained herein shall be governed by [email protected])
Indian law and shall be subject to the jurisdiction of the Indian Courts. Fax : 011-3090-2010
Courier: Customer Services Department
8.16 Territorial Jurisdiction Max Bupa Health Insurance Company Limited
All benefits are available in India only and all claims shall be payable in 2nd Floor, Plot No D-5, Sec-59, Noida,
India in Indian Rupees only. Gautam Buddh Nagar, Uttar Pradesh – 201301
8.17 Notices Insured person may also approach the grievance cell at any of the
Any notice, direction or instruction given under this Policy shall be in company’s branches with the details of grievance.
writing and delivered by hand, post, or facsimile to:
If Insured person is not satisfied with the redressal of grievance
a. You/the Insured Person at the address specified in the Policy through one of the above methods, Insured Person may contact the
Schedule or at the changed address of which We must receive grievance officer at:
written notice.
b. Us at the following address: Grievance Redressal Officer
Max Bupa Health Insurance Company Limited Max Bupa Health Insurance Company Limited
2nd Floor, Plot No D-5, Sec-59, Noida, 2nd Floor, Plot No D-5, Sec-59, Noida,
Gautam Buddh Nagar, Uttar Pradesh – 201301 Gautam Buddh Nagar, Uttar Pradesh – 201301
Fax No.: 011-3090-2010 Email: [email protected] or [email protected]
c. No insurance agents, brokers or other person/entity is authorized
to receive any notice on Our behalf. For details of grievance officer, kindly refer the link https://www.
d. In addition, We may send You/the Insured Person other maxbupa.com/customer-care/health-services/grievance-redressal.
information through electronic and telecommunications means
aspx
with respect to Your Policy from time to time.
If Insured person is not satisfied with the redressal of grievance through
8.18 Alteration to the Policy
This Policy constitutes the complete contract of insurance. Any change above methods, the Insured Person may also approach the office of
in the Policy will only be evidenced by a written endorsement signed Insurance Ombudsman of the respective area/region for redressal of
and stamped by Us. No one except Us can within the permission of the grievance at the addresses given in Annexure III.
IRDAI change or vary this Policy.
Grievance may also be lodged at IRDAI Integrated Grievance
8.19 Zonal pricing Management System - https://igms.irda.gov.in/
For the purpose of calculating premium, the country has been divided
into the following 2 zones: 8.23 Assignment
a. Zone 1: Delhi NCR, Mumbai (including Navi Mumbai and Thane), The Policy can be assigned subject to applicable laws.
Kolkata and Gujarat StateDelhi NCR includes Delhi, Baghpat,
Bulandshahr, Gautam Buddh Nagar, Ghaziabad, Hapur, Meerut, 8.24 Claim settlement (Provision for Penal interest
Muzaffarnagar, Shamli, Charkhi Dadri, Faridabad, Gurugram, I. The Company shall settle or reject a claim, as the case may be,
Jhajjar, Jind, Karnal, Mahendragarh, Nuh, Palwal, Panipat, Rewari, within 30 days from the date of receipt of last necessary document.
Rohtak and Sonipat II. ln the case of delay in the payment of a claim, the Company
b. Zone 2: Rest of India shall be liable to pay interest to the policyholder from the date
of receipt of last necessary document to the date of payment of
8.20 Possibility of Revision of Terms of the Policy Including the claim at a rate 2% above the bank rate.
Premium Rates III. However, where the circumstances of a claim warrant an
The Company, with prior approval of IRDAI, may revise or modify the investigation in the opinion of the Company, it shall initiate and
terms of the Policy including the premium rates. The Insured Person complete such investigation at the earliest, in any case not later
shall be notified three months before the changes are effected. than 30 days from the date of receipt of last necessary document-

ln such cases, the Company shall settle or reject the claim within 8.28 Portability
45 days from the date of receipt of last necessary document. The Insured Person will have the option to port the Policy to other
IV. ln case of delay beyond stipulated 45 days, the Company shall be insurers by applying to such insurer to port the entire Policy along with
liable to pay interest to the policyholder at a rate 2% above the all the members of the family, if any, at least 45 days before, but not
bank rate from the date of receipt of last necessary document to earlier than 60 days from the premium due date of his / her existing
the date of payment of claim. Policy as per extant guidelines related to portability. If such person
(Explanation: “Bank rate” shall mean the rate fixed by the Reserve is presently covered and has been continuously covered without
Bank of lndia (RBl) at the beginning of the financial year in which claim any lapses under any health insurance policy with an Indian General
has fallen due) / Health insurer, the proposed insured person will get the accrued
continuity benefits in waiting periods as per extant guidelines on
8.25 Moratorium Period portability.
After completion of eight continuous years under the Policy no look
back to be applied. This period of eight years is called as moratorium For Detailed Guidelines on portability, kindly refer the link
period. The moratorium would be applicable for the sums insured of https://www.irdai.gov.in/ADMINCMS/cms/whatsNew_Layout.
the first Policy and subsequently completion of 8 continuous years aspx?page=PageNo3987&flag=1
would be applicable from date of enhancement of sums insured only
on the enhanced limits. After the expiry of Moratorium Period no 8.29 Disclosure of Information
health insurance claim shall be contestable except for proven fraud The Policy shall be void and all premium paid thereon shall be forfeited
and permanent exclusions specified in the Policy contract. The policies to the Company in the event of misrepresentation, mis-description or
would however be subject to all limits, sub limits, co-payments, non-disclosure of any material fact by the policyholder
deductibles as per the Policy contract.
(Explanation: “Material facts” for the purpose of this policy shall mean
8.26 Multiple Policies all relevant information sought by the company in the proposal form
ln case of multiple policies taken by an insured person during a period and other connected documents to enable it to take informed decision
from one or more insurers to indemnify treatment costs, the insured in the context of underwriting the risk)
person shall have the right to require a settlement of his/her claim in
terms of any of his/her policies. ln all such cases the insurer chosen by 8.30 Condition Precedent to Admission of Liability
the insured person shall be obliged to settle the claim as long as the The terms and conditions of the policy must be fulfilled by the insured
claim is within the limits of and according to the terms of the chosen person for the Company to make any payment for claim(s) arising
policy. under the policy.
lnsured person having multiple policies shall also have the right to 8.31 Premium Payment in Installments
prefer claims under this policy for the amounts disallowed under any lf the insured person has opted for Payment of Premium on an
other policy / policies even if the sum insured is not exhausted. Then instalment basis i.e. Half Yearly, Quarterly or Monthly, as mentioned in
the insurer shall independently settle the claim subject to the terms the policy Schedule/Certificate of insurance, the following Conditions
and conditions of this policy. shall apply (notwithstanding any terms contrary elsewhere in the
policy)
lf the amount to be claimed exceeds the sum insured under a single i. Grace Period of 30 days in case of single premium policies,
policy, the insured person shall have the right to choose insurer from and a period of 15 days in case of other than single premium
whom he/she wants to claim the balance amount. policies, would be given to pay the instalment premium due
for the policy.
Where an insured person has policies from more than one insurer to ii. During such grace period, coverage will not be available from
cover the same risk on indemnity basis, the insured person shall only the due date of instalment premium till the date of receipt of
be indemnified the treatment costs in accordance with the terms and premium by Company.
conditions of the chosen policy iii. The insured person will get the accrued continuity benefit in
respect of the “Waiting Periods”, “Specific Waiting Periods” in
8.27 Migration the event of payment of premium within the stipulated grace
The Insured Person will have the option to migrate the Policy to other Period.
health insurance products / plans offered by the Company policy by
iv. No interest will be charged lf the instalment premium is not
applying for migration of the policy 30 days before the premium due
paid on due date
date of his / her existing Policy as per extant guidelines on Migration.
v. ln case of instalment premium due not received within the
If such person is presently covered and has been continuously covered
grace period, the policy will get cancelled.
without any lapses under any health insurance product / plan offered
by the Company, the proposed insured person will get the accrued vi. ln the event of a claim, all subsequent premium instalments
continuity benefits in waiting periods as per extant guidelines on shall immediately become due and payable.
migration. The company has the right to recover and deduct all the pending
installments from the claim amount due under the policy.
For Detailed Guidelines on migration, kindly refer the link
https://www.irdai.gov.in/ADMINCMS/cms/whatsNew_Layout. 9. Defined Terms
aspx?page=PageNo3987&flag=1 The terms listed below in Section 9 and used elsewhere in the Policy in
Initial Capitals shall have the meaning set out against them in Section 9.

9.1 Accident or Accidental means a sudden, unforeseen and a. All tumors which are histologically described as carcinoma in
involuntary event caused by external, visible and violent means. situ, benign, pre-malignant, borderline malignant, low malignant
potential, neoplasm of unknown behavior, or non-invasive,
9.2 Age means age as on last birthday. including but not limited to: Carcinoma in situ of breasts, Cervical
dysplasia CIN-1, CIN - 2 and CIN-3.
9.3 Associated Medical Expenses shall include Room Rent, nursing b. Any non-melanoma skin carcinoma unless there is evidence of
charges, Medical Practitioners’ fees and operation theatre charges metastases to lymph nodes or beyond;
c. Malignant melanoma that has not caused invasion beyond the
9.4 AYUSH Hospital is a healthcare facility wherein medical / epidermis;
surgical / para-surgical treatment procedures and interventions are d. All tumors of the prostate unless histologically classified as having
carried out by AYUSH Medical Practitioner(s) comprising of any of the a Gleason score greater than 6 or having progressed to at least
following: clinical TNM classification T2N0M0
a. Central or state government AYUSH Hospital; or e. All Thyroid cancers histologically classified as T1N0M0 (TNM
b. Teaching Hospital attached to AYUSH college recognized by Classification) or below;
the Central Government / Central Council of Indian Medicine / f. Chronic lymphocytic leukaemia less than RAI stage 3
Central Council of Homeopathy; or g. Non-invasive papillary cancer of the bladder histologically
c. AYUSH Hospital, standalone or co-located with in-patient described as TaN0M0 or of a lesser classification
healthcare facility of any recognized system of medicine, h. All Gastro-Intestinal Stromal Tumors histologically classified as
registered with the local authorities, wherever applicable and is T1N0M0 (TNM Classification) or below and with mitotic count of
under the supervision of a qualified registered AYUSH Medical less than or equal to 5/50 HPFs;
Practitioner and must comply with all the following criterion: i. All tumors in the presence of HIV infection.
i. Having at least five in-patient beds;
ii. Having qualified AYUSH Medical Practitioner in charge round 9.10 Cashless Facility means a facility extended by the insurer to the
the clock; insured where the payments, of the costs of treatment undergone by
iii. Having dedicated AYUSH therapy sections as required and/ the insured in accordance with the policy terms and conditions, are
or has equipped operation theatre where surgical procedures directly made to the network provider by the insurer to the extent
are to be carried out; pre-authorization is approved.
iv. Maintaining daily records of the patients and making
them accessible to the insurance company’s authorized 9.11 Congenital Anomaly means a condition which is present since
representative. birth, and which is abnormal with reference to form, structure or
AYUSH Hospitals referred above shall also obtain either pre-entry position.
level certificate (or higher level of certificate) issued by National a. Internal Congenital Anomaly: Congenital Anomaly which is not in
Accreditation Board for Hospitals and Healthcare Providers (NABH) or the visible and accessible parts of the body.
State Level Certificate (or higher level of certificate) under National b. External Congenital Anomaly: Congenital Anomaly which is in the
Quality Assurance Standards (NQAS), issued by National Health visible and accessible parts of the body.
Systems Resources Centre (NHSRC).
9.12 Co-payment means a cost-sharing requirement under a health
9.5 AYUSH Treatment refers to the medical and / or hospitalization insurance policy that provides that the Policyholder/insured will bear
treatments given under Ayurveda, Yoga and Naturopathy, Unani, Sidha a specified percentage of the admissible claim amount. A Co-payment
and Homeopathy systems. does not reduce the Sum Insured.
9.6 Base Sum Insured means the amount stated in the Policy 9.13 Cumulative Bonus means any increase or addition in the Sum
Schedule. Insured granted by the insurer without an associated increase in
premium.
9.7 Bone Marrow Transplant is the actual undergoing of a transplant
of human bone marrow using haematopoietic stem cells. The 9.14 Day Care Center means any institution established for Day Care
undergoing of a transplant has to be confirmed by a specialist medical Treatment of Illness and/or Injuries or a medical set-up with a Hospital
practitioner. The following will be excluded: and which has been registered with the local authorities, wherever
a. Other stem-cell transplants applicable, and is under the supervision of a registered and qualified
b. Where only islets of langerhans are transplanted Medical Practitioner AND must comply with all minimum criterion as
under:
9.8 Break in Policy means the period of gap that occurs at the end a. has Qualified Nursing staff under its employment;
of the existing policy term, when the premium due for renewal on a b. has qualified Medical Practitioner(s) in charge;has a fully
given policy is not paid on or before the premium renewal date or equipped operation theatre of its own where Surgical Procedures
within 30 days thereof. are carried out;
c. maintains daily records of patients and will make these accessible
9.9 Cancer means a malignant tumor characterized by the to the insurance company’s authorized personnel.
uncontrolled growth and spread of malignant cells with invasion
and destruction of normal tissues. This diagnosis must be supported 9.15 Day Care Treatment refers to medical treatment, and/or
by histological evidence of malignancy. The term cancer includes Surgical Procedure which is:
leukemia, lymphoma and sarcoma. a. undertaken under General or Local Anaesthesia in a Hospital/
The following are excluded: Day Care Center in less than 24 hrs because of technological
advancement, and

b. which would have otherwise required a Hospitalization of more e. maintains daily records of patients and makes these accessible to
than 24 hours. the Insurance company’s authorized personnel.
Treatment normally taken on an OPD basis is not included in the scope
of this definition. 9.25 Hospitalization or Hospitalized means the admission in a
Hospital for a minimum period of 24 consecutive Inpatient Care hours
9.16 Deductible means a cost-sharing requirement under a health except for specified procedures/treatments, where such admission
insurance policy that provides that the Insurer will not be liable for could be for a period of less than 24 consecutive hours.
a specified rupee amount in case of indemnity policies and for a
specified number of days/hours in case of hospital cash policies which 9.26 ICU (Intensive Care Unit) Charges means the amount charged by
will apply before any benefits are payable by the insurer. A deductible a Hospital towards ICU expenses which shall include the expenses for
does not reduce the Sum Insured. ICU bed, general medical support services provided to any ICU patient
including monitoring devices, critical care nursing and intensivist
9.17 Dental Treatment means a treatment related to teeth or charges.
structures supporting teeth including examinations, fillings (where
appropriate), crowns, extractions and Surgery. 9.27 Illness means a sickness or a disease or pathological condition
leading to the impairment of normal physiological function and
requires medical treatment.
9.18 Diagnostic Services means those diagnostic tests and
a. Acute condition - Acute condition is a disease, illness or injury that
exploratory or therapeutic procedures required for the detection,
is likely to respond quickly to treatment which aims to return the
identification and treatment of a medical condition.
person to his or her state of health immediately before suffering
the disease/ illness/ injury which leads to full recovery
9.19 Domiciliary Hospitalization means medical treatment for an b. Chronic condition - A chronic condition is defined as a disease,
Illness/disease/Injury which in the normal course would require care illness, or injury that has one or more of the following
and treatment at a Hospital but is actually taken while confined at characteristics:
home under any of the following circumstances: i. it needs ongoing or long-term monitoring through
a. the condition of the patient is such that he/she is not in a condition consultations, examinations, check-ups, and /or tests
to be removed to a Hospital, or ii. it needs ongoing or long-term control or relief of
b. the patient takes treatment at home on account of non availability symptoms
of room in a Hospital. iii. it requires rehabilitation for the patient or for the patient
to be specially trained to cope with it
9.20 Emergency care (Emergency) means management for an iv. it continues indefinitely
Illness or Injury which results in symptoms which occur suddenly and v. it recurs or is likely to recur
unexpectedly, and requires immediate care by a Medical Practitioner
to prevent death or serious long term impairment of the Insured 9.28 Individual Policy means a Policy described as such in the Policy
Person’s health. Schedule where the individual(s) named in the Policy Schedule is / are
the Insured Person(s) under this Policy.
9.21 Family Floater Policy means a Policy described as such in the
Policy Schedule where the family members (two or more) named in 9.29 Information Summary Sheet means the information and details
the Policy Schedule are insured under this Policy. provided to Us or Our representatives over the telephone for the
purposes of applying for this Policy which has been recorded by Us
9.22 First Policy means for the purposes of this Policy the Policy and confirmed by You.
Schedule issued to the Policyholder at the time of inception of the first
Policy mentioned in the Policy Schedule with Us. 9.30 Injury means Accidental physical bodily harm excluding Illness or
disease solely and directly caused by external, violent and visible and
9.23 Grace Period means the specified period of time (30 days) evident means which is verified and certified by a Medical Practitioner.
immediately following the premium due date during which a payment
can be made to Renew or continue a policy in force without loss of 9.31 Inpatient means admission for treatment in a Hospital for more
continuity benefits such as Waiting Periods and coverage of Pre- than 24 hours for an Insured Event.
existing Diseases. Coverage is not available for the period for which no 9.32 Inpatient Care means treatment for which the Insured Person
premium is received. has to stay in a Hospital for more than 24 hours for a covered event.
9.24 Hospital means any institution established for Inpatient Care 9.33 IRDAI means the Insurance Regulatory and Development
and Day Care Treatment of Illness and / or Injuries and which has been Authority of India.
registered as a Hospital with the local authorities under the Clinical
9.34 Insured Event means any event specifically mentioned as
Establishments (Registration and Regulation) Act, 2010 or under the
covered under this Policy.
enactments specified under the Schedule of Section 56(1) of the said
Act OR complies with all minimum criteria as under:
a. has Qualified Nursing staff under its employment round the clock; 9.35 Insured Person means person(s) named as insured persons in
b. has at least 10 Inpatient beds in towns having a population of less the Policy Schedule.
than 10,00,000 and at least 15 Inpatient beds in all other places;
c. has qualified Medical Practitioner(s) in charge round the clock; 9.36 Intensive Care Unit means an identified section, ward or wing
d. has a fully equipped operation theatre of its own where Surgical of a Hospital which is under the constant supervision of a dedicated
Procedures are carried out; Medical Practitioner(s), and which is specially equipped for the

continuous monitoring and treatment of patients who are in a critical 9.47 OPD Treatment means the one in which the Insured visits a
condition, or require life support facilities and where the level of care clinic / Hospital or associated facility like a consultation room for
and supervision is considerably more sophisticated and intensive than diagnosis and treatment based on the advice of a Medical Practitioner.
in the ordinary and other wards. The Insured is not admitted as a day care or In-patient.
9.37 Maternity Expense shall include: 9.48 Policy means these terms and conditions, the Policy Schedule
a. Medical Treatment Expenses traceable to childbirth (including (as amended from time to time), Your statements in the Proposal and
complicated deliveries and caesarean sections incurred during the Information Summary Sheet and any endorsements attached by
Hospitalization); Us to the Policy from time to time.
b. Expenses towards lawful medical termination of pregnancy during
the Policy Period. 9.49 Policy Period is the period between the inception date and the
expiry date of the Policy as specified in the Policy Schedule or the date
9.38 Medical Advice means any consultation or advice from a of cancellation of this Policy, whichever is earlier.
Medical Practitioner including the issuance of any prescription or
follow-up prescription. 9.50 Policy Year means the period of one year commencing on
the date of commencement specified in the Policy Schedule or any
9.39 Medical Expenses means those expenses that an Insured Person anniversary thereof.
has necessarily and actually incurred for medical treatment on account
of Illness or Accident on the advice of a Medical Practitioner, as long as 9.51 Pre-existing Disease means any condition, ailment, injury or
these are no more than would have been payable if the Insured Person disease
had not been insured and no more than other Hospitals or doctors in a. That is/are diagnosed by a physician within 48 months prior
the same locality would have charged for the same medical treatment. to the effective date of the policy issued by the insurer or its
reinstatement or
9.40 Medical Practitioner means a person who holds a valid b. For which medical advice or treatment was recommended by, or
registration from the Medical Council of any State or Medical Council received from, a physician within 48 months prior to the effective
of India or Council for Indian Medicine or for Homeopathy set up by the date of the policy issued by the insurer or its reinstatement.
Government of India or a State Government and is thereby entitled to
practice medicine within its jurisdiction; and is acting within the scope 9.52 Pre-hospitalization Medical Expenses means medical
and jurisdiction of his licence. expenses incurred during pre-defined number of days preceding the
hospitalization of the Insured Person, provided that:
9.41 Medical Record means the collection of information as a. Such Medical Expenses are incurred for the same condition for
submitted in claim documentation concerning a Insured Person’s which the Insured Person’s Hospitalization was required, and
Illness or Injury that is created and maintained in the regular course of b. The Inpatient Hospitalization claim for such Hospitalization is
management, made by Medical Practitioners who have knowledge of admissible by the Insurance Company.
the acts, events, opinions or diagnoses relating to the Insured Person’s
Illness or Injury, and made at or around the time indicated in the 9.53 Post-hospitalization Medical Expenses means medical expenses
documentation. incurred during pre-defined number of days immediately after the
Insured Person is discharged from the Hospital, provided that:
9.42 Medically Necessary Treatment means any treatment, tests, a. Such Medical Expenses are for the same condition for which the
medication, or stay in Hospital or part of a stay in Hospital which: Insured Person’s Hospitalization was required, and
a. is required for the medical management of the Illness or Injury b. The Inpatient Hospitalization claim for such Hospitalization is
suffered by the insured; admissible by the Insurance Company.
b. must not exceed the level of care necessary to provide safe,
adequate and appropriate medical care in scope, duration, or 9.54 Policy Schedule means a certificate issued by Us, and, if more
intensity; than one, then the latest in time. The Policy Schedule contains details
c. must have been prescribed by a Medical Practitioner; of the Policyholder, Insured Persons, the Sum Insured and other
d. must conform to the professional standards widely accepted in relevant details related to the coverage.
international medical practice or by the medical community in
India. 9.55 Portability means the right accorded to an individual health
insurance policyholders (including all members under family cover), to
9.43 Migration means the right accorded to health insurance transfer the credit gained for pre-existing conditions and time bound
policyholders (including all members under family cover and members exclusions, from one insurer to another insurer.
of group health insurance policy), to transfer the credit gained for pre-
existing conditions and time bound exclusions, with the same insurer. 9.56 Qualified Nurse means a person who holds a valid registration
from the Nursing Council of India or the Nursing Council of any state
9.44 Network Provider means Hospital enlisted by an insurer, TPA or in India.
jointly by an insurer and TPA to provide medical services to an insured
by a Cashless Facility. 9.57 Reasonable and Customary Charges means the charges for
9.45 Non-Network means any Hospital, Day Care Center or other services or supplies, which are the standard charges for the specific
provider that is not part of the network. provider and consistent with the prevailing charges in the geographical
area for identical or similar services, taking into account the nature of
9.46 Notification of Claim means the process of intimating a the Illness / Injury involved.
claim to the insurer or TPA through any of the recognized modes of
communication.

9.58 Reimbursement means settlement of claims paid directly by Us In case of Family Floater Policy, Sum Insured means the total of the
to the Policyholder/Insured Person. Base Sum Insured, Booster Benefit and Sum Insured Safeguard (if
applicable). Our maximum, total and cumulative liability for all claims
9.59 Renewal means the terms on which the contract of insurance during the Policy Year in respect of all Insured Persons taken together
can be renewed on mutual consent with a provision of Grace Period will be Sum Insured and amount provided under ReAssure benefit.
for treating the renewal continuous for the purpose of gaining credit
for pre-existing diseases, time bound exclusions and for all Waiting If the Policy Period is 2 years or 3 years, then the Sum Insured shall be
Periods. applied separately for each Policy Year in the Policy Period.
9.60 Room Rent means the amount charged by a Hospital towards 9.64 Surgery or Surgical Procedure means manual and / or operative
Room and Boarding expenses and shall include the associated medical procedure (s) required for treatment of an Illness or Injury, correction
expenses. of deformities and defects, diagnosis and cure of diseases, relief from
suffering or prolongation of life, performed in a Hospital or Day Care
9.61 Service Provider means any person, organization, institution Centre by a Medical Practitioner.
that has been empanelled with Us to provide services specified under
the benefits to the Insured Person. 9.65 Unproven/Experimental treatment means the treatment
including drug experimental therapy which is not based on established
9.62 Standby Services are services of another Medical Practitioner medical practice in India, is treatment experimental or unproven.
requested by treating Medical Practitioner and involving prolonged
attendance without direct (face-to-face) patient contact or 9.66 Waiting Period means a time-bound exclusion period related
involvement. to condition(s) specified in the Policy Schedule or the Policy which
shall be served before a claim related to such condition(s) becomes
9.63 Sum Insured: admissible.
In case of Individual Policy, Sum Insured means the total of the Base Sum
Insured, Booster Benefit, and Sum Insured Safeguard (if applicable) for 9.67 We/Our/Us means Max Bupa Health Insurance Company
that Insured Person. Our maximum, total and cumulative liability for Limited.
all claims during the Policy Year in respect of the Insured Person will be
Sum Insured and amount provided under ReAssure benefit. 9.68 You/Your/Policyholder means the person named in the Policy
Schedule who has concluded this Policy with Us.
Disclaimer: Max Bupa Health Insurance Company Limited, IRDAI Registration No. 145. ‘Max’, Max logo, ‘Bupa’ and Heartbeat logo are registered trademarks of their respective owners and
are being used by Max Bupa Health Insurance Company Limited under license. CIN No. U66000DL2008PLC182918. Registered Office: C-98, Lajpat Nagar 1, Delhi-110024. Website: www.
maxbupa. com, Fax: 011-30902010, Customer Helpline No.: 1860 500 8888. Insurance is the subject matter of solicitation. Please read sales brochure carefully before concluding a sale.

Annexure I
Product Benefit Table (all limits in INR unless defined as percentage)
Plan Type (all limits in Rs unless defined as Individual / Family Floater

percentage)
Base Sum Insured 3 lacs 4 5 7.5 10 12.5 15 20 25 50 75 100
lacs lacs lacs lacs lacs lacs lacs lacs lacs lacs lacs
Benefits
Inpatient Care Covered up to Sum Insured
Day Care Treatment Covered up to Sum Insured
Alternative Treatments Covered up to Sum Insured
Domiciliary Hospitalization Covered up to Sum Insured
Modern treatments Covered up to Sum Insured with sub-limit of Rs. 1Lac on few robotic surgeries
Pre-Hospitalization Medical Expenses (60 days) Covered up to Sum Insured
Post-Hospitalization Medical Expenses (180 days) Covered up to Sum Insured
Living Organ Donor Transplant Covered up to Sum Insured
Emergency Ambulance Covered upto Rs.2,000 per hospitalization
Cashless claim: Covered up to Sum Insured / Reimbursement claim: Covered up to Rs.
Air Ambulance
2.5 Lacs
Home care treatment Covered up to Sum Insured
In case of claim free year, increase of 50% of expiring Base Sum Insured in a Policy
Booster Benefit Year; maximum up to 100% of Base Sum Insured (In case of a claim, reduction of
Unlimited reinstatement up to base Sum Insured. (Applicable for both same &
ReAssure
different illness)
Shared accommodation Cash Benefit Rs. 800 per day; maximum Rs. 4,800 Rs. 1,000 per day; maximum Rs. 6,000
Annual (From Day 1); For defined list of tests; up to Rs. 500 for every Rs. 1 Lac Sum
Insured
Health Check-up (Individual policy: maximum Rs. 5,000 per Insured; Family Floater policy: maximum Rs.
10,000 per policy)
Second Medical Opinion Once for any condition for which hospitalization is triggered
Live healthy benefit Discount on renewal premium basis number of steps taken
Optional benefits
Up to 5 Lac base sum insured: 1,000/day
Hospital Cash 7.5 Lacs to 15 Lacs base sum insured: 2,000/day
Above 15 Lacs base sum insured: 4,000/day
Personal Accident cover (for insured aged 18 years & Personal Accident cover will be equal to 5 times of Base Sum Insured; subject to
above on individual basis) maximum of Rs. 100 Lacs
a. Claim Safeguard: Non-payable items paid up to Sum Insured
b. Booster Benefit Safeguard: No impact on Booster benefit if claim in a policy year is
Safeguard
less than Rs. 50,000
c. Sum Insured Safeguard: CPI linked increase in Base Sum Insured

Annexure II
The expenses that are not covered or subsumed into room charges / procedure charges / costs of treatment
List I – Expenses not covered

S.No Item S.No Item
1 BABY FOOD 34 WALKING AIDS CHARGES
2 BABY UTILITIES CHARGES 35 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE HOSPITAL)
3 BEAUTY SERVICES 36 SPACER
4 BELTS/ BRACES 37 SPIROMETRE
5 BUDS 38 NEBULIZER KIT
6 COLD PACK/HOT PACK 39 STEAM INHALER
7 CARRY BAGS 40 ARMSLING
8 EMAIL / INTERNET CHARGES 41 THERMOMETER
9 FOOD CHARGES (OTHER THAN PATIENT's DIET PROVIDED BY 42 CERVICAL COLLAR
HOSPITAL) 43 SPLINT
10 LEGGINGS 44 DIABETIC FOOT WEAR
11 LAUNDRY CHARGES 45 KNEE BRACES (LONG/ SHORT/ HINGED)
12 MINERAL WATER 46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER
13 SANITARY PAD 47 LUMBO SACRAL BELT
14 TELEPHONE CHARGES 48 NIMBUS BED OR WATER OR AIR BED CHARGES
15 GUEST SERVICES 49 AMBULANCE COLLAR
16 CREPE BANDAGE 50 AMBULANCE EQUIPMENT
17 DIAPER OF ANY TYPE 51 ABDOMINAL BINDER
18 EYELET COLLAR 52 PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES
19 SLINGS 53 SUGAR FREE Tablets
20 BLOOD GROUPING AND CROSS MATCHING OF DONORS 54 CREAMS POWDERS LOTIONS (Toiletries are not payable,
SAMPLES only prescribed medical pharmaceuticals payable)
21 SERVICE CHARGES WHERE NURSING CHARGE ALSO 55 ECG ELECTRODES
CHARGED 56 GLOVES
22 TELEVISION CHARGES 57 NEBULISATION KIT
23 SURCHARGES 58 ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT,
24 ATTENDANT CHARGES ORTHOKIT, RECOVERY KIT, ETC]
25 EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH FORMS 59 KIDNEY TRAY
PART OF BED CHARGE) 60 MASK
26 BIRTH CERTIFICATE 61 OUNCE GLASS
27 CERTIFICATE CHARGES 62 OXYGEN MASK
28 COURIER CHARGES 63 PELVIC TRACTION BELT
29 CONVEYANCE CHARGES 64 PAN CAN
30 MEDICAL CERTIFICATE 65 TROLLY COVER
31 MEDICAL RECORDS 66 UROMETER, URINE JUG
32 PHOTOCOPIES CHARGES 67 AMBULANCE
33 MORTUARY CHARGES 68 VASOFIX SAFETY
List II – Items that are to be subsumed into Room Charges
S.No Item S.No Item

1 BABY CHARGES (UNLESS SPECIFIED/INDICATED) 6 COMB
2 HAND WASH 7 EAU-DE-COLOGNE / ROOM FRESHNERS
3 SHOE COVER 8 FOOT COVER
4 CAPS 9 GOWN
5 CRADLE CHARGES 10 SLIPPERS

S.No Item S.No Item
11 TISSUE PAPER 25 CLEAN SHEET
12 TOOTH PASTE 26 BLANKET/WARMER BLANKET
13 TOOTH BRUSH 27 ADMISSION KIT
14 BED PAN 28 DIABETIC CHART CHARGES
15 FACE MASK 29 DOCUMENTATION CHARGES / ADMINISTRATIVE EXPENSES
16 FLEXI MASK 30 DISCHARGE PROCEDURE CHARGES
17 HAND HOLDER 31 DAILY CHART CHARGES
18 SPUTUM CUP 32 ENTRANCE PASS / VISITORS PASS CHARGES
19 DISINFECTANT LOTIONS 33 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE
20 LUXURY TAX 34 FILE OPENING CHARGES
21 HVAC 35 INCIDENTAL EXPENSES / MISC. CHARGES (NOT EXPLAINED)
22 HOUSE KEEPING CHARGES 36 PATIENT IDENTIFICATION BAND / NAME TAG
23 AIR CONDITIONER CHARGES 37 PULSEOXYMETER CHARGES
24 IM IV INJECTION CHARGES
List III – Items that are to be subsumed into Procedure Charges

S.No Item S.No Item
1 HAIR REMOVAL CREAM 13 SURGICAL DRILL
2 DISPOSABLES RAZORS CHARGES (for site preparations) 14 EYE KIT
3 EYE PAD 15 EYE DRAPE
4 EYE SHEILD 16 X-RAY FILM
5 CAMERA COVER 17 BOYLES APPARATUS CHARGES
6 DVD, CD CHARGES 18 COTTON
7 GAUSE SOFT 19 COTTON BANDAGE
8 GAUZE 20 SURGICAL TAPE
9 WARD AND THEATRE BOOKING CHARGES 21 APRON
10 ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS 22 TORNIQUET
11 MICROSCOPE COVER 23 ORTHOBUNDLE, GYNAEC BUNDLE
12 SURGICAL BLADES, HARMONICSCALPEL,SHAVER
List IV – Items that are to be subsumed into costs of treatment

S.No Item S.No Item
1 ADMISSION/REGISTRATION CHARGES 10 HIV KIT
2 HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC 11 ANTISEPTIC MOUTHWASH
PURPOSE 12 LOZENGES
3 URINE CONTAINER 13 MOUTH PAINT
4 BLOOD RESERVATION CHARGES AND ANTE NATAL 14 VACCINATION CHARGES
BOOKING CHARGES 15 ALCOHOL SWABES
5 BIPAP MACHINE 16 SCRUB SOLUTION/STERILLIUM
6 CPAP/ CAPD EQUIPMENTS 17 GLUCOMETER & STRIPS
7 INFUSION PUMP– COST 18 URINE BAG
8 HYDROGEN PEROXIDE\SPIRIT\ DISINFECTANTS ETC
9 NUTRITION PLANNING CHARGES - DIETICIAN CHARGES-
DIET CHARGES

Annexure III
List of Insurance Ombudsmen
Office of the Name of the Contact Details Areas of Jurisdiction
Ombudsman Ombudsman
AHMEDABAD Shri. Kuldip Singh Office of the Insurance Ombudsman, Gujarat , Dadra & Nagar Haveli, Daman and Diu
Jeevan Prakash Building, 6th floor,
Tilak Marg, Relief Road,
Ahmedabad – 380 001.
Tel.: 079 - 25501201/02/05/06
Email: [email protected]
BENGALURU Smt. Neerja Shah Office of the Insurance Ombudsman, Karnataka
Jeevan Soudha Building,PID No. 57-27-N-19
Ground Floor, 19/19, 24th Main Road,
JP Nagar, 1st Phase,
Bengaluru – 560 078.
Tel.: 080 - 26652048 / 26652049
BHOPAL Shri Guru Saran Office of the Insurance Ombudsman, Madhya Pradesh & Chhattisgarh
Shrivastava Janak Vihar Complex,
2nd Floor, 6, Malviya Nagar,
Opp. Airtel Office, Near New Market,
Bhopal-462 003.
Tel.:- 0755-2769201/2769202
Fax : 0755-2769203
BHUBANESHWAR Shri Suresh Office of the Insurance Ombudsman, Orissa
Chandra Panda 62, Forest park
Bhubneshwar – 751 009.
Tel.: 0674 - 2596461 /2596455
Fax: 0674 - 2596429
CHANDIGARH Dr. Dinesh Kumar Office of the Insurance Ombudsman, Punjab , Haryana, Himachal Pradesh, Jammu &
Verma S.C.O. No. 101, 102 & 103, 2nd Floor, Kashmir , Chandigarh
Batra Building, Sector 17 – D,
Chandigarh – 160 017.
Tel.: 0172 - 2706196 / 2706468
Fax: 0172 - 2708274
CHENNAI Shri M. Vasantha Office of the Insurance Ombudsman, Tamil Nadu, Pondicherry Town and Karaikal
Krishna Fatima Akhtar Court, 4th Floor, 453, (which are part of Pondicherry)
Anna Salai, Teynampet,
CHENNAI – 600 018.
Tel.: 044 - 24333668 / 24335284
Fax: 044 - 24333664
DELHI Shri Sudhir Krishna Office of the Insurance Ombudsman, Delhi
2/2 A, Universal Insurance Building,
Asaf Ali Road,
New Delhi – 110 002.
Tel.: 011 - 23232481 / 23213504

Ombudsman Ombudsman
GUWAHATI Shri Kiriti .B. Saha Office of the Insurance Ombudsman, Assam , Meghalaya, Manipur, Mizoram,
Jeevan Nivesh, 5th Floor, Arunachal Pradesh, Nagaland and Tripura
Nr. Panbazar over bridge, S.S. Road,
Guwahati – 781001(ASSAM).
Tel.: 0361 - 2632204 / 2602205
Fax: 0361 - 2732937
HYDERABAD Shri I. Suresh Babu Office of the Insurance Ombudsman, Andhra Pradesh, Telangana, Yanam and part of
6-2-46, 1st floor, “Moin Court”, territory of Pondicherry
Lane Opp. Saleem Function Palace,
A. C. Guards, Lakdi-Ka-Pool,
Hyderabad - 500 004.
Tel.: 040 - 67504123 / 23312122
Fax: 040 - 23376599
JAIPUR Smt. Sandhya Office of the Insurance Ombudsman, Rajasthan
Baliga Jeevan Nidhi – II Bldg., Gr. Floor,
Bhawani Singh Marg,
Jaipur - 302 005.
Tel.: 0141 - 2740363
ERNAKULAM Ms. Poonam Bodra Office of the Insurance Ombudsman, Kerala , Lakshadweep , Mahe – a part of
2nd Floor, Pulinat Bldg., Pondicherry
Opp. Cochin Shipyard, M. G. Road,
Ernakulam - 682 015.
Tel.: 0484 - 2358759 / 2359338
Fax: 0484 - 2359336
KOLKATA Shri. P.K.Rath Office of the Insurance Ombudsman, West Bengal , Andaman & Nicobar Islands ,
Hindustan Bldg. Annexe, 4th Floor, Sikkim
4, C.R. Avenue,
KOLKATA - 700 072.
Tel.: 033 - 22124339 / 22124340
Fax : 033 - 22124341
LUCKNOW Shri Justice Anil Office of the Insurance Ombudsman, Districts of Uttar Pradesh:
Kumar Srivastava 6th Floor, Jeevan Bhawan, Phase-II, Laitpur, Jhansi, Mahoba, Hamirpur, Banda,
Nawal Kishore Road, Hazratganj, Chitrakoot, Allahabad, Mirzapur, Sonbhabdra,
Lucknow - 226 001. Fatehpur, Pratapgarh, Jaunpur,Varanasi, Gazipur,
Tel.: 0522 - 2231330 / 2231331 Jalaun, Kanpur, Lucknow, Unnao, Sitapur,
Fax: 0522 - 2231310 Lakhimpur, Bahraich, Barabanki, Raebareli,
Email: [email protected] Sravasti, Gonda, Faizabad, Amethi, Kaushambi,
Balrampur, Basti, Ambedkarnagar, Sultanpur,
Maharajgang, Santkabirnagar, Azamgarh,
Kushinagar, Gorkhpur, Deoria, Mau, Ghazipur,
Chandauli, Ballia, Sidharathnagar.
MUMBAI Shri Milind A. Office of the Insurance Ombudsman, Goa, Mumbai metropolitan region excluding Navi
Kharat 3rd Floor, Jeevan Seva Annexe, Mumbai & Thane
S. V. Road, Santacruz (W),
Mumbai - 400 054.
Tel.: 022 - 26106552 / 26106960
Fax: 022 - 26106052

Ombudsman Ombudsman
NOIDA Shri Chandra Office of the Insurance Ombudsman, State of Uttaranchal and the following Districts of
Shekhar Prasad Bhagwan Sahai Palace Uttar Pradesh:
4th Floor, Main Road, Agra, Aligarh, Bagpat, Bareilly, Bijnor, Budaun,
Naya Bans, Sector 15 Bulandshehar, Etah, Kanooj, Mainpuri, Mathura,
Distt: Gautam Budh Nagar, Meerut, Moradabad, Muzaffarnagar, Oraiyya,
UP – 201301 Pilibhit, Etawah, Farrukhabad, Firozbad,
Tel: 0120-2514250/2514252/2514253 Gautambodhanagar, Ghaziabad, Hardoi,
Email: [email protected] Shahjahanpur, Hapur, Shamli, Rampur, Kashganj,
Sambhal, Amroha, Hathras, Kanshiramnagar,
Saharanpur.
PATNA Shri N.K.Singh Office of the Insurance Ombudsman, Bihar,
1st Floor, Kalpana Arcade Building, Jharkhand.
Bazar Samiti Road,
Bahadurpur,
Patna 800006
Tel: 0612-2680952
PUNE Shri Vinay Sah Office of the Insurance Ombudsman, Maharashtra,
Jeevan Darshan Bldg., 3rd Floor, Area of Navi Mumbai and Thane
C.T.S. No.s. 195 to 198, excluding Mumbai Metropolitan Region.
N.C. Kelkar Road, Narayan Peth,
Pune – 411 030.
Tel.: 020-41312555
EXECUTIVE COUNCIL OF INSURERS,

3rd Floor, Jeevan Seva Annexe,
S. V. Road, Santacruz (W),
Mumbai - 400 054.
Tel.: 022 - 26106889 / 671 / 980

Fax: 022 - 26106949
Shri. M.M.L. Verma, Secretary General
Smt. Moushumi Mukherji, Secretary

ReAssure
Proposal Form
URN: 015
1. Proposer Details:
Title Mr. Name Renu Shukla

DOB 03/01/1978 Gender Male Nationality Indian
Current Address MS Renu Shukla, 1741 Bada Gaon Gate Bahar Dadiyapur, Vilaiya Ka Baag, Jhansi Khas
Landmark City JHANSI

District State Uttar Pradesh Pin Code 284002
Landline Number 08448706929 Mobile No. 08448706929
Alternate Number Email ID [email protected]
PAN Number (Mandatory for premium above Rupees 50,000 in cash and Rupees 1 lac through other modes)
Annual income (Rs)

Occupation: House wife Other, please specify
Premium paid by Relationship with Proposer Self
Yes I wish to receive my policy related information and updates over WhatsApp on my mobile number.
I have read, understood and accepted all Terms and Condition & hereby authorize Max Bupa Health Insurance or any of its Agents and/or third
Yes party(ies)/ affiliates to contact me via SMS/Email/Phone/WhatsApp/Facebook or any other modes on my registered phone number over-riding my
'DND' registration to make welcome calls/SMS, Service calls/SMS or any other commercial Communication
Are you or any of the proposed applicants a PEP#? No

#
Politically Exposed Persons (PEP) are individuals who are or have been entrusted with prominent public functions i.e. Heads/ministers of central or state
government, senior politicians, senior government, judicial or military officials, senior executives of government companies, important party officials. (If you
have ticked against PEP, kindly fill the separate PEP questionnaire)
Bank Details:
Bank Name Account Type
Branch City
Account Number IFSC Code
Details of Electronic Insurance Account (eIA)

Do you wish to have this Policy credited to an e-Insurance account ? (Please select any one)
If Yes, Please share existing e-Insurance Account No.
Please select Insurance Repository Name (you have opened your account with)
Or
I do not have existing e-Insurance account and I am interested in creating a new e-Insurance account
(Please submit electronic insurance account opening form (eIA form) along with relevant documents).
Renewal payment sign-up:
Payment of renewal premium of your health insurance Policy can be made every year through continuing your existing Automated clearing House (ACH) /
Standing instructions (SI) with the Company. Under this option, your Policy can be renewed promptly, but subject to you completing all additional requirements
of information and documentation as may be required by the Company.
If you have opted for the ACH/SI renewal option and policy is renewed using the same, a discount of 2.5% will be applicable on the renewal premium.

2. Details Of Applicants For Insurance:
Name Renu Shukla
Gender Male Height 5 (ft) 1 (inch) Weight 60 (kg)
Mobile number 8448706929 Date of Birth 03/01/1978 Please tick if not Indian Indian
Applicant 1
Relationship to Proposer Self
If a registered Medical Practitioner*, please provide: i. Medical Registration Number
ii. Council Name
iii. Address of workplace
Name Shreya Shukla
Gender Female Height 5 (ft) 2 (inch) Weight 70 (kg)
Applicant 2
Relationship to Proposer Daughter
ii. Council Name
Name Shaurya Shukla
Gender Male Height 5 (ft) 10 (inch) Weight 58 (kg)
Applicant 3
Relationship to Proposer Son
ii. Council Name
*Avail a discount of 5% on the premium. Medical Practitioner 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 State Government and is Thereby entitled to practice
medicine within its jurisdiction; and is acting within the scope and jurisdiction of his licence.
Notes: 1. if the relationship of Applicant 1 with Proposer is employee, then the relationship of other Applicants are with Applicant 1.
2. For Live Healthy benefit, eligible Insured Persons will be: a. All members expect son / daughter under a Family Floater policy
b. Any member of age atleast 18 years under an Individual policy

3. Coverage selection
Are you applying for portability No

(If "Yes", please fill the separate portability form also)
Base Coverage
Policy type: Family Floater
Base Sum Insured: (Rs.) 10,00,000
Policy term: 1 Year
Optional Coverage:
1. Hospital Cash : Rs 1,000 per day (for Sum Insured up to Rs. 5 Lacs), Rs No
2,000 per day for Sum Insured Rs. 7.5 Lacs to Rs. 15 Lacs) & Rs 4,000 per
day (for Sum Insured above Rs. 15 Lacs)
2. Safeguard No
Applicant Number
1 2 3 4 5 6
3. Please tick if opting for 'Personal Accident cover' (The option is available 0 0 0
only to Applicants of age 18 years or above)
4. Nomination
In the event of the death of the Proposer, any payment due under the Policy shall become payable to the Nominee named below. The receipt of the such
payment by the Nominee would constitute discharge of the Company's liability under the Policy.
Nominee Name Date of Birth Relationship Address and contact details of Appointee Name (if nominee is less than
with the Proposer Nominee 18 year of age)
Shreya Shukla Daughter Same as proposer 9898989898
5. Medical And Habits Information
IMPORTANT: Please ensure that all the questions in this section are answered truthfully and completely as the information You provide here will form basis
of underwriting by Max Bupa. Please note any incomplete, incorrect, partially correct information may affect your medical claim and/or coverage.
SECTION A: Please share information on medical conditions Applicant Number

Please answer the following questions for each applicant. 1 2 3 4 5 6
Please circle Yes (Y) or No (N)
i. Other than common cold, flu, infections, minor injury or other minor ailments; has the Applicant No No No
ever been diagnosed with any disease and / or hospitalized for more than 5 days and / or
undergone / advised to undergo any surgical procedures and / or taken any medication/ had any
symptoms for more than 14 days? Medication is including but not limited to inhalers, Injections,
oral drugs and external medical applications on body parts.
ii. Has the Applicant ever had adverse findings to any diagnostic tests or investigations related to No No No
Thyroid Profile, Lipid Profile, Treadmill test, Angiography, Echocardiography, Endoscopy,
Ultrasound, CT Scan, MRI, Biopsy and FNAC?
iii. Does the Applicants have diabetes or pre-diabetes or has he/she EVER had high blood sugar? No No No
iv Does the Applicant have Hypertension or High Blood Pressure? No No No
v. Has the Applicant ever been diagnosed or treated for any genetic / hereditary disorders or HIV / No No No
AIDS?

vi. Has the Applicant ever been diagnosed or treated for any mental/ psychiatric disorders? No No No
vii. Has any proposal for life, health, hospital daily cash or critical illness insurance on the life of the No No No
Applicant ever been declined, postponed, loaded or subjected to any special conditions such as
exclusions by any insurance company?
SECTION B: (Please fill this section only if the applicant Applicant Number
smokes or consumes tobacco / gutkha / pan masala or alcohol)
1 2 3 4 5 6
i. Chewable tobacoo / Gutkha / Pan Masala -

please specify number of pouches per day
ii. Alcohol - please specify ml per week and /

or Daily Drinker
iii. Cigarettes / Bidi / Cigar - please specify
consumption per day
SECTION C: For questions marked Yes (Y) in Section A, please specify following information:
Applicant Details of symptom(s) or investigation(s) or diagnosis or procedure / Medication Dosage Current status (e.g. Treating doctor's Documents
Name surgery undergone (s) Complete / partial name & contact attached
If Diabetes If High blood pressure Any Other Onset date recovery or details (Yes / No)
HbA1c Level BP Level Details (DD/MM/YYYY) ongoing treatment)
Systolic Diastolic
Renu No
Shukla
Shreya No
Shukla
Shaurya No
Shukla
6. Authorization for Electronic Policy fulfillment and Service Communications
Would you like to protect environment and help save paper by authorizing the Company to send all your Policy and service related communication to the
email ID as mentioned here in the application form ? Yes

Customer ID: 2001458365
Member No. Name Age Valid From
11406181 Renu Shukla 43 25/08/2021
11406182 Shreya Shukla 20 25/08/2021
11406183 Shaurya Shukla 14 25/08/2021

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(Formerly Known As Max Bupa Health Insurance Co. LTD.) : Product Name: Reassure - Product Uin: Maxhlip21060V012021

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Date: 25/08/2021

Policy Number: 31919267202100

MR. RENU SHUKLA

Subject : Max Bupa Health Insurance Policy No. 31919267202100

Dear MR. RENU SHUKLA,

Director - Operations & Customer Service

Important - Please read this document and keep in a safe place.

Product Name: ReAssure | Product UIN: MAXHLIP21060V012021

POLICY SERVICING Turnaround time*

CLAIM SERVICING Turnaround time*

GRIEVANCE HANDLING Turnaround time*

Acknowledge a grievance – from the date of receipt of grievance 3 Days

Resolve a grievance– from the date of receipt of grievance 14 Days

Product Name: ReAssure | Product UIN: MAXHLIP21060V012021

Policyholder Name: MR. RENU SHUKLA Policy Number 31919267202100

Details of Electronic Insurance Account (eIA)

Mr. Renu Shukla 10,00,000 0 0 10,00,000 No

Ms. Shreya Shukla No

Mr. Shaurya Shukla No

Nominee Name Relationship with the Policyholder

Shreya Shukla Daughter

Intermediary Name Intermediary Code Intermediary Contact No.

Claim Administrator Servicing Branch Details

Optional Benefit/Feature Details

Personal Accident Cover Not opted

Product Name: ReAssure | Product UIN: MAXHLIP21060V012021

Hospital Cash Not opted

Product Benefit Table1

Insured Person Details

Permanent Exclusion (if any):

Product Name: ReAssure | Product UIN: MAXHLIP21060V012021

Product Name: ReAssure | Product UIN: MAXHLIP21060V012021

Policyholder Name Mr. Renu Shukla Policy Number 31919267202100

Policy Commencement Date # 25/08/2021 Policy Expiry Date 24/08/2022

(A) Premium (Rs.) - Base Product 13,857.00

(B) Premium (Rs.) - Personal Accident Cover 0.00

(C) Premium (Rs.) - Safeguard 0.00

(D) Premium (Rs.) - Hospital Cash 0.00

Underwriting Loading (Rs.) 0.00

Total Discount (Rs.) 693.00

Net Premium / Taxable value (Rs.) 13,164.00

Integrated Goods and Service Tax (18.00 %) 0.00

Central Goods and Service Tax (9.00 %) 1,184.76

State/UT Goods and Service Tax (9.00 %) 1,184.76

Gross Premium (Rs.) 15,534.00

Details of persons Insured:

Mr. Renu Shukla 43 Male Applicant

Ms. Shreya Shukla 20 Female Daughter

Mr. Shaurya Shukla 14 Male Son

Product Name: ReAssure | Product UIN: MAXHLIP21060V012021

Location: New Delhi Director - Operations & Customer Service

Product Name: ReAssure | Product UIN: MAXHLIP21060V012021

Sl. No Policy Clause

ReAssure v1, July 2020

Product Name: ReAssure | Product UIN: MAXHLIP21060V012021

For Reimbursement of Claim: 7.3

Product Name: ReAssure | Product UIN: MAXHLIP21060V012021

Product Name: ReAssure | Product UIN: MAXHLIP21060V012021

1. Preamble unless otherwise specified in the respective section. Thereafter