Policy Document Young India Digi Health Policy

THE NEW INDIA ASSURANCE CO. LTD.
REGISTERED & HEAD OFFICE: 87, MAHATMA GANDHI ROAD, MUMBAI 400001
Young India Digi Health Policy

POLICY CLAUSE
1. PREAMBLE
This is Your Young India Digi Health Policy, which has been issued by Us, relying on the
information disclosed by You in Your Proposal for this Policy or its preceding Policy/Policies
of which this is a renewal.
The terms and conditions set out in this Policy and its Schedule will be the basis for any claim
and/or benefit under this Policy.
Please read this Policy carefully and point out discrepancy, if any, in the Schedule.
Otherwise, it will be presumed that the Policy and the Schedule correctly represent the
cover agreed upon.
If during the Period of Insurance, You or any Insured Person incurs Hospitalisation Expenses
which are Reasonable and Customary, and Medically Necessary for treatment of any Illness
or Injury, We will reimburse such expense incurred by You, through the Third Party
Administrator, in the manner stated herein.
2. DEFINITIONS
STANDARD DEFINITIONS
2.1 ACCIDENT means a sudden, unforeseen and involuntary event caused by external, visible and
violent means.
2.2 ANY ONE ILLNESS means continuous Period of Illness and it includes relapse within 45 days
from the date of last consultation with the Hospital where treatment may have been taken.
2.3 AYUSH HOSPITAL is a Healthcare facility wherein medical / surgical / para-surgical treatment
procedures and interventions are carried out by AYUSH Medical Practitioner(s) comprising of
any of the following:
a. Central or State Government AYUSH Hospital or
b. Teaching hospital attached to AYUSH College recognized by the Central Government /
Central Council of Indian Medicine / Central Council for Homeopathy; or
c. AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any
recognized system of medicine, registered with the local authorities, wherever applicable,
and is under the supervision of a qualified registered AYUSH Medical Practitioner and must
comply with all the following criterion:
i. Having at least 5 in-patient beds;
ii. Having qualified AYUSH Medical Practitioner in charge round the clock;
iii. Having dedicated AYUSH therapy sections as required and/or has equipped
operation theatre where surgical procedures are to be carried out;
iv. Maintaining daily records of the patients and making them accessible to the
insurance Company’s authorized representatives.
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YOUNG INDIA DIGI HEALTH POLICY

2.4 AYUSH DAY CARE CENTRE means and includes Community Health Centre (CHC), Primary Health
Centre (PHC), Dispensary, Clinic, Polyclinic or any such health centre which is registered with
the local authorities, wherever applicable and having facilities for carrying out treatment
procedures and medical or surgical/para-surgical interventions or both under the supervision
of registered AYUSH Medical Practitioner(s) on day care basis without in-patient services and
must comply with all the following criterion:
i. Having qualified registered AYUSH Medical Practitioner(s) in charge;
ii. Having dedicated AYUSH therapy sections as required and/or has equipped operation
theatre where surgical procedures are to be carried out;
iii. Maintaining daily records of the patients and making them accessible to the insurance
company’s authorized representative.
2.5 CASHLESS FACILITY means a facility extended by Us to You where the payments, of the costs of
treatment undergone by You in accordance with the policy terms and conditions, are directly
made to the Network provider by Us to the extent of pre-authorization approved.
2.6 CONDITION PRECEDENT means a Policy term or condition upon which Our liability under the
Policy is conditional upon
2.7 CONGENITAL ANOMALY refers to a condition(s) which is present since birth, and which is
abnormal with reference to form, structure or position.
i. CONGENITAL INTERNAL ANOMALY means a Congenital Anomaly which is not in the visible
and accessible parts of the body.
ii. CONGENITAL EXTERNAL ANOMALY means a Congenital Anomaly which is in the visible
and accessible parts of the body.
2.8 CRITICAL ILLNESSES mean the following Illnesses:
2.8.1 CANCER OF SPECIFIED SEVERITY means

I. A malignant tumour characterized by the uncontrolled growth and spread of malignant cells
with invasion and destruction of normal tissues. This diagnosis must be supported by
histological evidence of malignancy. The term cancer includes leukaemia, lymphoma and
sarcoma.
II. The following are excluded -
i. All tumors which are histologically described as carcinoma in situ, benign, pre-
malignant, borderline malignant, low malignant potential, neoplasm of unknown
behavior, or non-invasive, including but not limited to: Carcinoma in situ of breasts,
Cervical dysplasia CIN-1, CIN-2 and CIN-3.
ii. Any non-melanoma skin carcinoma unless there is evidence of metastases to lymph
nodes or beyond.
iii. Malignant melanoma that has not caused invasion beyond the epidermis.
iv. All tumors of the prostate unless histologically classified as having a Gleason score
greater than 6 or having progressed to at least clinical TNM classification T2N0M0
v. All Thyroid cancers histologically classified as T1N0M0 (TNM Classification) or below;
vi. Chronic lymphocytic leukaemia less than RAI stage 3
vii. Non-invasive papillary cancer of the bladder histologically described as TaN0M0 or of
a lesser classification,
viii. All Gastro-Intestinal Stromal Tumors histologically classified as T1N0M0 (TNM
Classification) or below and with mitotic count of less than or equal to 5/50 HPFs;
ix. All tumors in the presence of HIV infection.
2.8.2 MYOCARDIAL INFARCTION (FIRST HEART ATTACK OF SPECIFIED SEVERITY)

I. The first occurrence of heart attack or myocardial infarction, which means the death of a
portion of the heart muscle as a result of inadequate blood supply to the relevant area. The
diagnosis for Myocardial Infarction should be evidenced by all of the following criteria:
i. a history of typical clinical symptoms consistent with the diagnosis of Acute Myocardial
Infarction (for e.g. typical chest pain)
ii. New characteristic electrocardiogram changes
iii. Elevation of infarction specific enzymes, Troponins or other specific biochemical
markers.
II. The following are excluded:
i. Other acute Coronary Syndromes
ii. Any type of angina pectoris.
iii. A rise in cardiac biomarkers or Troponin T or I in absence of overt ischemic heart
disease OR following an intra-arterial cardiac procedure.
2.8.3 OPEN CHEST CABG

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

I. The actual undergoing of open-heart valve Surgery is to replace or repair one or more heart
valves, as a consequence of defects in, abnormalities of, or disease-affected cardiac valve(s).
The diagnosis of the valve abnormality must be supported by an echocardiography and the
realization of Surgery has to be confirmed by a specialist Medical Practitioner. Catheter
based techniques including but not limited to, balloon valvotomy/valvuloplasty are
excluded.
2.8.5 COMA OF SPECIFIED SEVERITY

I. A state of unconsciousness with no reaction or response to external stimuli or internal
needs. This diagnosis must be supported by evidence of all of the following:
i. No response to external stimuli continuously for at least 96 hours;
ii. Life support measures are necessary to sustain life; and
iii. Permanent neurological deficit which must be assessed at least 30 days after the onset
of the coma.
II. The condition has to be confirmed by a specialist Medical Practitioner. Coma resulting
directly from alcohol or drug abuse is excluded.
2.8.6 KIDNEY FAILURE REQUIRING REGULAR DIALYSIS

I. End stage renal disease presenting as chronic irreversible failure of both kidneys to function,
as a result of which either regular renal dialysis (haemodialysis or peritoneal dialysis) is
instituted or renal transplantation is carried out. Diagnosis has to be confirmed by a
specialist Medical Practitioner.
2.8.7 STROKE RESULTING IN PERMANENT SYMPTOMS

I. Any cerebrovascular incident producing permanent neurological sequelae. This includes
infarction of brain tissue, thrombosis in an intracranial vessel, haemorrhage and
emobilisation from an extracranial source. Diagnosis has to be confirmed by a specialist
Medical Practitioner and evidenced by typical clinical symptoms as well as typical findings

in CT scan or MRI of the brain. Evidence of permanent neurological deficit lasting for at least
3 months has to be produced
i. Transient ischemic attacks (TIA)
ii. Traumatic injury of the brain
iii. Vascular disease affecting only the eye or optic nerve or vestibular functions.
2.8.8 MAJOR ORGAN /BONE MARROW TRANSPLANT

I. The actual undergoing of a transplant of:
i. One of the following human organs: heart, lung, liver, kidney, pancreas, that resulted
from irreversible end-stage failure of the relevant organ, or
ii. Human bone marrow using haematopoietic stem cells. The undergoing of a transplant
has to be confirmed by a specialist Medical Practitioner.
i. Other stem-cell transplants
ii. Where only islets of Langerhans are transplanted
2.8.9 PERMANENT PARALYSIS OF LIMBS

I. Total and irreversible loss of use of two or more limbs as a result of injury or disease of the
brain or spinal cord. A specialist Medical Practitioner must be of the opinion that the
paralysis will be permanent with no hope of recovery and must be present for more than 3
months.
2.8.10 MOTOR NEURONE DISEASE WITH PERMANENT SYMPTOMS

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

I. The definite occurrence of multiple sclerosis. The diagnosis must be supported by all of the
following:
i. Investigations including typical MRI and CSF findings, which unequivocally confirm the
diagnosis to be multiple sclerosis and
ii. There must be current clinical impairment of motor or sensory function, which must
have persisted for a continuous period of at least 6 months
II. Other causes of neurological damage such as SLE and HIV are excluded.
2.8.12 THIRD DEGREE BURNS

There must be third-degree burns with scarring that cover at least 20% of the body’s surface
area. The diagnosis must confirm the total area involved using standardized, clinically
accepted, body surface area charts covering 20% of the body surface area.
2.8.13 MAJOR HEAD TRAUMA

I. Accidental head injury resulting in permanent Neurological deficit to be assessed no sooner
than 3 months from the date of the accident. This diagnosis must be supported by unequivocal
findings on Magnetic Resonance Imaging, Computerized Tomography, or other reliable
imaging techniques. The accident must be caused solely and directly by accidental, violent,
external and visible means and independently of all other causes.

II. The Accidental Head injury must result in an inability to perform at least three (3) of the
following Activities of Daily Living either with or without the use of mechanical equipment,
special devices or other aids and adaptations in use for disabled persons. For the purpose of
this benefit, the word “permanent” shall mean beyond the scope of recovery with current
medical knowledge and technology.
III. The Activities of Daily Living are:
a. Washing: the ability to wash in the bath or shower (including getting into and out of
the bath or shower) or wash satisfactorily by other means;
b. Dressing: the ability to put on, take off, secure and unfasten all garments and, as
appropriate, any braces, artificial limbs or other surgical appliances;
c. Transferring: the ability to move from a bed to an upright chair or wheelchair and vice
versa;
d. Mobility: the ability to move indoors from room to room on level surfaces;
e. Toileting: the ability to use the lavatory or otherwise manage bowel and bladder
functions so as to maintain a satisfactory level of personal hygiene;
f. Feeding: the ability to feed oneself once food has been prepared and made available.
IV. The following are excluded:
 Spinal cord injury;
2.8.14 END STAGE LUNG FAILURE
End stage lung disease, causing chronic respiratory failure, as confirmed and evidenced by all
of the following:
a. FEV1 test results consistently less than 1 litre measured on 3 occasions 3 months
apart; and
b. Requiring continuous permanent supplementary oxygen therapy for hypoxemia; and
c. Arterial blood gas analysis with partial oxygen pressure of 55mmHg or less (PaO2 <
55mmHg); and
d. Dyspnea at rest.
2.8.15 END STAGE LIVER FAILURE

I. Permanent and irreversible failure of liver function that has resulted in all three of the
following:
a. Permanent jaundice; and
b. Ascites; and
c. Hepatic encephalopathy.
II. Liver failure secondary to drug or alcohol abuse is excluded.
2.9 CUMULATIVE BONUS means any increase or addition in the Sum Insured granted by Us without
an associated increase in premium.
2.10 DAY CARE CENTRE means any institution established for day care treatment of Illness or Injury,
or a medical set-up within a Hospital and which has been registered with the local authorities,
wherever applicable, and is under the supervision of a registered and qualified Medical
Practitioner AND must comply with all minimum criteria as under:
- has qualified nursing staff under its employment
- has qualified Medical Practitioner(s) in charge
- has a fully equipped operation theatre of its own where Surgery is carried out
- maintains daily records of patients and will make these accessible to the Insurance Company’s
authorized personnel.
2.11 DAY CARE TREATMENT refers to medical treatment or Surgery which are:

- undertaken under general or local anesthesia in a Hospital/ Day Care Centre in less than 24
hours because of technological advancement, and
- which would have otherwise required a Hospitalisation of more than 24 hours.
Treatment normally taken on an out-patient basis is not included in the scope of this definition.
2.12 DENTAL TREATMENT is treatment carried out by a dental practitioner including examinations,
fillings (where appropriate), crowns, extractions and Surgery.
2.13 DISCLOSURE TO INFORMATION NORM: The policy shall be void and all premium paid thereon
shall be forfeited to Us in the event of misrepresentation, mis-description or non-disclosure of
any material fact.
2.14 EMERGENCY CARE means management for an Illness or Injury which results in symptoms which
occur suddenly and unexpectedly, and requires immediate care by a medical practitioner to
prevent death or serious long-term impairment of the Insured Person’s health.
2.15 GRACE PERIOD means specified period of time immediately following the premium due date
during which a payment can be made to renew or continue the Policy in force without loss of
continuity benefits such as waiting period and coverage of pre-existing diseases. Coverage is
not available for the period for which no premium is received.
2.16 HOSPITAL means any institution established for Inpatient Care and Day Care Treatment of
Illness or Injury and which has been registered as a Hospital with the local authorities under the
Clinical Establishment (Registration and Regulation) Act, 2010 or under the enactments
specified under the schedule of Section 56(1) of the said act OR complies with all minimum
criteria as under:
- Has qualified nursing staff under its employment round the clock;
- Has at least 10 Inpatient beds in towns having a population of less than 10,00,000 and at least
15 In-patient beds in all other places;
- Has qualified Medical Practitioner(s) in charge round the clock;
- Has a fully equipped operation theatre of its own where Surgery is carried out;
- Maintains daily records of patients and makes these accessible to the insurance company’s
authorized personnel.
2.17 HOSPITALISATION means admission as an Inpatient in a Hospital for a minimum period of 24

consecutive hours except for the procedures/ treatments mentioned in Annexure I, where such
admission could be for a period of less than 24 consecutive hours.
Note: Procedures/treatments usually done in outpatient department are not payable under
the Policy even if converted as an in-patient in the Hospital for more than 24 hours.
2.18 ILLNESS means a sickness or a disease or pathological condition leading to the impairment of
normal physiological function which manifests itself during the Policy Period and requires
medical treatment.
i. Acute Condition means a disease, illness or injury that is likely to respond quickly to
treatment which aims to return the person to his or her state of health immediately before
suffering the disease/ illness/ injury which leads to full recovery.
ii. Chronic Condition means a disease, illness, or injury that has one or more of the following
characteristics
a. it needs ongoing or long-term monitoring through consultations, examinations, check-
ups, and / or tests

b. it needs ongoing or long-term control or relief of symptoms
c. it requires rehabilitation for the patient or for the patient to be special trained to cope
with it
d. it continues indefinitely
e. it recurs or is likely to recur
2.19 INJURY means accidental physical bodily harm excluding Illness or disease solely and directly
caused by external, violent and visible and evident means which is verified and certified by a
Medical Practitioner.
2.20 INPATIENT CARE means treatment for which the Insured Person has to stay in a Hospital for
more than 24 hours for a covered event.
2.21 INTENSIVE CARE UNIT (ICU) means an identified section, ward or wing of a Hospital which is
under the constant supervision of a dedicated Medical Practitioner and which is specially
equipped for the continuous monitoring and treatment of patients who are in a critical
condition, or require life support facilities and where the level of care and supervision is
considerably more sophisticated and intensive than in the ordinary and other wards.
2.22 ICU (INTENSIVE CARE UNIT) CHARGES means the amount charged by a Hospital towards ICU
expenses on a per day basis which shall include the expenses for ICU bed, general medical
support services provided to any ICU patient including monitoring devices, critical care nursing
and intensivist charges.
2.23 MEDICAL ADVICE means any consultation or advice from a Medical Practitioner including the
issue of any prescription or follow up prescription.
2.24 MEDICAL EXPENSES means those expenses that an Insured Person has necessarily and actually
incurred for medical treatment on account of Illness or Injury on the advice of a Medical
Practitioner, as long as these are no more than would have been payable, if You had not been
Insured and no more than other Hospitals or doctors in the same locality would have charged
for the same medical treatment.
2.25 MEDICALLY NECESSARY TREATMENT means any treatment, tests, medication, or stay in
Hospital or part of a stay in Hospital which
- Is required for the medical management of the Illness or Injury suffered by You;
- Must not exceed the level of care necessary to provide safe, adequate and appropriate
medical care in scope, duration, or intensity;
- Must have been prescribed by a Medical Practitioner,
- Must conform to the professional standards widely accepted in international medical practice
or by the medical community in India.
2.26 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 a State Government and is thereby entitled
to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of the
licence.
The term Medical Practitioner shall not include any Insured Person or any member of
his family.

2.27 MATERNITY EXPENSES shall mean:
a. Medical Treatment Expenses traceable to childbirth (including complicated deliveries and
caesarean sections incurred during Hospitalisation),
b. Expenses towards lawful medical termination of pregnancy during the Policy Period.
2.28 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 a State Government and is thereby entitled
to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of his
license.
The term Medical Practitioner shall not include any Insured Person or any member of
his family.
2.29 NETWORK PROVIDER means Hospitals enlisted by Us, TPA or jointly by Us and TPA to provide
medical services to an insured by a cashless facility.
2.30 NON-NETWORK PROVIDER means any hospital that is not part of the network.
2.31 NEW BORN BABY means a baby born during the Period of Insurance to a female Insured Person.
2.32 NOTIFICATION OF CLAIM means the process of intimating a claim to Us or TPA through any of
the recognized modes of communication.
2.33 OPD TREATMENT is one in which the Insured visits a clinic / Hospital or associated facility like a
consultation room for diagnosis and treatment based on the advice of a Medical Practitioner.
The Insured is not admitted as a day care or in-patient.
2.34 PRE-EXISTING DISEASE (PED) means any condition, ailment, Injury or Illness
a. That is/are diagnosed by a physician within 24 months prior to the effective date of the
Policy issued by Us and its reinstatement or
b. For which medical advice or treatment was recommended by, or received from, a physician
within 24 months prior to the effective date of the Policy or its reinstatement.
2.35 PRE-HOSPITALISATION MEDICAL EXPENSES means Medical Expenses incurred, for Any One
Illness, immediately before the Insured Person is Hospitalised, provided that:
i. Such Medical Expenses are incurred for the same condition for which the Insured Person’s
Hospitalisation was required, and
ii. The Inpatient Hospitalisation claim for such Hospitalisation is admissible by Us.
iii. Such Medical Expenses are incurred not earlier than sixty days before the Date of
Hospitalisation.
2.36 POST-HOSPITALISATION MEDICAL EXPENSES means Medical Expenses incurred, for Any One
Illness, immediately after the Insured Person is discharged from the Hospital, provided that:
i. Such Medical Expenses are incurred for the same condition for which the Insured Person’s
Hospitalisation was required, and
ii. The In-patient Hospitalisation claim for such Hospitalisation is admissible by Us.
iii. Such Medical Expenses are incurred not later than ninety days after the date of discharge
from the Hospital.
2.37 QUALIFIED NURSE means a person who holds a valid registration from the Nursing Council of
India or the Nursing Council of any state in India.

2.38 REASONABLE AND CUSTOMARY CHARGES mean the charges for services or supplies, which are
the standard charges for the specific provider and consistent with the prevailing charges in the
geographical area for identical or similar services, taking into account the nature of the Illness /
Injury involved.
2.39 RENEWAL means the terms on which the contract of insurance can be renewed on mutual
consent with a provision of grace period for treating the renewal continuous for the purpose of
gaining credit for pre-existing diseases, time-bound exclusions and for all waiting periods.
2.40 ROOM RENT means the amount charged by a hospital towards Room and Boarding expenses
and shall include the associated medical expenses.
2.41 SURGERY OR SURGICAL PROCEDURE means manual or operative procedure required for
treatment of an Illness or Injury, correction of deformities and defects, diagnosis and cure of
diseases, relief of suffering or prolongation of life, performed in a Hospital or Day Care Centre
by a Medical Practitioner.
2.42 UNPROVEN / EXPERIMENTAL TREATMENT is treatment, including drug Experimental therapy,

which is not based on established medical practice in India, is treatment experimental or
unproven.
SPECIFIC DEFINITIONS
2.43 AGE means age of the Insured person on last birthday as on date of commencement of the
Policy.
2.44 ASSOCIATE MEDICAL EXPENSES means medical expenses such as Professional fees of Surgeon,
Anaesthetist, Consultant, Specialist; Operating Theatre Charges and Procedure Charges such as
Dialysis, Chemotherapy, Radiotherapy & similar medical expenses related to the treatment.
2.45 AYUSH TREATMENT refers to Hospitalisation treatments given under Ayurveda, Yoga and
Naturopathy, Unani, Siddha and Homeopathy systems.
2.46 BREAK IN POLICY means the period of gap that occurs at the end of the existing policy term,
when the premium due for renewal on a given policy is not paid on or before the premium
renewal date or within 30 days thereof.
2.47 CANCELLATION defines the terms on which the Policy contract can be terminated either by Us
or You by giving sufficient notice to other which is not lower than a period of fifteen days.
2.48 CLAIM FREE YEAR means coverage under this Policy for a period of one year during which no
claim is paid or payable under the terms and conditions of the Policy in respect of any Insured
Person under any Clause of SECTION III.
2.49 INSURED PERSON means You and each of the others who are covered under this Policy as
shown in the Schedule.
2.50 MENTAL HEALTH ESTABLISHMENT means any health establishment, including Ayurveda, Yoga
and Naturopathy, Unani, Siddha and Homoeopathy establishment, by whatever name called,
either wholly or partly, meant for the care of persons with mental illness, established, owned,
controlled or maintained by the appropriate Government, local authority, trust, whether
private or public, corporation, co-operative society, organisation or any other entity or person,
where persons with mental illness are admitted and reside at, or kept in, for care, treatment,

convalescence and rehabilitation, either temporarily or otherwise; and includes any general
hospital or general nursing home established or maintained by the appropriate Government,
local authority, trust, whether private or public, corporation, co-operative society, organisation
or any other entity or person; but does not include a family residential place where a person
with mental illness resides with his relatives or friends;
2.51 MENTAL HEALTH PROFESSIONAL means
i. a psychiatrist: means a medical practitioner possessing a post-graduate degree or

diploma in psychiatry awarded by an university recognised by the University Grants
Commission established under the University Grants Commission Act, 1956, or
awarded or recognised by the National Board of Examinations and included in the First
Schedule to the Indian Medical Council Act, 1956, or recognised by the Medical
Council of India, constituted under the Indian Medical Council Act, 1956, and includes,
in relation to any State, any medical officer who having regard to his knowledge and
experience in psychiatry, has been declared by the Government of that State to be a
psychiatrist for the purposes of this Policy
ii. a professional registered with the concerned State Authority; (or)
iii. a professional having a post-graduate degree (Ayurveda) in Mano Vigyan Avum Manas
Roga or a post-graduate degree (Homoeopathy) in Psychiatry or a post-graduate
degree (Unani) in Moalijat (Nafasiyatt) or a post-graduate degree (Siddha) in Sirappu
Maruthuvam
2.52 POLICY means these Policy wordings, the Policy Schedule and any applicable endorsements or
extensions attaching to or forming part thereof. The Policy contains details of the extent of
cover available to the Insured person, what is excluded from the cover and the terms &
conditions on which the Policy is issued to The Insured person.
2.53 POLICY PERIOD means period of one policy year as mentioned in the schedule for which the
Policy is issued.
2.54 POLICY SCHEDULE means the Policy Schedule attached to and forming part of Policy.
2.55 POLICY YEAR means a period of twelve months beginning from the date of commencement of
the policy period and ending on the last day of such twelve-month period. For the purpose of
subsequent years, policy year shall mean a period of twelve months commencing from the end
of the previous policy year and lapsing on the last day of such twelve-month period, till the
policy period, as mentioned in the schedule
2.56 SUB-LIMIT means a cost sharing requirement under this policy in which We would not be liable
to pay any amount in excess of the pre-defined limit.
2.57 SUM INSURED means the amount specified in the Policy Schedule, which represents Our
maximum, total and cumulative liability for in respect of the Insured Person for any and all
claims incurred during the policy year.
Note: Sum Insured as shown in the schedule excluding Cumulative Bonus.
2.58 TPA (THIRD PARTY ADMINISTRATORS) means a Company registered with the Authority, and
engaged by an Insurer, for a fee or by whatever name called and as may be mentioned in the
health services agreement, for providing health services.

2.59 WAITING PERIOD means a period from the inception of first Policy during which specified
diseases/treatments are not covered. On completion of the period, diseases/treatments shall
be covered provided the Policy has been continuously renewed without any break.
2.60 WE/OUR/US/COMPANY means The New India Assurance Co. Ltd.
2.61 YOU/YOUR means the person who has taken this Policy and is shown as Insured Person or the
first Insured Person (if more than one) in the Schedule.
3.0 HOW MUCH WE WILL REIMBURSE

3.1 Our liability for all claims admitted during the Period of Insurance will be only up to Sum Insured
for which the Insured Person is covered as mentioned in the Schedule. In respect of those
Insured Persons with Cumulative Bonus, Our liability for claims admitted under this Policy shall
not exceed aggregate of Sum Insured and Cumulative Bonus. Subject to this, We will reimburse
the following Reasonable and Medically Necessary Expenses admissible as per the terms and
conditions of the Policy:
Single AC Room including Boarding, DMO / RMO / CMO / RMP Charges, Nursing (Including
3.1 (a) Injection / Drugs and Intra venous fluid administration expenses) as provided by the
hospital
Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU), Intensivist charges, Monitor
3.1 (b)
and Pulse Oxymeter expenses.
Associate Medical Expenses; such as Professional fees of Surgeon, Anaesthetist,
3.1 (c) Consultant, Specialist; Operating Theatre Charges and Procedure Charges such as Dialysis,
Chemotherapy, Radiotherapy & similar medical expenses related to the treatment.
Cost of Pharmacy and Consumables including Anaesthesia, Blood and Oxygen, Cost of
3.1 (d)
Implants and Medical Devices and Cost of Diagnostics.
Pre-Hospitalization Medical expenses upto 60 days prior to the date of admission to the
3.1 (e)
hospital
Post-Hospitalization Medical expenses upto 90 days from the date of discharge from the
3.1 (f)
hospital.
3.2 PROPORTIONATE DEDUCTION

Proportionate Deduction is applicable on the Associate Medical Expenses, if the Insured Person
opts for a higher Room than his eligible category. It shall be effected in the same proportion as
the eligible rate per day bears to the actual rate per day of Room Rent. However, it is not
applicable on
1. Cost of Pharmacy and Consumables

2. Cost of Implants and Medical Devices
3. Cost of Diagnostics.
Proportionate Deduction shall also not be applied in respect of Hospitals which do not follow
differential billing or for those expenses in which differential billing is not adopted based on the
room category, as evidenced by the Hospital’s schedule of charges / tariff.
3.3 MEDICAL EXPENSES INCURRED UNDER TWO POLICY PERIODS:

If the claim event falls within two policy periods, the claims shall be paid taking into
consideration the available Sum Insured under expiring Policy only. Sum Insured of the Renewed
Policy will not be considered for the claim event which has commenced in the expiring Policy.

3.4 MEDICAL EXPENSES FOR ORGAN TRANSPLANT:
If treatment involves Organ Transplant to Insured Person, then We will also pay Hospitalisation
Expenses (excluding cost of organ) incurred on the donor, provided Our liability towards
expenses incurred on the donor and the Insured recipient shall not exceed the available Sum
Insured.
3.5 HOSPITAL CASH

We will pay Hospital Cash Rs. 500/- for each day of Hospitalisation admissible under the Policy.
The payment under this Clause shall be for maximum five days for Any One Illness.
The payment under this Clause is applicable only where the period of Hospitalisation exceeds
twenty-four hours. Payment under this Clause will reduce the Sum Insured.
Hospital cash will be payable for completion of every 24 hours and not part thereof.
3.6 ROAD AMBULANCE CHARGES

We will pay You the charges incurred towards Ambulance services Reasonably incurred for
shifting any Insured Person to Hospital for admission, or from one Hospital to another Hospital
for Any One Illness not exceeding 1% of the Sum Insured up to a maximum of Rs. 5,000/-.
However, if an Insured Person, at the time of discharge from the Hospital, has to be shifted to
their place of residence in an Ambulance, such expenses will also be reimbursed additionally at
1% of Sum Insured maximum up to Rs. 5,000, provided the requirement of an Ambulance is
certified by the Medical Practitioner.
3.7 TREATMENT FOR CONGENITAL DISEASES

Congenital Internal Disease or Defects or anomalies, except those related to Genetic disorders,
shall be covered upto Sum Insured, after twelve months of Continuous Coverage, if it is
unknown to You or to the Insured Person at the commencement of such Continuous Coverage.
The requirement for Continuous Coverage for twelve months would not apply to a New Born
Baby during the year of birth and also in subsequent renewals, provided Premium is paid for
such New Born Baby at the time of renewal and the renewals are effected before or within the
Grace Period of expiry of the Policy.
Congenital External Disease or Defects or anomalies shall be covered after twenty four months
of Continuous Coverage, but such cover for Congenital External Disease or Defects or Anomalies
shall be limited to 10% of the average Sum Insured in preceding twenty four months.
3.8 COVERAGE FOR CATARACT:

Our liability for payment of any claim within the Period of Insurance, relating to Cataract for
each eye/per insured shall not exceed 10% of the Sum Insured or Rs. 50,000/- whichever is less.
3.9 COVERAGE FOR HAZARDOUS SPORTS

We shall be liable to pay expenses incurred towards treatment of any Injury or Illness arising
out of the following hazardous sports:
Bobsledding; Bungee Jumping; Canopying; Hang Gliding; Heli-skiing; Horseback Riding; Jet,
Snow and Water Skiing; Kayaking; Martial Arts; Motorcycling; Mountain Biking; Mountain
Climbing (under 14,000 feet); Paragliding; Parasailing; Safari; Scuba Diving, Skydiving;
Snowboarding; Snowmobiling; Spelunking; Surfing; Trekking; White water Rafting; Wind
Surfing; Zip Lining, Equestrian; Fencing; Rugby.

Our liability under this Clause shall not exceed 10% of the Sum Insured during a policy period.
However, if Injury or Illness is related to particular line of employment or occupation (not for
recreational purpose), it will be covered up to Sum Insured.
Payment under this Clause is admissible only if the expenses are incurred in Hospital as In-
Patient in India.
3.10 SPECIFIC COVERAGES:

a) Artificial life maintenance including life support machine use, where such treatment
will not result in recovery or restoration of normal state of Health under any
circumstances. We cover the expenses up to 25% of the Sum Insured and for a
maximum of 15 days per policy period for covered illness. This sub limit is applicable
only for person who is declared to be in a vegetative state as certified by the treating
medical practitioner.
b) Puberty and Menopause related Disorders: Treatment for any symptoms, Illness,
complications arising due to physiological conditions associated with Puberty,
Menopause such as menopausal bleeding or flushing is covered only as Inpatient
procedure after 12 months of continuous coverage. This cover will have a sub-limit of
up to 25% of Sum Insured per policy period.
c) Age Related Macular Degeneration (ARMD) is covered after 24 months of continuous
coverage only for Intravitreal Injections and anti - VEGF medication. This cover will
have a sub-limit of upto a maximum of 20% of sum insured per policy period.
d) Genetic diseases or disorders are covered with a sub-limit of 25% of Sum Insured per
policy period with 24 months waiting periods.
e) Treatment of Mental Illness: The Company shall indemnify the Medical Expenses
incurred towards treatment of Mental Illness subject to the condition that Treatment
shall be undertaken at a Hospital categorized as Mental Health Establishment or at a
Hospital with a specific department for Mental Illness, under a Medical Practitioner
qualified as Mental Health Professional.
The following Mental Illnesses are covered after completion of 24 months of
Continuous Coverage with a sub-limit up to 25% of Sum Insured per policy period.
ICD Code ICD Code Description

F01-F09 Mental disorders due to known physiological conditions
F10-F19 Mental and behavioral disorders due to psychoactive substance use
Schizophrenia, schizotypal, delusional, and other non-mood psychotic
F20-F29 disorders
F60-F69 Disorders of adult personality and behavior
F70-F79 Intellectual disabilities
Exclusions: Any kind of Psychological counselling, cognitive/ family/ group/ behaviour/

palliative therapy or psychotherapy shall not be covered.
3.11 COVERAGE FOR MODERN TREATMENTS OR PROCEDURES: The following procedures will be
covered (wherever medically indicated) either as in patient or as part of day care treatment in
a hospital up to the limit specified against each procedure during the policy period.

S No Treatment or Procedure Limit (Per Policy Period)
Uterine Artery Embolization and HIFU (High Upto 20% of Sum Insured subject to a
3.11.1
intensity focused ultrasound) Maximum upto Rs. 1 Lakh
Upto 20% of Sum Insured subject to a
3.11.2 Balloon Sinuplasty
Maximum upto Rs. 1 Lakh
3.11.3 Deep Brain stimulation
maximum upto Rs. 2 Lakh
Upto 10% of Sum Insured subject to
3.11.4 Oral chemotherapy
Maximum upto Rs. 50,000
Immunotherapy- Monoclonal Antibody to Upto 25% of Sum Insured subject to a
3.11.5
be given as injection Maximum of Rs 2 Lakh.
3.11.6 Intravitreal injections
Maximum of Rs.75,000.
3.11.7 Robotic surgeries
Maximum of Rs. 2 Lakh.
3.11.8 Stereotactic radio surgeries
Maximum Rs. 2 Lakh.
3.11.9 Bronchial Thermoplasty
Vaporisation of the prostrate (Green laser Upto 25% of Sum Insured subject to
3.11.10
treatment or holmium laser treatment) Maximum of Rs. 1 Lakh.
3.11.11 IONM - (Intra Operative Neuro Monitoring)
Maximum of Rs. 30,000.
Stem cell therapy: Hematopoietic stem cells
3.11.12 for bone marrow transplant for
Maximum of Rs. 1.5 Lakh.
haematological conditions to be covered
3.12 HEALTH CHECK-UP

The Insured Person(s) shall be entitled for reimbursement of the cost of Medical check-up at the
end of a block of every two Claim Free Years. Such payment shall be restricted to Rs. 3,500.
Note:
a) Any payment made under this clause shall not be considered as a Claim.
b) The unutilized amount under this benefit cannot be carried forward.
c) In case the Policy is issued on an Individual Sum Insured basis, the above limit shall be
available individually to the Insured Person. In case the Policy is on Floater Sum Insured
basis, the above limit shall be available to all Family Members on a Floater basis.
3.13 MEDICAL SECOND OPINION: In case of any Insured Person requires to undergo Surgery for any
of the Critical Illnesses defined under section 2.8 of the Policy Clause, Consultation Expenses
incurred on Medical Second Opinion shall be reimbursed up to a Maximum of Rs. 5,000/- during
a Policy Period.
Note: In case the Policy is issued on an Individual Sum Insured basis, the above limit shall be
available individually to the Insured Persons. In case the Policy is on Floater Sum Insured basis,
the above limit shall be available to all Insured persons on a Floater basis.
3.14 REINSTATEMENT OF SUM INSURED

If the Sum Insured is exhausted due to a claim(s) admissible and paid under the Policy, then the
Sum Insured shall be reinstated, subject to the following conditions:
1. The Reinstatement of Sum Insured shall be upon full utilization of the Sum Insured.

2. The sequence of utilization of Sum Insured will be as below:
a. Sum Insured;
b. Cumulative Bonus (if any);
c. Reinstated Sum Insured
3. The Reinstatement of Sum Insured shall be available for illnesses or Injuries other than
for which Claim is paid or admissible during the Policy Period.
4. Such Reinstatement shall only be available once in a Policy Period and only for Policies
issued on Individual Sum Insured basis.
5. Reinstatement of Sum Insured is not available for Modern Treatments listed under 3.11
of the Policy Clause.
6. The unutilized amount cannot be carried forward.
3.15 TREATMENTS UNDER AYURVEDIC / HOMEOPATHIC / UNANI SYSTEMS

Expenses incurred for Ayurvedic / Homeopathic / Unani Treatment are admissible up to the Sum
Insured provided the treatment for Illness or Injury, is taken in an Ayush Hospital excluding
centers for spas, massage and health rejuvenation procedures as an Inpatient.
3.16 CUMULATIVE BONUS

Insured Person will be entitled for Cumulative Bonus of 10% at each claim free year of insurance,
subject to maximum of 30%. If a claim is made in any particular year; the cumulative bonus
accrued shall be reduced at the same rate at which it is accrued.
Note:
i. In case where the policy is on individual basis, the CB shall be available individually to the
insured person who has not claimed under the expiring policy.
ii. In case where the policy is on floater basis, the CB shall be available to the family on floater
basis, provided no claim is reported under the expiring policy.
iii. CB shall be available only if the Policy is renewed within the Grace Period.
iv. If the Insured Persons in the expiring policy are covered on an individual basis and the
policy has been Renewed on a floater policy basis, the applicable CB for the renewed policy
shall be the Lowest among all the Insured Persons.
v. In case of floater policies where Insured Persons Renew their expiring policy by splitting
the Sum Insured in to two or more floater policies/individual policies, the same CB of the
expiring policy shall be applicable to each Individual of such Renewed Policies.
vi. If the Sum Insured has been reduced at the time of Renewal, the applicable Cumulative
Bonus percentage shall be applied on the reduced Sum Insured.
vii. If the Sum Insured under the Policy has been increased at the time of Renewal the
Cumulative Bonus shall be calculated on the Sum Insured of the Expiring Policy.
viii. If a claim is made in the expiring Policy Year, and is notified to Us after the acceptance of
Renewal premium any awarded CB, if any, shall be reduced suitably.
3.17 NEW BORN BABY COVERAGE

A New Born Baby is covered for any Illness or Injury from the date of birth till the expiry of this
Policy, within the terms of this Policy. Any expense incurred towards post-natal care, pre-term
or pre-mature care or any such expense incurred in connection with delivery of such New Born
Baby would not be covered.
Congenital External Anomaly of the New Born Baby is covered only after 24 months Waiting
Period.

Waiting Period for Congenital Internal Disease would not apply to a New Born Baby during the
year of birth and in subsequent renewals also, provided Premium is paid for such New Born
Baby at the time of renewal and the renewals are effected before or within the Grace Period of
expiry of the Policy.
No coverage for the New Born Baby would be available during subsequent renewals unless the
child is declared for insurance and covered as an Insured Person.
Note: New Born Baby means a baby born during the Policy Period to a female Insured Person,
who has twenty-four months of Continuous Coverage with Us.
3.18 DENTAL TREATMENT (Inpatient): We will cover for medical expenses incurred towards dental
treatment done under anesthesia necessitated due to an accident/injury/illness requiring
Hospitalization as Inpatient treatment.
4.0 EXCLUSIONS
No claim will be payable under this Policy for the following:
STANDARD EXCLUSIONS
4.1 PRE-EXISTING DISEASES (Code- Excl01)
a. Expenses related to the treatment of a pre-existing Disease (PED) and its direct
complications shall be excluded until the expiry of 24 months of continuous coverage after
the date of inception of the first policy with us.
b. In case of enhancement of Sum Insured the exclusion shall apply afresh to the extent of
Sum Insured increase.
c. If the Insured Person is continuously covered without any break as defined under the
portability norms of the extant IRDAI (Health Insurance) Regulations then waiting period
for the same would be reduced to the extent of prior coverage.
d. Coverage under the policy after the expiry of 24 months for any pre-existing disease is
subject to the same being declared at the time of application and accepted by us.
4.2 SPECIFIC WAITING PERIOD (Code- Excl02)

a. Expenses related to the treatment of the following listed conditions, surgeries /
treatments shall be excluded until the expiry of Ninety Days / 12 / 24 months of
continuous coverage, as may be the case after the date of inception of the first policy with
the insurer. This exclusion shall not be applicable for claims arising due to an accident.
b. In case of enhancement of sum insured the exclusion shall apply afresh to the extent of
sum insured increase.
c. If any of the specified disease/procedure falls under the waiting period specified for pre-
existing diseases, then the longer of the two waiting periods shall apply.
d. The waiting period for listed conditions shall apply even if contracted after the policy or
declared and accepted without a specific exclusion.
e. If the Insured Person is continuously covered without any break as defined under the
applicable norms on portability stipulated by IRDAI, then waiting period for the same
would be reduced to the extent of prior coverage.
(i) 90 Days Waiting Period

1. Diabetes Mellitus
2. Hypertension

3. Cardiac Conditions
(ii) 12 Months waiting period

1. All internal and external benign tumours, cysts, polyps of any kind, including benign
breast lumps
2. Benign ear, nose, throat disorders
3. Benign prostate hypertrophy
4. Cataract and age related eye ailments
5. Gastric/ Duodenal Ulcer
6. Gout and Rheumatism
7. Hernia of all types
8. Hydrocele
9. Non Infective Arthritis
10. Piles, Fissures and Fistula in anus
11. Pilonidal sinus, Sinusitis and related disorders
12. Prolapse inter Vertebral Disc and Spinal Diseases unless arising from accident
13. Skin Disorders
14. Stone in Gall Bladder and Bile duct, excluding malignancy
15. Stones in Urinary system
16. Treatment for Menorrhagia/Fibromyoma, Myoma and Prolapsed uterus
17. Varicose Veins and Varicose Ulcers
18. Renal Failure
19. Puberty and Menopause related Disorders
20. Internal Congenital Diseases
(iii) 24 Months waiting period

1. Joint Replacement due to Degenerative Condition
2. Age-related Osteoarthritis & Osteoporosis
3. Treatment of Mental Illness (ICD Code: F01-F29 & F60-F79)
4. Age Related Macular Degeneration (ARMD)
5. Genetic diseases or disorders
6. External Congenital Diseases
4.3 FIRST THIRTY DAYS WAITING PERIOD (Code- Excl03)

a. Expenses related to the treatment of any illness within 30 days from the first policy
commencement date shall be excluded except claims arising due to an accident, provided
the same are covered.
b. This exclusion shall not, however, apply if the Insured Person has Continuous Coverage
for more than twelve months.
c. The within referred waiting period is made applicable to the enhanced sum insured in the
event of granting higher sum insured subsequently.
4.4 EXCLUSIONS
The Company shall not be liable to make any payment under the policy, in respect of any
expenses incurred in connection with or in respect of:
4.4.1 INVESTIGATION & EVALUATION (Code- Excl04)

a. Expenses related to any admission primarily for diagnostics and evaluation purposes.
b. Any diagnostic expenses which are not related or not incidental to the current diagnosis
and treatment
4.4.2 REST CURE, REHABILITATION AND RESPITE CARE (Code- Excl05) Expenses related to any

admission primarily for enforced bed rest and not for receiving treatment. This also includes:
a. Custodial care either at home or in a nursing facility for personal care such as help with
activities of daily living such as bathing, dressing, moving around either by skilled nurses
or assistant or non-skilled persons.
b. Any services for people who are terminally ill to address physical, social, emotional and
spiritual needs.
4.4.3 OBESITY/ WEIGHT CONTROL (Code- Excl06) Expenses related to the surgical treatment of
obesity that does not fulfil all the below conditions:
a. Surgery to be conducted is upon the advice of the Doctor
b. The surgery/Procedure conducted should be supported by clinical protocols
c. The member has to be 18 years of age or older and
d. Body Mass Index (BMI);
1. greater than or equal to 40 or
2. greater than or equal to 35 in conjunction with any of the following severe co-
morbidities following failure of less invasive methods of weight loss:
i. Obesity-related cardiomyopathy
ii. Coronary heart disease
iii. Severe Sleep Apnea
iv. Uncontrolled Type2 Diabetes
4.4.4 CHANGE-OF-GENDER TREATMENTS (Code- Excl07)

Expenses related to any treatment, including surgical management, to change characteristics of
the body to those of the opposite sex.
4.4.5 COSMETIC OR PLASTIC SURGERY (Code- Excl08)

Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for
reconstruction following an Accident, Burn(s) or Cancer or as part of medically necessary
treatment to remove a direct and immediate health risk to the insured. For this to be considered
a medical necessity, it must be certified by the attending Medical Practitioner.
4.4.6 HAZARDOUS OR ADVENTURE SPORTS (Code- Excl09)

Expenses related to any treatment necessitated due to participation as a professional in
hazardous or adventure sports, including but not limited to, para-jumping, rock climbing,
mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving,
deep-sea diving.
4.4.7 BREACH OF LAW (Code- Excl10)

Expenses for treatment directly arising from or consequent upon any Insured Person
committing or attempting to commit a breach of law with criminal intent.
4.4.8 EXCLUDED PROVIDERS (Code-Excl11)

Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other
provider specifically excluded by the Insurer and disclosed in its website / notified to the
policyholders are not admissible. However, in case of life-threatening situations or following an
accident, expenses up to the stage of stabilization are payable but not the complete claim.
4.4.9 Treatment for, Alcoholism, drug or substance abuse or any addictive condition and
consequences thereof. (Code- Excl12)
4.4.10 Treatments received in health hydros, nature cure clinics, spas or similar establishments or
private beds registered as a nursing home attached to such establishments or where

admission is arranged wholly or partly for domestic reasons. (Code- Excl13)
4.4.11 Dietary supplements and substances that can be purchased without prescription, including
but not limited to Vitamins, minerals and organic substances unless prescribed by a medical
practitioner as part of hospitalization claim or day care procedure. (Code- Excl14)
4.4.12 REFRACTIVE ERROR (Code- Excl15)

Expenses related to the treatment for correction of eye sight due to refractive error less than
7.5 dioptres.
4.4.13 UNPROVEN TREATMENTS (Code- Excl16)

Expenses related to any unproven treatment, services and supplies for or in connection with
any treatment. Unproven treatments are treatments, procedures or supplies that lack
significant medical documentation to support their effectiveness.
4.4.14 STERILITY AND INFERTILITY (Code- Excl17)

Expenses related to sterility and infertility. This includes:
a. Any type of contraception, sterilization

b. Assisted Reproduction services including artificial insemination and advanced
reproductive technologies such as IVF, ZIFT, GIFT, ICSI
c. Gestational Surrogacy
d. Reversal of sterilization
4.4.15 MATERNITY EXPENSES (Code - Excl18)

a. Medical treatment expenses traceable to childbirth (including complicated deliveries and
caesarean sections incurred during hospitalization) except ectopic pregnancy;
b. Expenses towards miscarriage (unless due to an accident) and lawful medical termination
of pregnancy during the policy period.
SPECIFIC EXCLUSIONS
4.4.16 Acupressure, acupuncture, magnetic therapies.
4.4.17 Any expenses incurred on Domiciliary Hospitalization.
4.4.18 Service charges, Surcharges, Luxury Tax, Admission fees, Registration fees, Record Charges
and Telephone Charges levied by the Hospital.
4.4.19 Bodily Injury or Illness due to intentional self-inflicted Injury and attempted suicide.
4.4.20 Circumcision unless Medically Necessary or as may be necessitated due to an Accident.
4.4.21 Convalescence and General debility.
4.4.22 Cost of braces, equipment or external prosthetic devices, eyeglasses, Cost of spectacles and
contact lenses, hearing aids including cochlear implants.
4.4.23 External Medical / Non-medical equipment used for diagnosis and/or treatment including
CPAP/BIPAP, Oxygen Concentrator, Infusion pump , Ambulatory devices (walker, crutches,
Collars, Caps, Splints, Elasto crepe bandages, external orthopaedic pads) and sub cutaneous
insulin pump, Diabetic foot wear, Glucometer / Thermometer and equipment, which is
subsequently used at home and outlives the use and life of the Insured Person.

4.4.24 Naturopathy and Siddha Treatments.
4.4.25 Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from
or from any other cause or event contributing concurrently or in any other sequence to the
loss, claim or expense. For the purpose of this exclusion:
a. Nuclear attack or weapons means the use of any nuclear weapon or device or waste or
combustion of nuclear fuel or the emission, discharge, dispersal, release or escape of
fissile/ fusion material emitting a level of radioactivity capable of causing any Illness,
incapacitating disablement or death.
b. Chemical attack or weapons means the emission, discharge, dispersal, release or escape
of any solid, liquid or gaseous chemical compound which, when suitably distributed, is
capable of causing any Illness, incapacitating disablement or death.
c. Biological attack or weapons means the emission, discharge, dispersal, release or escape
of any pathogenic (disease producing) micro-organisms and/or biologically produced
toxins (including genetically modified organisms and chemically synthesized toxins) which
are capable of causing any Illness, incapacitating disablement or death.
4.4.26 Stem cell implantation/Surgery for other than those treatments mentioned in clause 3.11.12
4.4.27 Expenses incurred for Rotational Field Quantum Magnetic Resonance (RFQMR), External
Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen
Therapy.
4.4.28 Treatment taken outside the geographical limits of India
4.4.29 Vaccination and/or inoculation
4.4.30 War (whether declared or not) and war like occurrence or invasion, acts of foreign enemies,
hostilities, civil war, rebellion, revolutions, insurrections, mutiny, military or usurped power,
seizure, capture, arrest, restraints and detainment of all kinds.
5.0 GENERAL TERMS AND CLAUSES

STANDARD GENERAL TERMS AND CLAUSES
5.1 CANCELLATION
i. The policyholder may cancel this policy by giving 15 days written notice and in such an event,
the Company shall refund premium for the unexpired policy period as detailed below.
Period On Risk Rate of Premium To Be Charged (Retained By The Insurer)

Up to one month 1/4th of the annual rate
Up to three months 1/2 of the annual rate
Up to six months 3/4th of the annual rate
Exceeding six months Full annual rate
In the event of death of insured in the middle of policy year/during the course of policy period,
the premium for the unexpired policy period shall be refunded proportionately.

Notwithstanding anything contained herein or otherwise, no refunds of premium shall be
made in respect of Cancellation where, any claim has been admitted or has been lodged or
any benefit has been availed by the insured person under the policy.
ii. The Company may cancel the policy at any time on grounds of misrepresentation non-
disclosure of material facts, fraud by the insured person by giving 15 days' written notice.
There would be no refund of premium on cancellation on grounds of misrepresentation, non-
disclosure of material facts or fraud.
5.2 CONDITION PRECEDENT TO ADMISSION OF LIABILITY:
The terms and conditions of the policy must be fulfilled by the insured person for the Company
to make any payment for claim(s) arising under the policy.
5.3 COMPLETE DISCHARGE
Any payment to the policyholder, insured person or his/ her nominees or his/ her legal
representative or assignee or to the Hospital, as the case may be, for any benefit under the policy
shall be a valid discharge towards payment of claim by the Company to the extent of that amount
for the particular claim.
5.4 DISCLOSURE OF INFORMATION
The policy shall be void and all premium paid thereon shall be forfeited to the Company in the
event of misrepresentation, mis description or non-disclosure of any material fact by the
policyholder.
(Explanation: "Material facts" for the purpose of this policy shall mean all relevant information
sought by the company in the proposal form and other connected documents to enable it to take
informed decision in the context of underwriting the risk).
5.5 FRAUD
lf any claim made by the insured person, is in any respect fraudulent, or if any false statement, or
declaration is made or used in support thereof, or if any fraudulent means or devices are used by
the insured person or anyone acting on his/her behalf to obtain any benefit under this policy, all
benefits under this policy and the premium paid shall be forfeited.
Any amount already paid against claims made under this policy but which are found fraudulent
later shall be repaid by all recipient(s)/policyholder(s), who has made that particular claim, who
shall be jointly and severally liable for such repayment to the insurer.
For the purpose of this clause, the expression "fraud" means any of the following acts committed
by the insured person or by his agent or the hospital/doctor/any other party acting on behalf of
the insured person, with intent to deceive the insurer or to induce the insurer to issue an insurance
policy:
i. the suggestion, as a fact of that which is not true and which the insured person does not
believe to be true;

ii. the active concealment of a fact by the insured person having knowledge or belief of the fact;
iii. any other act fitted to deceive; and
iv. any such act or omission as the law specially declares to be fraudulent
The Company shall not repudiate the claim and / or forfeit the policy benefits on the ground of
Fraud, if the insured person / beneficiary can prove that the misstatement was true to the best of
his knowledge and there was no deliberate intention to suppress the fact or that such
misstatement of or suppression of material fact are within the knowledge of the insurer.
5.6 FREE LOOK PERIOD
The Free Look Period shall be applicable on new individual health insurance policies and not on
renewals or at the time of porting/migrating the policy.
The insured person shall be allowed free look period of fifteen days from date of receipt of the
policy document to review the terms and conditions of the policy, and to return the same if not
acceptable.
lf the insured has not made any claim during the Free Look Period, the insured shall be entitled
to
i. a refund of the premium paid less any expenses incurred by the Company on medical
examination of the insured person and the stamp duty charges or
ii. where the risk has already commenced and the option of return of the policy is exercised by
the insured person, a deduction towards the proportionate risk premium for period of cover
or
iii. Where only a part of the insurance coverage has commenced, such proportionate premium
commensurate with the insurance coverage during such period;
5.7 MULTIPLE POLICIES

i. ln case of multiple policies taken by an insured person during a period from one or more
insurers to indemnify treatment costs, the insured person shall have the right to require a
settlement of his/her claim in terms of any of his/her policies. ln all such cases the Insurer
chosen by the insured person shall be obliged to settle the claim as long as the claim is within
the limits of and according to the terms of the chosen policy.
ii. lnsured person having multiple policies shall also have the right to prefer claims under this
policy for the amounts disallowed under any other policy / policies even if the sum insured is
not exhausted. Then the insurer shall independently settle the claim subject to the terms and
conditions of this policy.
iii. If the amount to be claimed exceeds the sum insured under a single policy, the insured person
shall have the right to choose insurer from whom he/she wants to claim the balance amount
iv. Where an insured person has policies from more than one insurer to cover the same risk on
indemnity basis, the insured person shall only be indemnified the treatment costs in
accordance with the terms and conditions of the chosen policy
5.8 MORATORIUM PERIOD

After completion of eight continuous years under this policy no look back would be applied. This
period of eight years is called as moratorium period. The moratorium would be applicable for

the Sums Insured of the first policy and subsequently completion of eight continuous years
would be applicable from date of enhancement of Sums Insured only on the enhanced limits.
After the expiry of Moratorium Period no claim under this policy shall be contestable except for
proven fraud and permanent exclusions specified in the policy contract. The policies would
however be subject to all limits, sub limits, co-payments as per the policy.
5.9 NOMINATION:
The policyholder is required at the inception of the policy to make a nomination for the purpose
of payment of claims under the policy in the event of death of the policyholder. Any change of
nomination shall be communicated to the company in writing and such change shall be effective
only when an endorsement on the policy is made. ln the event of death of the policyholder, the
Company will pay the nominee {as named in the Policy Schedule/Policy Certificate/Endorsement
(if any)} and in case there is no subsisting nominee, to the legal heirs or legal representatives of
the policyholder whose discharge shall be treated as full and final discharge of its liability under
the policy.
5.10 CLAIM SETTLEMENT (PROVISION FOR PENAL INTEREST)

i. The Company shall settle or reject a claim, as the case may be, within 30 days from the date
of receipt of last necessary document.
ii. ln the case of delay in the payment of a claim, the Company shall be liable to pay interest to
the policyholder from the date of receipt of last necessary document to the date of payment
of claim at a rate 2% above the bank rate.
iii. However, where the circumstances of a claim warrant an investigation in the opinion of the
Company, it shall initiate and complete such investigation at the earliest, in any case not later
than 30 days from the date of receipt of last necessary document. ln such cases, the Company
shall settle or reject the claim within 45 days from the date of receipt of last necessary
document.
iv. ln case of delay beyond stipulated 45 days, the Company shall be liable to pay interest to the
policyholder at a rate 2% above the bank rate from the date of receipt of last necessary
document to the date of payment of claim.
v. "Bank rate" shall mean the rate fixed by the Reserve Bank of lndia (RBl) at the beginning of
the financial year in which claim has fallen due.
5.11 RENEWAL OF POLICY
The policy shall ordinarily be renewable except on grounds of fraud, misrepresentation by the
insured person.
i. The Company shall endeavor to give notice for renewal. However, the Company is not under
obligation to give any notice for renewal.
ii. Renewal shall not be denied on the ground that the insured person had made a claim or claims
in the preceding policy years.
iii. Request for renewal along with requisite premium shall be received by the Company before
the end of the policy period.
iv. At the end of the policy period, the policy shall terminate and can be renewed within the
Grace Period of 30 days to maintain continuity of benefits without break in policy. Coverage
is not available during the Grace Period.

v. No loading shall apply on renewals based on individual claims experience.
5.12 WITHDRAWAL OF POLICY

i. ln the likelihood of this product being withdrawn in future, the Company will intimate the
insured person about the same 90 days prior to expiry of the policy.
ii. lnsured Person will have the option to migrate to similar health insurance product available
with the Company at the time of renewal with all the accrued continuity benefits such as
cumulative bonus, waiver of waiting period. as per IRDAI guidelines, provided the policy has
been maintained without a break.
5.13 POSSIBILITY OF REVISION OF TERMS OF THE POLICY, INCLUDING THE PREMIUM RATES
The Company, with prior approval of lRDAl, may revise or modify the terms of the policy including
the premium rates. The insured person shall be notified three months before the changes are
effected.
5.14 REDRESSAL OF GRIEVANCE
ln case of any grievance the insured person may contact the company through
Website: https://www.newindia.co.in/portal/readMore/Grievances
Toll free: 1800-209-1415
E-mail, Fax and Courier: As mentioned in the above address
Senior Citizens may write to [email protected]
lnsured person may also approach the grievance cell at any of the company's branches with the details
of grievance.
lf lnsured person is not satisfied with the redressal of grievance through one of the above methods,
insured person may contact the grievance officer at
https://www.newindia.co.in/portal/readMore/Grievances For updated details of grievance officer,
kindly refer the link https://www.newindia.co.in/portal/readMore/Grievances
lf lnsured person is not satisfied with the redressal of grievance through above methods, the insured
person may also approach the office of lnsurance Ombudsman of the respective area/region for
redressal of grievance as per lnsurance Ombudsman Rules 2017. Please refer to Annexure III.
Grievance may also be lodged at IRDAI lntegrated Grievance Management System - https://igms.
irdai.gov.in
5.15 PORTABILITY AND MIGRATION:
Migration:
You will have the option to migrate the policy to other Health Insurance products/plans
offered by the company by applying for migration of the policy at-least 30 days before
the policy renewal date as per IRDAI guidelines on Migration. If You are presently covered
and has been continuously covered without any lapses under any Health Insurance

product/plan offered by the Company, then You will get the accrued continuity benefits
in waiting periods as per IRDAI guidelines on Migration. For detailed guidelines on
Migration. Kindly refer the link
https://www.irdai.gov.in/ADMINCMS/cms/frmGeneral_NoYearList.aspx?DF=RL&mid=4.
2
Portability:
You will have the option to port the policy to other Insurers by applying to such Insurer
to port the entire policy along with all the members of the family, if any, at-least 45 days
before, but not earlier than 60 days from the policy renewal date as per IRDAI guidelines
related to portability. If such person is presently covered and has been continuously
covered without any lapses under any Health Insurance policy with an India
General/Health Insurer, the proposed Insured person will get the accrued continuity
benefits in waiting periods as per IRDAI guidelines on portability. For detailed guidelines
on Portability. Kindly refer the link
https://www.irdai.gov.in/ADMINCMS/cms/frmGeneral_NoYearList.aspx?DF=RL&mid=4.
2
SPECIFIC TERMS AND CLAUSES

5.16 BASIS OF INSURANCE:
This Policy is issued on the basis of the truth and accuracy of statements in the Proposal. If there
is any misrepresentation or non-disclosure We will be entitled to treat the Policy as void.
5.17 PREMIUM:
Unless premium is paid before commencement of risk, this Policy shall have no effect.
5.18 PLACE OF TREATMENT AND PAYMENT:

This Policy covers medical/surgical treatment and/or services rendered only in India.
Admissible claims shall be payable only in Indian Rupees.
Payment shall be made directly to Network Hospital if Cashless facility is applied for before
treatment and accepted by TPA. If request for Cashless facility is not accepted by TPA, bills shall
be submitted to the TPA after payment of Hospital bills by you.
Note: Cashless facility is only a mode of claim payment and cannot be demanded in every claim.
If we/TPA have doubts regarding admissibility of a claim at the initial stage, which cannot
be decided without further verification of treatment records, request for Cashless facility
may be declined. Such decision by TPA or Us shall be final. Denial of Cashless facility
would not imply denial of claim. If Cashless facility is denied, You may submit the papers
on completion of treatment and admissibility of the claim would be subject to the terms,
conditions and exceptions of the Policy.
5.19 COMMUNICATION:
You must send all communications and papers regarding a claim to the TPA at the address shown
in the Schedule.
For all other matters relating to the policy, communication must be sent to our Policy issuing
office.

Communications you wish to rely upon must be in writing.
5.20 SETTLEMENT/REJECTION OF CLAIM:

i. We shall settle or reject a claim, as may be the case, within thirty days of the receipt of the
last ‘necessary’ document.
ii. While efforts will be made by Us to not call for any document not listed in Clause 5.21, where
any additional document or clarification is necessary to take a decision on the claim, such
additional documents will be called for.
iii. All necessary claim documents pertaining to Hospitalization should be furnished by the
Insured Person in original to the TPA (as mentioned in the Schedule), within seven days from
the date of discharge from the Hospital. However, claims filed even beyond such period will
be considered if there are valid reasons for delay in submission.
a. In case of any deficiency in submission of documents, the TPA shall issue a deficiency
request.
b. In case of non-submission of documents requested in the deficiency request within
seven days from the date of receipt of the deficiency request, three reminders shall
be sent by the TPA at an interval of seven days each.
c. The claim shall stand repudiated if the documents, mandatory for taking the decision
of admissibility of the Claim, are not submitted within seven days of the third
reminder.
d. If the required documents are such that it does not affect the admissibility of the claim
and is limited to payment of certain expenditure only, the Claim will be paid after
reducing such amount from the admissible amount.
e. In the event of a claim lodged under the Policy and the original documents having
been submitted to any other insurer, the Company shall accept the copy of the
documents and claim settlement advice, duly certified by the other insurer.
5.21 NOTICE OF CLAIM:

If You intend to make any claim under this Policy You must:
a. Intimate TPA in writing on detection of any Illness/Injury being suffered immediately or forty
eight hours before Hospitalisation.
b. Intimate within twenty four hours from the time of Hospitalisation in case of Hospitalisation
due to medical emergency.
c. Submit following supporting documents TPA relating to the claim within seven days from
the date of discharge from the Hospital:
i. Bill, Receipt and Discharge certificate / card from the Hospital.

ii. Cash Memos from the Hospitals (s) / Chemists (s), supported by proper
prescriptions.
iii. Receipt and Pathological test reports from Pathologist supported by the note
from the attending Medical Practitioner / Surgeon recommending such
Pathological tests / pathological.
iv. Surgeon's certificate stating nature of operation performed and Surgeons’ bill
and receipt.
v. Attending Doctor's/ Consultant's/ Specialist's / Anesthetist’s bill and receipt,
and certificate regarding diagnosis.
d. In case of Post-Hospitalisation treatment (limited to sixty days), submit all claim documents
within 7 days after completion of such treatment.
e. Provide TPA with authorization to obtain medical and other records from any Hospital,

Laboratory or other agency.
Note: The above stipulations are not intended merely to prejudice Your claims, but their
compliance is of utmost importance and necessity for Us to identify and verify all facts
and surrounding circumstances relating to a claim and determine whether it is payable.
Waiver of delay may be considered in extreme cases of hardship, but only if it is proved
to Our satisfaction it was not possible for You or any other person to comply with the
prescribed time-limit.
5.22 The Insured person shall submit to the TPA all original bills, receipts and other documents upon
which a claim is based and shall also give the TPA/Us such additional information and assistance
as the TPA / We may require.
5.23 Any Medical Practitioner authorised by the TPA/Us shall be allowed to examine the Insured
Person, at our cost, if We deem Medically Necessary in connection with any claim.
5.24 ENHANCEMENT OF SUM INSURED:

You may seek enhancement of Sum Insured in writing before payment of premium for renewal,
which may be granted as per the Company’s underwriting guidelines.
Enhancement of Sum Insured will not be considered for:
1) Any Insured Person over 65 years of age.

2) Any Insured Person suffering from any Critical Illness and Recurring Illness
In respect of any enhancement of Sum Insured, exclusions 4.1, 4.2 and 4.3 would apply to the
additional Sum Insured from such date.
5.25 CUMULATIVE BONUS:

Cumulative Bonus could be carried over to the next year only if the renewal is effected before,
or within thirty days of, expiry of the Policy.
5.26 ARBITRATION:
If We admit liability for any claim but any difference or dispute arises as to the amount payable
for any claim the same shall be decided by reference to Arbitration.
The Arbitrator shall be appointed in accordance with the provisions of the Arbitration and
Conciliation Act, 1996.
No reference to Arbitration shall be made unless We have admitted Our liability for a claim in
writing.
If a claim is declined and within twelve calendar months from such disclaimer any suit or
proceeding is not filed then the claim shall for all purposes be deemed to have been abandoned
and shall not thereafter be recoverable hereunder.
5.27 PREMIUM PAYMENT IN INSTALLMENTS

If the Insured Person has opted for Payment of Premium on an instalment basis i.e. Half Yearly,
Quarterly or Monthly, as mentioned in Your Policy Schedule, the following Conditions shall
apply (notwithstanding any terms contrary elsewhere in the Policy).
1. The instalment premium shall be paid on or before the due date as mentioned in the Policy
Schedule.

2. Grace Period of 7 days for monthly instalment and 15 days for quarterly and half-yearly
mode will be given to pay the installment premium due for the Policy. During such Grace
Period, Coverage will not be available from the instalment premium due date until the date
of receipt of premium by Company.
3. If the instalment premium is not paid within the Grace Period, then policy shall cease to
exist at midnight of such due date and will be treated as lapsed and company shall not be
liable to pay any claim whatsoever.
4. All claims that fall beyond such premium instalment due date shall not be payable under
the policy.
5. In case of a claim, Policyholder will be liable to pay the balance premium due under the
policy before the claim is Intimated.
5.28 PROTECTION OF POLICY HOLDERS’ INTEREST:

This policy is subject to IRDAI (Protection of Policyholders’ Interests) Regulation, 2017.
5.29 ZONE CLASSIFICATION: For the purpose of policy issuance, the premium will be computed
based on the Zone Opted by the Insured Person in the proposal form. Classification of Zones
are as follows:
Zone 1: Delhi, National Capital Region (NCR), Mumbai, Mumbai Suburban, Thane and Navi
Mumbai, Surat, Ahmedabad and Vadodara
Zone 2: Rest of India
Conditions:
a. Insured Person opting for Zone I can avail treatment anywhere in India and No Co-pay shall
be applicable.
b. In case the Insured Person opting Zone II takes treatment in Zone I, Co-pay of 10% shall be
applicable on admissible claim.
c. Co-Pay shall not be applicable for immediate hospitalization arising out of Accident.
d. Co-Pay shall also not be applicable for Illness or Treatments having sub-limits.
5.30 The expenses that are not covered in this policy are placed under List-I of Annexure-II. The list
of expenses that are to be subsumed into room charges, or procedure charges or costs of
treatment are placed under List-II, List-III and List-IV of Annexure-II respectively.

ANNEXURE I: LIST OF DAY CARE PROCEDURES:
No LIST OF DAY-CARE TREATMENTS No LIST OF DAY-CARE TREATMENTS

ENT General Surgery
1 Stapedotomy 148 Infected keloid excision
2 Myringoplasty(Type I Tympanoplasty) 149 Incision of a pilonidal sinus / abscess
3 Revision stapedectomy 150 Infected sebaceous cyst
4 Labyrinthectomy for severe Vertigo 151 Infected lipoma excision
5 Stapedectomy under GA 152 Maximal anal dilatation
6 Ossiculoplasty 153 Surgical Treatment Of Haemorrhoids
7 Myringotomy with Grommet Insertion 154 Liver Abscess- catheter drainage
8 Tympanoplasty (Type III) 155 Fissure in Ano- fissurectomy
9 Stapedectomy under LA 156 Fibroadenoma breast excision
10 Revision of the fenestration of the inner ear. 157 Oesophageal varices Sclerotherapy
11 Tympanoplasty (Type IV) 158 ERCP – pancreatic duct stone removal
Endolymphatic Sac Surgery for Meniere’s
12 159 Perianal abscess I&D
Disease
13 Turbinectomy 160 Perianal hematoma Evacuation
14 Removal of Tympanic Drain under LA 161 Fissure in ano sphincterotomy
15 Endoscopic Stapedectomy 162 UGI scopy and Polypectomy oesophagus
16 Fenestration of the inner ear 163 Breast abscess I& D
17 Incision and drainage of perichondritis 164 Feeding Gastrostomy
Oesophagoscopy and biopsy of growth
18 Septoplasty 165
oesophagus
19 Vestibular Nerve section 166 ERCP – Bile duct stone removal
20 Thyroplasty Type I 167 Ileostomy closure
21 Tympanoplasty (Type II) 168 Polypectomy colon
22 Reduction of fracture of Nasal Bone 169 Splenic abscesses Laparoscopic Drainage
23 Excision and destruction of lingual tonsils 170 UGI SCOPY and Polypectomy stomach
24 Conchoplasty 171 Rigid Oesophagoscopy for FB removal
25 Thyroplasty Type II 172 Feeding Jejunostomy
26 Tracheostomy 173 Colostomy
27 Excision of Angioma Septum 174 Ileostomy
28 Turbinoplasty 175 Colostomy closure
29 Incision & Drainage of Retro Pharyngeal Abscess 176 Submandibular salivary duct stone removal
30 Uvulo Palato Pharyngo Plasty 177 Pancreatic Pseudocysts Endoscopic Drainage
31 Palatoplasty 178 Subcutaneous mastectomy
32 Tonsillectomy without adenoidectomy 179 Excision of Ranula under GA
Rigid Oesophagoscopy for dilation of benign
33 Adenoidectomy with Grommet insertion 180
Strictures
34 Adenoidectomy without Grommet insertion 181 Eversion of Sac
35 Vocal Cord lateralisation Procedure 182 1. a) Unilateral
36 Incision & Drainage of Para Pharyngeal Abscess 183 b)Bilateral
Transoral incision and drainage of a pharyngeal
37 184 Lord’s plication
abscess
38 Tonsillectomy with adenoidectomy 185 Jaboulay’s Procedure
39 Tracheoplasty 186 Scrotoplasty
40 Reconstruction Of The Middle Ear 187 Surgical treatment of varicocele
41 Mastoidectomy 188 Epididymectomy
Excision And Destruction Of Diseased Tissue Of
42 189 Circumcision for Trauma
The Nose

Incision (Opening) And Destruction
43 190 Meatoplasty
(Elimination) Of The Inner Ear
44 Incision Of The Mastoid Process And Middle Ear 191 Intersphincteric abscess incision and drainage
45 Nasal Sinus Aspiration 192 Psoas Abscess Incision and Drainage
Other Microsurgical Operations On The Middle
46 193 Thyroid abscess Incision and Drainage
Ear
47 Other Operations On The Auditory Ossicles 194 TIPS procedure for portal hypertension
48 Plastic Surgery To The Floor Of The Mouth 195 PAIR Procedure of Hydatid Cyst liver
49 Incision Of The Hard And Soft Palate 196 Excision of Cervical RIB
External Incision And Drainage In The Region Of
50 197 Surgery for fracture Penis
The Mouth, Jaw And Face
Other Operations On The Salivary Glands And
51 198 Parastomal hernia
Salivary Ducts
Ophthalmology 199 Revision colostomy
52 Incision of tear glands 200 Prolapsed colostomy- Correction
53 Other operation on the tear ducts 201 Laparoscopic cardiomyotomy( Hellers)
54 Incision of diseased eyelids 202 Laparoscopic pyloromyotomy( Ramstedt)
Excision and destruction of the diseased tissue
55 203 Orchiectomy
of the eyelid
Removal of foreign body from the lens of the
56 204 Incision Of The Breast
eye.
Corrective surgery of the entropion and
57 205 Operations On The Nipple
ectropion
Incision And Excision Of Tissue In The Perianal
58 Operations for pterygium 206
Region
59 Corrective surgery of blepharoptosis 207 Surgical Treatment Of Anal Fistulas
60 Removal of foreign body from conjunctiva 208 Division Of The Anal Sphincter (Sphincterotomy)
61 Removal of Foreign body from cornea 209 Glossectomy
62 Incision of the cornea 210 Reconstruction Of The Tongue
Incision, Excision And Destruction Of Diseased
63 Other operations on the cornea 211
Tissue Of The Tongue
64 Operation on the canthus and epicanthus 212 Operations On The Seminal Vesicles
Removal of foreign body from the orbit and the Other Operations On The Spermatic Cord,
65 213
eye ball. Epididymis And Ductus Deferens
Local Excision And Destruction Of Diseased
66 Surgery for cataract 214
Tissue Of The Penis
67 Treatment of retinal lesion 215 Other Operations On The Penis
Removal of foreign body from the posterior Other Excisions Of The Skin And Subcutaneous
68 216
chamber of the eye Tissues
Other Incisions Of The Skin And Subcutaneous
Oncology 217
Tissues
Simple Restoration Of Surface Continuity Of The
69 IV Push Chemotherapy 218
Skin And Subcutaneous Tissues
70 Continuous Infusional Chemotherapy 219 Free Skin Transplantation, Donor Site
71 Infusional Chemotherapy 220 Free Skin Transplantation, Recipient Site
72 CCRT-Concurrent Chemo + RT 221 Reconstruction Of The Testis
Incision Of The Scrotum And Tunica Vaginalis
73 SRS- Stereotactic radiosurgery 222
Testis
74 TBI- Total Body Radiotherapy 223 Excision In The Area Of The Epididymis
75 Adjuvant Radiotherapy 224 Revision Of Skin Plasty
Other Restoration And Reconstruction Of The
76 Radical chemotherapy 225
Skin And Subcutaneous Tissues
Destruction Of Diseased Tissue In The Skin And
77 Neoadjuvant radiotherapy 226
Subcutaneous Tissues
78 Palliative Radiotherapy Orthopedics

79 Radical Radiotherapy 227 Arthroscopic Repair of ACL tear knee
80 Palliative chemotherapy 228 Arthroscopic repair of PCL tear knee
81 Neoadjuvant chemotherapy 229 Tendon shortening
82 Adjuvant chemotherapy 230 Arthroscopic Meniscectomy – Knee
83 Induction chemotherapy 231 Treatment of clavicle dislocation
84 Consolidation chemotherapy 232 Arthroscopic meniscus repair
85 Maintenance chemotherapy 233 Haemarthrosis knee- lavage
Urology 234 Abscess knee joint drainage
86 AV fistula 235 Repair of knee cap tendon
87 URSL with stenting 236 ORIF with K wire fixation- small bones
88 URSL with lithotripsy 237 ORIF with plating- Small long bones
89 ESWL 238 Arthrotomy Hip joint
90 Haemodialysis 239 Syme’s amputation
91 Cystoscopy and removal of polyp 240 Arthroplasty
92 Excision of urethral diverticulum 241 Partial removal of rib
93 Removal of urethral Stone 242 Treatment of sesamoid bone fracture
94 Ureter endoscopy and treatment 243 Amputation of metacarpal bone
95 Surgery for pelvi ureteric junction obstruction 244 Repair / graft of foot tendon
96 Injury prepuce- circumcision 245 Revision/Removal of Knee cap
97 Frenular tear repair 246 Remove/graft leg bone lesion
98 Meatotomy for meatal stenosis 247 Repair/graft achilles tendon
99 Surgery for fournier’s gangrene scrotum 248 Biopsy elbow joint lining
100 Surgery filarial scrotum 249 Biopsy finger joint lining
101 Surgery for watering can perineum 250 Tendon lengthening
102 Repair of penile torsion 251 Surgery of bunion
103 Drainage of prostate abscess 252 Tendon transfer procedure
104 Cystoscopy and removal of FB 253 Removal of knee cap bursa
Transurethral Excision And Destruction Of
105 254 Treatment of fracture of ulna
Prostate Tissue
Transurethral And Percutaneous Destruction Of
106 255 Treatment of scapula fracture
Prostate Tissue
Open Surgical Excision And Destruction Of
107 256 Removal of tumor of arm/ elbow under RA/GA
Prostate Tissue
108 Radical Prostatovesiculectomy 257 Repair of ruptured tendon
Other Excision And Destruction Of Prostate
109 258 Revision of neck muscle ( Torticollis release )
Tissue
110 Incision Of The Prostate 259 Treatment fracture of radius & ulna
111 Incision And Excision Of Periprostatic Tissue 260 Incision On Bone, Septic And Aseptic
Closed Reduction On Fracture, Luxation Or
112 Other Operations On The Prostate 261
Epiphyseolysis With Osteosynthesis
Gynaecology 262 Reduction Of Dislocation Under Ga
113 Hysteroscopic removal of myoma Paediatric surgery
114 D&C 263 Vaginoplasty
Dilatation of accidental caustic stricture
115 Hysteroscopic resection of septum 264
oesophageal
116 Hysteroscopic adhesiolysis 265 Presacral Teratomas Excision
117 Polypectomy Endometrium 266 Removal of vesical stone
118 Hysteroscopic resection of fibroid 267 Excision Sigmoid Polyp
119 LLETZ 268 Sternomastoid Tenotomy
120 Conization 269 High Orchidectomy for testis tumours
121 Polypectomy cervix 270 Excision of cervical teratoma
122 Hysteroscopic resection of endometrial polyp 271 Rectal-Myomectomy
123 Vulval wart excision 272 Rectal prolapse (Delorme’s procedure)
124 Laparoscopic paraovarian cyst excision 273 Orchidopexy for undescended testis

125 Uterine artery embolization 274 Detorsion of torsion Testis
126 Bartholin Cyst excision 275 Lap.Abdominal exploration in cryptorchidism
127 Laparoscopic cystectomy 276 EUA + biopsy multiple fistula in ano
128 Endometrial ablation 277 Excision of fistula-in-ano
129 Vaginal wall cyst excision Others
130 Vulval cyst Excision 278 Coronary Angiography
131 Laparoscopic paratubal cyst excision 279 Ultrasound Guided Aspirations
132 Hysteroscopy, removal of myoma 280 Chemosurgery To The Skin
133 TURBT
134 Laparoscopic Myomectomy
135 Surgery for SUI
136 Pelvic floor repair( excluding Fistula repair)
137 Laparoscopic oophorectomy
138 Incision Of The Ovary
139 Insufflation Of The Fallopian Tubes
140 Dilatation Of The Cervical Canal
141 Conisation Of The Uterine Cervix
142 Hysterotomy
143 Therapeutic Curettage
144 Culdotomy
145 Incision Of The Vagina
Local Excision And Destruction Of Diseased
146
Tissue Of The Vagina And The Pouch Of Douglas
147 Incision Of The Vulva

ANNEXURE II:
List I – Items for which coverage is not available in the policy
S No Item
1 BABY FOOD
2 BABY UTILITIES CHARGES
3 BEAUTY SERVICES
4 BELTS/ BRACES
5 BUDS
6 COLD PACK/HOT PACK
7 CARRY BAGS
8 EMAIL / INTERNET CHARGES
9 FOOD CHARGES (OTHER THAN PATIENT's DIET PROVIDED BY HOSPITAL)
10 LEGGINGS
11 LAUNDRY CHARGES
12 MINERAL WATER
13 SANITARY PAD
14 TELEPHONE CHARGES
15 GUEST SERVICES
16 CREPE BANDAGE
17 DIAPER OF ANY TYPE
18 EYELET COLLAR
19 SLINGS
20 BLOOD GROUPING AND CROSS MATCHING OF DONORS SAMPLES
21 SERVICE CHARGES WHERE NURSING CHARGE ALSO CHARGED
22 Television Charges
23 SURCHARGES
24 ATTENDANT CHARGES
25 EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH FORMS PART OF BED CHARGE)
26 BIRTH CERTIFICATE
27 CERTIFICATE CHARGES
28 COURIER CHARGES
29 CONVEYANCE CHARGES
30 MEDICAL CERTIFICATE
31 MEDICAL RECORDS
32 PHOTOCOPIES CHARGES
33 MORTUARY CHARGES
34 WALKING AIDS CHARGES
35 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE HOSPITAL)
36 SPACER
37 SPIROMETRE
38 NEBULIZER KIT
39 STEAM INHALER
40 ARMSLING
41 THERMOMETER
42 CERVICAL COLLAR
43 SPLINT
44 DIABETIC FOOT WEAR
45 KNEE BRACES (LONG/ SHORT/ HINGED)
46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER
47 LUMBO SACRAL BELT
48 NIMBUS BED OR WATER OR AIR BED CHARGES

49 AMBULANCE COLLAR
50 AMBULANCE EQUIPMENT
51 ABDOMINAL BINDER
52 PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES
53 SUGAR FREE Tablets
54 CREAMS POWDERS LOTIONS (Toiletries are not payable, only prescribed medical pharmaceuticals
payable)
55 ECG ELECTRODES
56 GLOVES
57 NEBULISATION KIT
58 ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT, ORTHOKIT, RECOVERY KIT, ETC]
59 KIDNEY TRAY
60 MASK
61 OUNCE GLASS
62 OXYGEN MASK
63 PELVIC TRACTION BELT
64 PAN CAN
65 TROLLY COVER
66 UROMETER, URINE JUG
67 AMBULANCE
68 VASOFIX SAFETY
List II – Items that are to be subsumed into Room Charges
S No Item
1 BABY CHARGES (UNLESS SPECIFIED/INDICATED)
2 HAND WASH
3 SHOE COVER
4 CAPS
5 CRADLE CHARGES
6 COMB
7 EAU-DE-COLOGNE / ROOM FRESHNERS
8 FOOT COVER
9 GOWN
10 SLIPPERS
11 TISSUE PAPER
12 TOOTH PASTE
13 TOOTH BRUSH
14 BED PAN
15 FACE MASK
16 FLEXI MASK
17 HAND HOLDER
18 SPUTUM CUP
19 DISINFECTANT LOTIONS
20 LUXURY TAX
21 HVAC
22 HOUSE KEEPING CHARGES
23 AIR CONDITIONER CHARGES
24 IM IV INJECTION CHARGES
25 CLEAN SHEET
26 BLANKET/WARMER BLANKET
27 ADMISSION KIT
28 DIABETIC CHART CHARGES

29 DOCUMENTATION CHARGES / ADMINISTRATIVE EXPENSES
30 DISCHARGE PROCEDURE CHARGES
31 DAILY CHART CHARGES
32 ENTRANCE PASS / VISITORS PASS CHARGES
33 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE
34 FILE OPENING CHARGES
35 INCIDENTAL EXPENSES / MISC. CHARGES (NOT EXPLAINED)
36 PATIENT IDENTIFICATION BAND / NAME TAG
37 PULSEOXYMETER CHARGES
List III – Items that are to be subsumed into Procedure Charges
S No Item
1 HAIR REMOVAL CREAM
2 DISPOSABLES RAZORS CHARGES (for site preparations)
3 EYE PAD
4 EYE SHEILD
5 CAMERA COVER
6 DVD, CD CHARGES
7 GAUSE SOFT
8 GAUZE
9 WARD AND THEATRE BOOKING CHARGES
10 ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS
11 MICROSCOPE COVER
12 SURGICAL BLADES, HARMONICSCALPEL,SHAVER
13 SURGICAL DRILL
14 EYE KIT
15 EYE DRAPE
16 X-RAY FILM
17 BOYLES APPARATUS CHARGES
18 COTTON
19 COTTON BANDAGE
20 SURGICAL TAPE
21 APRON
22 TORNIQUET
23 ORTHOBUNDLE, GYNAEC BUNDLE
List IV – Items that are to be subsumed into costs of treatment
S No Item
1 ADMISSION/REGISTRATION CHARGES
2 HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC PURPOSE
3 URINE CONTAINER
4 BLOOD RESERVATION CHARGES AND ANTE NATAL BOOKING CHARGES
5 BIPAP MACHINE
6 CPAP/ CAPD EQUIPMENTS
7 INFUSION PUMP– COST
8 HYDROGEN PEROXIDE\SPIRIT\ DISINFECTANTS ETC
9 NUTRITION PLANNING CHARGES - DIETICIAN CHARGES- DIET CHARGES
10 HIV KIT
11 ANTISEPTIC MOUTHWASH
12 LOZENGES
13 MOUTH PAINT

14 VACCINATION CHARGES
15 ALCOHOL SWABES
16 SCRUB SOLUTION/STERILLIUM
17 Glucometer& Strips
18 URINE BAG

ANNEXURE III: CONTACT DETAILS OF INSURANCE OMBUDSMEN
AHMEDABAD - Shri Kuldip Singh BHOPAL - Shri Guru Saran Shrivastava

Office of the Insurance Ombudsman, Office of the Insurance Ombudsman,
Jeevan Prakash Building, 6th floor, Janak Vihar Complex, 2nd Floor, 6, Malviya Nagar, Opp. Airtel Office,
Tilak Marg, Relief Road, Ahmedabad – 380 001. Near New Market, Bhopal – 462 003.
Tel.: 079 - 25501201/02/05/06 Tel.: 0755 - 2769201 / 2769202
Email: [email protected] Fax: 0755 - 2769203
Email: [email protected]
BHUBANESHWAR - Shri Suresh Chandra Panda CHANDIGARH - Dr. Dinesh Kumar Verma
62, Forest park, Bhubneshwar – 751 009. S.C.O. No. 101, 102 & 103, 2nd Floor,
Tel.: 0674 - 2596461 /2596455 Batra Building, Sector 17 – D, Chandigarh – 160 017.
Fax: 0674 - 2596429 Tel.: 0172 - 2706196 / 2706468
CHENNAI - Shri M. Vasantha Krishna DELHI - Shri Sudhir Krishna
Office of the Insurance Ombudsman, Office of the Insurance Ombudsman, 2/2 A, Universal Insurance
Fatima Akhtar Court, 4th Floor, 453, Building,
Anna Salai, Teynampet, CHENNAI – 600 018. Asaf Ali Road, New Delhi – 110 002.
Tel.: 044 - 24333668 / 24335284 Tel.: 011 - 23232481/23213504
Fax: 044 - 24333664 Email: [email protected]
GUWAHATI - Shri Kiriti .B. Saha HYDERABAD - Shri I. Suresh Babu
Jeevan Nivesh, 5th Floor, 6-2-46, 1st floor, "Moin Court",
Nr. Panbazar over bridge, S.S. Road, Guwahati – Lane Opp. Saleem Function Palace, A. C. Guards, Lakdi-Ka-Pool,
781001(ASSAM). Hyderabad - 500 004.
Tel.: 0361 - 2632204 / 2602205 Tel.: 040 - 67504123 / 23312122
ERNAKULAM - Ms. Poonam Bodra KOLKATA - Shri P. K. Rath
Office of the Insurance Ombudsman, Office of the Insurance Ombudsman, Hindustan Bldg.
2nd Floor, Pulinat Bldg., Opp. Cochin Shipyard, M. G. Road, Annexe, 4th Floor, 4, C.R. Avenue, KOLKATA - 700
Ernakulam - 682 015. 072.
Tel.: 0484 - 2358759 / 2359338 Tel.: 033 - 22124339 / 22124340
Fax: 0484 - 2359336 Fax : 033 - 22124341
Email: [email protected] Email: [email protected]
LUCKNOW -Shri Justice Anil Kumar Srivastava MUMBAI - Shri Milind A. Kharat
6th Floor, Jeevan Bhawan, Phase-II, 3rd Floor, Jeevan Seva Annexe,
Nawal Kishore Road, Hazratganj, Lucknow - 226 001. S. V. Road, Santacruz (W), Mumbai - 400 054.
Tel.: 0522 - 2231330 / 2231331 Tel.: 022 - 26106552 / 26106960
Fax: 0522 - 2231310 Fax: 022 - 26106052
Email: [email protected] Email: [email protected]
JAIPUR - Smt. Sandhya Baliga PUNE - Shri Vinay Sah
Jeevan Nidhi – II Bldg., Gr. Floor, Bhawani Singh Marg, Jeevan Darshan Bldg., 3rd Floor,
Jaipur - 302 005. C.T.S. No.s. 195 to 198, N.C. Kelkar Road, Narayan Peth, Pune –
Tel.: 0141 - 2740363 411 030.
Email: [email protected] Tel.: 020-41312555
BENGALURU - Smt. Neerja Shah NOIDA - Shri Chandra Shekhar Prasad
Jeevan Soudha Building,PID No. 57-27-N-19 Ground Floor, 19/19, Bhagwan Sahai Palace, 4th Floor, Main Road, Naya Bans, Sector
24th Main Road, 15, Distt: Gautam Buddh Nagar, U.P-201301.
JP Nagar, Ist Phase, Bengaluru – 560 078. Tel.: 0120-2514250 / 2514252 / 2514253
Tel.: 080 - 26652048 / 26652049 Email: [email protected]
PATNA - Shri N. K. Singh
Office of the Insurance Ombudsman,
1st Floor,Kalpana Arcade Building,,
Bazar Samiti Road, Bahadurpur, Patna 800 006.
Tel.: 0612-2680952

Annexure IV:
Table of Coverages/Procedures with Sub-limits and Waiting Periods

Waiting
Nature of Disease/Procedure/Treatment Sublimit (Per Policy Period)
Period
Congenital Internal Disease (Not Applicable
Not Applicable 12 Months
for New Born Baby)
10% of the average Sum Insured in the
Congenital External Disease 24 Months
preceding 24 months
10% of the Sum Insured or Rs. 50,000/-
Cataract (per eye/per Insured.) 12 Months
whichever is less
Hazardous Sports for recreational purpose 10% of the Sum Insured NIL
Artificial life maintenance (This sub limit is
applicable only for person who is declared to 25% of the Sum Insured and a Maximum
NIL
be in a vegetative state as certified by the of 15 days
treating medical practitioner)
Puberty and Menopause related Disorders 25% of the Sum Insured 12 Months
Age Related Macular Degeneration (ARMD) 20% of the Sum Insured 24 Months
Genetic diseases or disorders 25% of the Sum Insured 24 Months
Treatment of Mental Illness (ICD Code: F01-
25% of the Sum Insured 24 Months
F29 & F60-F79)
Uterine Artery Embolization and HIFU (High Upto 20% of Sum Insured subject to a
NIL
intensity focused ultrasound) Maximum upto Rs. 1 Lakh
Balloon Sinuplasty NIL
Maximum upto Rs. 1 Lakh
Deep Brain stimulation NIL
maximum upto Rs. 2 Lakh
Oral chemotherapy NIL
Maximum upto Rs. 50,000
Immunotherapy- Monoclonal Antibody to be Upto 25% of Sum Insured subject to a
NIL
given as injection Maximum of Rs 2 Lakh.
Intravitreal injections NIL
Maximum of Rs.75,000.
Robotic surgeries NIL
Stereotactic radio surgeries NIL
Maximum Rs. 2 Lakh.
Bronchial Thermoplasty NIL
Vaporisation of the prostrate (Green laser Upto 25% of Sum Insured subject to
NIL
treatment or holmium laser treatment) Maximum of Rs. 1 Lakh.
IONM - (Intra Operative Neuro Monitoring) NIL
Maximum of Rs. 30,000.
Stem cell therapy: Hematopoietic stem cells
for bone marrow transplant for NIL
Maximum of Rs. 1.5 Lakh.
haematological conditions to be covered
Diabetes Mellitus NIL 90 Days
Hypertension NIL 90 Days
Cardiac Conditions NIL 90 Days

All internal and external benign tumours,
cysts, polyps of any kind, including benign NIL 12 Months
breast lumps
Benign ear, nose, throat disorders NIL 12 Months
Benign prostate hypertrophy NIL 12 Months
Age related eye ailments NIL 12 Months
Gastric/ Duodenal Ulcer NIL 12 Months
Gout and Rheumatism NIL 12 Months
Hernia of all types NIL 12 Months
Hydrocele NIL 12 Months
Non Infective Arthritis NIL 12 Months
Piles, Fissures and Fistula in anus NIL 12 Months
Pilonidal sinus, Sinusitis and related disorders NIL 12 Months
Prolapse inter Vertebral Disc and Spinal
NIL 12 Months
Diseases unless arising from accident
Skin Disorders NIL 12 Months
Stone in Gall Bladder and Bile duct, excluding
NIL 12 Months
malignancy
Stones in Urinary system NIL 12 Months
Treatment for Menorrhagia/Fibromyoma,
NIL 12 Months
Myoma and Prolapsed uterus
Varicose Veins and Varicose Ulcers NIL 12 Months
Renal Failure NIL 12 Months
Joint Replacement due to Degenerative
NIL 24 Months
Condition
Age-related Osteoarthritis & Osteoporosis NIL 24 Months

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THE NEW INDIA ASSURANCE CO. LTD.

Young India Digi Health Policy

YOUNG INDIA DIGI HEALTH POLICY

2.8 CRITICAL ILLNESSES mean the following Illnesses:

2.8.1 CANCER OF SPECIFIED SEVERITY means

2.8.2 MYOCARDIAL INFARCTION (FIRST HEART ATTACK OF SPECIFIED SEVERITY)

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YOUNG INDIA DIGI HEALTH POLICY

2.8.3 OPEN CHEST CABG

2.8.4 OPEN HEART REPLACEMENT OR REPAIR OF HEART VALVES

2.8.5 COMA OF SPECIFIED SEVERITY

2.8.6 KIDNEY FAILURE REQUIRING REGULAR DIALYSIS

2.8.7 STROKE RESULTING IN PERMANENT SYMPTOMS

YOUNG INDIA DIGI HEALTH POLICY

2.8.8 MAJOR ORGAN /BONE MARROW TRANSPLANT

2.8.9 PERMANENT PARALYSIS OF LIMBS

2.8.10 MOTOR NEURONE DISEASE WITH PERMANENT SYMPTOMS

2.8.11 MULTIPLE SCLEROSIS WITH PERSISTING SYMPTOMS

2.8.12 THIRD DEGREE BURNS

2.8.13 MAJOR HEAD TRAUMA

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YOUNG INDIA DIGI HEALTH POLICY

2.8.15 END STAGE LIVER FAILURE

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YOUNG INDIA DIGI HEALTH POLICY

2.17 HOSPITALISATION means admission as an Inpatient in a Hospital for a minimum period of 24

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2.42 UNPROVEN / EXPERIMENTAL TREATMENT is treatment, including drug Experimental therapy,

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YOUNG INDIA DIGI HEALTH POLICY

2.51 MENTAL HEALTH PROFESSIONAL means

i. a psychiatrist: means a medical practitioner possessing a post-graduate degree or

Note: Sum Insured as shown in the schedule excluding Cumulative Bonus.

YOUNG INDIA DIGI HEALTH POLICY

2.60 WE/OUR/US/COMPANY means The New India Assurance Co. Ltd.

3.0 HOW MUCH WE WILL REIMBURSE

3.2 PROPORTIONATE DEDUCTION

1. Cost of Pharmacy and Consumables

3.3 MEDICAL EXPENSES INCURRED UNDER TWO POLICY PERIODS:

YOUNG INDIA DIGI HEALTH POLICY

3.5 HOSPITAL CASH

3.6 ROAD AMBULANCE CHARGES

3.7 TREATMENT FOR CONGENITAL DISEASES

3.8 COVERAGE FOR CATARACT:

3.9 COVERAGE FOR HAZARDOUS SPORTS

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YOUNG INDIA DIGI HEALTH POLICY

3.10 SPECIFIC COVERAGES:

ICD Code ICD Code Description

Exclusions: Any kind of Psychological counselling, cognitive/ family/ group/ behaviour/

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YOUNG INDIA DIGI HEALTH POLICY

3.12 HEALTH CHECK-UP

3.14 REINSTATEMENT OF SUM INSURED