Senior First

Policy Wordings
1. Preamble
This Policy covers Allopathic and AYUSH treatments taken in India ONLY. Expense incurred outside the policy period will NOT be
covered. Unutilized Sum Insured will expire at the end of policy year. All applicable benefits and details are mentioned in your Policy
Schedule.

2. Definitions

2.1. Standard Definitions

I. Accident or Accidental means a sudden, unforeseen and involuntary event caused by external, visible and violent
means.

II. 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 of 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 five in-patient beds;
ii. Having qualified AYUSH Medical Practitioner in charge round the clock;
iii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where
surgical procedures are to be carried out;
iv. Maintaining daily records of the patients and making them accessible to the insurance company’s authorized
representative.
AYUSH Hospitals referred above shall also obtain either pre-entry level certificate (or higher level of certificate)
issued by National Accreditation Board for Hospitals and Healthcare Providers (NABH) or State Level Certificate
(or higher level of certificate) under National Quality Assurance Standards (NQAS), issued by National Health
Systems Resources Centre (NHSRC).

III. Cashless Facility means a facility extended by the insurer to the insured where the payments, of the costs of
treatment undergone by the insured in accordance with the policy terms and conditions, are directly made to the
network provider by the insurer to the extent pre-authorization is approved.

IV. Congenital Anomaly means a condition which is present since birth, and which is abnormal with reference to form,
structure or position.
a. Internal Congenital Anomaly: Congenital Anomaly which is not in the visible and accessible parts of the body.
b. External Congenital Anomaly: Congenital Anomaly which is in the visible and accessible parts of the body.

V. Cumulative Bonus means any increase or addition in the Sum Insured granted by the insurer without an associated
increase in premium.

VI. Day Care Centre means any institution established for Day Care Treatment of Illness and/or Injuries or a medical set-
up with a Hospital and which has been 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 criterion as under:
a. has Qualified Nursing staff under its employment;
b. has qualified Medical Practitioner(s) in charge;
c. has a fully equipped operation theatre of its own where Surgical Procedures are carried out;
d. maintains daily records of patients and will make these accessible to the insurance company’s authorized
personnel.

VII. Dental Treatment means a treatment related to teeth or structures supporting teeth including examinations, fillings
(where appropriate), crowns, extractions and Surgery.

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

VIII. Domiciliary Hospitalization means medical treatment for an Illness/disease/Injury which in the normal course
would require care and treatment at a Hospital but is actually taken while confined at home under any of the
following circumstances:
a. the condition of the patient is such that he/she is not in a condition to be removed to a Hospital, or
b. the patient takes treatment at home on account of non availability of room in a Hospital.

IX. Grace Period means the specified period of time (30 days) immediately following the premium due date during
which a payment can be made to Renew or continue a policy in force without loss of continuity benefits such
as Waiting Periods and coverage of Pre-existing Diseases. Coverage is not available for the period for which no
premium is received.

X. Hospital means any institution established for Inpatient Care and Day Care Treatment of Illness and / or Injuries and
which has been registered as a Hospital with the local authorities under the Clinical Establishments (Registration
and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act
OR complies with all minimum criteria as under:
a. has Qualified Nursing staff under its employment round the clock;
b. has at least 10 Inpatient beds in towns having a population of less than 10,00,000 and at least 15 Inpatient beds
in all other places;
c. has qualified Medical Practitioner(s) in charge round the clock;
d. has a fully equipped operation theatre of its own where Surgical Procedures are carried out;
e. maintains daily records of patients and makes these accessible to the Insurance company’s authorized personnel.

XI. Hospitalization means admission in a Hospital for a minimum period of 24 consecutive ‘In-patient Care’ hours
except for specified procedures/treatments, where such admission could be for a period of less than 24 consecutive
hours.

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

XIII. Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological
function and requires medical treatment.
a. Acute condition - Acute condition is a disease, illness or injury that is likely to respond quickly to treatment
which aims to return the person to his or her state of health immediately before suffering the disease/ illness/
injury which leads to full recovery
b. Chronic condition - A chronic condition is defined as a disease, illness, or injury that has one or more of the
following characteristics:
i. it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /or tests
ii. it needs ongoing or long-term control or relief of symptoms
iii. it requires rehabilitation for the patient or for the patient to be specially trained to cope with it
iv. it continues indefinitely
v. it recurs or is likely to recur

XIV. 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.

XV. Inpatient Care means treatment for which the Insured Person has to stay in a Hospital for more than 24 hours for
a covered event.

XVI. Intensive Care Unit means an identified section, ward or wing of a Hospital which is under the constant supervision
of a dedicated Medical Practitioner(s), and which is specially equipped for the continuous monitoring and treatment
of patients who are in a critical condition, or require life support facilities and where the level of care and supervision
is considerably more sophisticated and intensive than in the ordinary and other wards.

XVII. Medical Advice means any consultation or advice from a Medical Practitioner including the issuance of any
prescription or follow-up prescription.

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

 XVIII. Medical Expenses means those expenses that an Insured Person has necessarily and actually incurred for medical
treatment on account of Illness or Accident on the advice of a Medical Practitioner, as long as these are no more than
would have been payable if the Insured Person had not been insured and no more than other Hospitals or doctors
in the same locality would have charged for the same medical treatment.

XIX. 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 licence.

XX. Medically Necessary Treatment means any treatment, tests, medication, or stay in Hospital or part of a stay in
Hospital which:
i. is required for the medical management of the Illness or Injury suffered by the insured;
ii. must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope,
duration, or intensity;
iii. must have been prescribed by a Medical Practitioner;
iv. must conform to the professional standards widely accepted in international medical practice or by the medical
community in India.

XXI. Network Provider means Hospital enlisted by an insurer, TPA or jointly by an insurer and TPA to provide medical
services to an insured by a Cashless Facility.

XXII. Non-Network Provider means any Hospital, Day Care Centre or other provider that is not part of the network.

XXIII. Notification of Claim means the process of intimating a claim to the insurer or TPA through any of the recognized
modes of communication.

XXIV. OPD Treatment means the one in which the Insured visits a clinic / Hospital or associated facility like a consultation
room for diagnosis and treatment based on the advice of a Medical Practitioner. The Insured is not admitted as a
day care or In-patient.

XXV. Pre-existing Disease means any condition, ailment, injury or disease

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

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

XXVII. Post-hospitalization Medical Expenses means medical expenses incurred during pre-defined number of days
immediately after the Insured Person is discharged from the Hospital, provided that:
a. Such Medical Expenses are for the same condition for which the Insured Person’s Hospitalization was required,
and
b. The Inpatient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.

XXVIII. Portability means the right accorded to an individual health insurance policyholders (including all members under
family cover), to transfer the credit gained for pre-existing conditions and time bound exclusions, from one insurer
to another insurer.

XXIX. 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.

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

 XXX. Reasonable and Customary Charges means the charges for services or supplies, which are the standard charges
for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar
services, taking into account the nature of the Illness / Injury involved.

XXXI. Reimbursement means settlement of claims paid directly by Us to the Policyholder/Insured Person.

XXXII. 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.

XXXIII. Room Rent means the amount charged by a Hospital towards Room and Boarding expenses and shall include the
associated medical expenses.

XXXIV. Surgery or Surgical Procedure means manual and / or operative procedure (s) required for treatment of an Illness
or Injury, correction of deformities and defects, diagnosis and cure of diseases, relief from suffering or prolongation
of life, performed in a Hospital or Day Care Centre by a Medical Practitioner.

2.2. Specific Definitions

I. Age means age as on last birthday.

II. Base Sum Insured means the amount stated in the Policy Schedule.

III. 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.

IV. Insured Event means any event specifically mentioned as covered under this Policy.

V. Insured Person means person(s) named as insured persons in the Policy Schedule.

VI. Policy means these terms and conditions, the Policy Schedule (as amended from time to time), Your statements in
the Proposal and any endorsements attached by Us to the Policy from time to time.

VII. Policy Period is the period between the inception date and the expiry date of the Policy as specified in the Policy
Schedule or the date of cancellation of this Policy, whichever is earlier.

VIII. Policy Year means the period of one year commencing on the date of commencement specified in the Policy
Schedule or any anniversary thereof.

IX. Service Provider means any person, organization, institution that has been empanelled with Us to provide services
specified under the benefits to the Insured Person.

X. Single Private Room means an air conditioned room in a Hospital where a single patient is accommodated and
which has an attached toilet (lavatory and bath). Such room type shall be the most basic and the most economical
of all accommodations available as a single occupancy room in that Hospital.

XI. Sum Insured:

In case of Individual Policy, Sum Insured means the total of the Base Sum Insured and No claim Bonus (if applicable)
for that Insured Person. Our maximum, total and cumulative liability for all claims during the Policy Year in respect
of the Insured Person will be Sum Insured and amount provided under ReAssure benefit.

In case of Family Floater Policy, Sum Insured means the total of the Base Sum Insured and No claim Bonus (if
applicable). Our maximum, total and cumulative liability for all claims during the Policy Year in respect of all Insured
Persons taken together will be Sum Insured and amount provided under ReAssure benefit.

The sequence of utilization of Sum Insured will be as below:

i. Base Sum Insured followed by;
ii. Accumulated No Claim Bonus (if applicable) followed by;
iii. ReAssure benefit (if applicable)

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

 If the Policy Period is 2 years or 3 years, then the Sum Insured shall be applied separately for each Policy Year in the
Policy Period. All claims paid (except for Health Check-up) will reduce the Sum Insured for the Policy Year in which
the insured event has occurred. Any claim admitted under Pre & Post Hospitalization shall reduce the Sum Insured
for the Policy Year in which Hospital admission claim has incurred.

XII. Waiting Period means a time-bound exclusion period related to condition(s) specified in the Policy Schedule or the
Policy which shall be served before a claim related to such condition(s) becomes admissible.

XIII. We/Our/Us means Niva Bupa Health Insurance Company Limited.

XIV. You/Your/Policyholder means the person named in the Policy Schedule who has concluded this Policy with Us.

3. Benefits covered under the policy

DESCRIPTION (What we pay and what we DON’T) IMPORTANT TERMS

(what it means)
3.1. Expenses to reach hospital (Ambulance) Def 1: Emergency care
means management for an
By road, maximum Rs. 2,000 & by air maximum Rs.2,50,000 per hospitalization. Applies Illness or Injury which results
ONLY when Hospital admission claim is paid. in symptoms which occur
suddenly and unexpectedly,
IMPORTANT: You MUST use a registered ambulance / air ambulance provider. Air ambulance and requires immediate care
is available only for Emergency care. by a Medical Practitioner
to prevent death or serious
3.2. Expenses during hospitalization (Hospital admission) long term impairment of the
Insured Person’s health.
a. We will pay the expenses incurred by you on treatment (Naturally this excludes expenses
not linked to treatment like food, beverage, toiletries and cosmetics) if you were:

i. Admitted for 2 hours or more Def 2: AYUSH Treatment

NOTE: minimum 24 hours admission in AYUSH Hospital MUST for AYUSH treatment refers to the medical and /
coverage or hospitalization treatments
given under Ayurveda, Yoga
ii. You had Angiography, Dialysis (Hemo / Peritoneal), Radiotherapy or Chemotherapy and Naturopathy, Unani,
for cancer Sidha and Homeopathy
systems.
NOTE: Admission in a hospital happens in what is called wards or rooms of various
categories, ICUs, CCUs, NICU etc or in Day care.

IMPORTANT:

i. We will NOT pay, even if you were admitted, if there was no treatment and only
investigations were done. Example: Admission only for investigations like MRI, CT
Scan, Endoscopy, Colonoscopy etc.

ii. We will NOT pay for Automation machine for peritoneal dialysis

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

b. We pay for Modern treatments as specified below: Def 3: Day Care Treatment
1. Uterine 2. Immunotherapy- 3. Vaporisation of 4. Stem cell therapy: refers to medical treatment,
Artery Monoclonal the prostrate Hematopoietic and/or Surgical Procedure
Embolization Antibody to be (Green laser stem cells for bone which is:
and HIFU given as injection treatment or marrow transplant a. undertaken under
(High holmium laser for haematological General or Local
intensity treatment) conditions Anaesthesia in a
focused Hospital/Day Care
ultrasound) Centre in less than 24 hrs
because of technological
5. Balloon 6. Oral 7. Robotic 8. Stereotactic radio advancement, and
Sinuplasty Chemotherapy surgeries Surgeries b. which would have
9. Deep Brain 10. Intra vitreal 11. Bronchical 12. IONM - (Intra otherwise required a
stimulation injections Thermoplasty Operative Neuro Hospitalization of more
Monitoring) than 24 hours.
Treatment normally taken on
NOTE: A limit of maximum Rs. 1,00,000 per claim will apply to all robotic surgeries, except
an out patient basis is not
for total radical prostatectomy, cardiac surgeries, partial nephrectomy and surgeries for
included in the scope of this
malignancies.
definition.
3.3. Expenses before and after hospitalization (Pre & Post hospitalization)

We will pay expenses incurred on consultations, medicines, diagnostic tests 60 days before
date of admission and 180 days after date of discharge IF these are related to the condition
for which hospital admission or domiciliary hospitalization claim is paid.

3.4. Treatment at home (Domiciliary Hospitalization)

We will pay the expenses incurred by you on treatment at home only if:
a. the treating doctor has given in writing that there was no room available for treatment
at the hospital, or that the insured was not in a position to reach the hospital, and
b. minimum 3 consecutive days of treatment was received by the Insured

3.5. Organ donor

If you ever undergo an organ transplant, we will pay the hospitalization expenses of the
donor for harvesting the organ ONLY when your Hospital admission claim is paid.

3.6. No Claim Bonus (NCB)

For every claim free year, we will add 10% of expiring policy base sum insured as NCB,
maximum up to 100%.

NOTE:
Def 4: Migration means the
IMPORTANT: Below points apply for changes made within the same product. Change in
right accorded to health
product is called Migration in which you CAN NOT carry NCB.
insurance policyholders
a. NCB applies the same way as the policy sum insured type. If policy is floater, NCB is (including all members under
floater & if policy is individual sum insured, NCB too is individual basis. family cover and members
b. Individual NCB can be carried to any policy with individual sum insured as long as sum of group health insurance
insured is NOT reduced. policy), to transfer the credit
c. If two or more policies merge into a floater policy, the lowest of the NCB among all gained for pre-existing
policies will be carried to the new merged floater policy. conditions and time bound
d. In case You change individual sum insured policy to Floater, the lowest of the NCB of exclusions, with the same
members in previous policy will be carried to floater policy. insurer.
e. If Floater policy is converted to individual sum insured policy, NCB of previous policy
will be given to each of previously insured member on individual basis as long as sum
insured is NOT reduced.

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

 f. If any one reduces base sum insured, same percentage of NCB will be given as was the
previous NCB of the previous base sum insured.

Example:
Base Sum Accumulated Revised Base Revised
Insured NCB Sum Insured Accumulated
Base Sum NCB
Insured is
10 Lac 5 Lac reduced to 5 Lac 5 Lac 2.5 Lac
(after 5 claim
free years)

3.7. ReAssure

The first paid claim triggers ReAssure, a benefit with unlimited sum insured.
NOTE: Maximum amount ReAssure benefit pays for any single claim is up to base sum
insured.

Illustration:
Base Sum 1st paid Balance 2nd Claim Balance 3rd Claim
Insured Claim Base payable amount Base Sum Payable amount
Sum claim paid Insured claim paid
Insured
10 Lac 7 Lac ReAssure 3 Lac 12 Lac 12 Lac Nil 11 Lac 10 Lac
benefit is (3 Lac from
triggered from ReAssure
base SI
and 9
Lac from
ReAssure

3.8. Health Checkup

Available once every Policy Year, from day 1 of the policy, up to the amount as specified in
Your Policy Schedule. You can choose any test(s) from the list specified below. Please note
that the tests must be taken within the duration of 7 days.

List of tests covered:

Complete blood count Complete Physical Examination by Serum Electrolytes
Physician
Urine Routine Post prandial/lunch blood sugar HbA1C
(PPBS / PLBS)
Erythrocyte Uric Acid Thyroid profile (TSH)
Sedimentation Rate
(ESR)
Fasting Blood Glucose Lipid Profile Liver Function Test
(LFT)
Electrocardiogram Kidney function test Treadmill test (TMT)
S Cholesterol Serum Vitamin D Ultrasound test

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

4. Claim Cost Sharing

DESCRIPTION (What we pay and what we DON’T) IMPORTANT TERMS

(what it means)
4.1. Co-payment Def 5: Co-payment means a cost-
Co-payment once chosen CAN NOT be changed. It’s the percentage of admissible sharing requirement under a health
claim amount You would have to bear, Rest we will pay. insurance policy that provides that
Note: the Policyholder/insured will bear a
specified percentage of the admissible
a. Co-payment will NOT apply to Ambulance and Health Check-up benefits.
claim amount. A Co-payment does not
b. You will have to bear additional 10% co-payment IF treatment is taken in a reduce the Sum Insured.
higher room category than the eligible room category as specified in Your
Policy Schedule
4.2. Annual Aggregate Deductible (optional benefit) Def 6: Deductible means a cost-sharing
requirement under a health insurance
This is an aggregate amount in a year that is incurred by you on Hospital admission,
which we will NOT pay. Once the total expense exceeds this amount, balance we
policy that provides that the Insurer
will pay. This too, once chosen CAN NOT be changed. will not be liable for a specified rupee
amount in case of indemnity policies and
Note: for a specified number of days/hours in
case of hospital cash policies which will
a. Deductible amount borne by you should also be payable as per policy terms
apply before any benefits are payable
and conditions.
by the insurer. A deductible does not
b. Deductible will NOT apply to Health Check-up benefit. reduce the Sum Insured.
c. If Deductible is opted, then co-payment will NOT apply, except as specified in
section 4.1 (b) for admission to higher than eligible category of room

5. Exclusions

5.1. Standard Exclusions

I. 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.

II. Specified disease/procedure waiting period (Code- Excl02)

a. Expenses related to the treatment of the listed conditions, surgeries/treatments shall be excluded until the
expiry of 24 months of continuous coverage after the date of inception of the first Policy with us. This exclusion
shall not be applicable for claims arising due to an Accident.
b. In case of enhancement of Sum Insured the exclusion shall apply afresh to the extent of Sum Insured increase.
c. If any of the specified disease/procedure falls under the waiting period specified for pre-Existing diseases, then
the longer of the two waiting periods shall apply.
d. The waiting period for listed conditions shall apply even if contracted after the Policy or declared and accepted
without a specific exclusion.
e. If the Insured 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.

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

 f. List of specific diseases/procedures:
i. Pancreatitis and stones in biliary and urinary system
ii. Cataract, glaucoma and retinal detachment
iii. Hyperplasia of prostate, hydrocele and spermatocele
iv. Prolapse uterus and cervix, endometriosis, Fibroids, PCOD, hysterectomy (unless necessitated by
Malignancy)
v. Hemorrhoids, fissure or fistula or abscess of anal and rectal region
vi. Hernia of all sites,
vii. Osteoarthritis, joint replacement, osteoporosis, systemic connective tissue disorders, inflammatory
polyarthropathies, Rheumatoid Arthritis, gout, intervertebral disc disorders, arthroscopic surgeries for
ligament repair
viii. Varicose veins of lower extremities
ix. All internal or external benign or neoplasms/ tumours, cyst, sinus, polyp, nodules, mass or lump
x. Ulcer, erosion and varices of gastro intestinal tract
xi. Surgical treatment for diseases of middle ear and mastoid (including otitis media, cholesteatoma,
perforation of tympanic membrane), Tonsils and adenoids, nasal septum and nasal sinuses

III. 30-day 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.

IV. Investigation & Evaluation (Code-Excl04)

a. Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.
b. Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are
excluded.

V. 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.

VI. 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);
i. greater than or equal to 40 or
ii. 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:
1. Obesity-related cardiomyopathy
2. Coronary heart disease
3. Severe Sleep Apnea
4. Uncontrolled Type2 Diabetes

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

 VII. 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.
VIII. 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.

IX. 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.

X. 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.

XI. Excluded Providers (Code-Excl11)

Expenses incurred towards treatment in any Hospital or by any Medical Practitioner or any other provider specifically
excluded by Us and disclosed in Our 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.
The complete list of excluded providers can be referred to on our website.

XII. Treatment for, alcoholism, drug or substance abuse or any addictive condition and consequences thereof. (Code-
Excl12)

XIII. Treatments received in heath hydros, nature cure clinics, spas or similar establishments or private beds registered
as a nursing home attached to such establishments or where admission is arranged wholly or partly for domestic
reasons. (Code-Excl13)

XIV. 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)

XV. Refractive Error (Code-Excl15)

Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres.

XVI. 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.

XVII. 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

XVIII. 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.

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

5.2. Specific Exclusions

I. Personal Waiting Periods:

Conditions specified for an Insured Person under Personal Waiting Period in the Policy Schedule will be subject to
a Waiting Period of 24 months from the inception of the First Policy with Us.

II. Charges related to a Hospital stay not expressly mentioned as being covered. This will include RMO charges,
surcharges and service charges levied by the Hospital.

III. Circumcision:
Circumcision unless necessary for the treatment of a disease or necessitated by an Accident.

IV. Conflict & Disaster:

Treatment for any Injury or Illness resulting directly or indirectly from nuclear, radiological emissions, war or war
like situations (whether war is declared or not), rebellion (act of armed resistance to an established government or
leader), acts of terrorism.

V. External Congenital Anomaly:

Screening, counseling or treatment related to external Congenital Anomaly.

VI. Dental/oral treatment:

Treatment, procedures and preventive, diagnostic, restorative, cosmetic services related to disease, disorder and
conditions related to natural teeth and gingiva except if required by an Insured Person while Hospitalized due to an
Accident.

VII. Hormone Replacement Therapy:

Treatment for any condition / illness which requires hormone replacement therapy.

VIII. Multifocal Lens and ambulatory devices such as walkers, crutches, splints, stockings of any kind and also any medical
equipment which is subsequently used at home.

IX. Sexually transmitted Infections & diseases (other than HIV / AIDS):
Screening, prevention and treatment for sexually related infection or disease (other than HIV / AIDS).

X. Sleep disorders:
Treatment for any conditions related to disturbance of normal sleep patterns or behaviors.

XI. Any treatment or medical services received outside the geographical limits of India.

XII. Any expenses incurred on OPD treatment.

XIII. Unrecognized Physician or Hospital:

a. Treatment or Medical Advice provided by a Medical Practitioner not recognized by the Medical Council of India
or by Central Council of Indian Medicine or by Central council of Homeopathy.
b. Treatment provided by anyone with the same residence as an Insured Person or who is a member of the Insured
Person’s immediate family or relatives.
c. Treatment provided by Hospital or health facility that is not recognized by the relevant authorities in India.

XIV. Treatment related to intentional self inflicted Injury or attempted suicide by any means.

XV. Costs which are not Reasonable and Customary and treatments which are not Medically Necessary.

XVI. Artificial life maintenance for the Insured Person who has been declared brain dead or in vegetative state as
demonstrated by:
a. Deep coma and unresponsiveness to all forms of stimulation; or
b. Absent pupillary light reaction; or
c. Absent oculovestibular and corneal reflexes; or
d. Complete apnea.

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

6. General Terms and Clauses

6.1. Standard Terms and Clauses What it means?

I. Free Look Period Free look is a 15 / 30

The Free Look Period shall be applicable on new individual health insurance policies and days period during which
not on renewals or at the time of porting/migrating the policy.
you can return back your
The insured person shall be allowed free look period of fifteen days (thirty days for policies
with a term of 3 years, if sold through distance marketing) from date of receipt of the policy policy, if you don’t like
document to review the terms and conditions of the policy, and to return the same if not what you have purchased.
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
II. Cancellation
i. The policyholder may cancel this policy by giving 15 days’ written notice and in such
You can cancel your policy
an event, the Company shall refund premium for the unexpired policy period as
whenever you wish.
detailed below.
NOTE: We will NOT refund
Notwithstanding anything contained herein or otherwise, no refunds of premium any premium if we have
shall be made in respect of Cancellation where, any claim has been admitted or has paid a claim.
been lodged or any benefit has been availed by the insured person under the policy.

1 year 2 years 3 years We will refund part of

the premium depending
Policy Refund Policy in-force Refund Policy in-force Refund on how many days your
in-force Premium up to Premium up to Premium policy has been running
up to (%) (%) (%) for, if there is no claim.
Up to 30 75% Up to 30 days 87.5% Up to 30 days 90%
days
31 to 90 50% 31 to 90 days 75% 31 to 90 days 87.5%
days If we ever cancel your
policy, it will be for Fraud
91 to 180 25% 91 to 180 days 62.5% 91 to 180 days 75% or Non disclosure only.
days Insurance contract is a
exceeding 0% 181 to 365 days 50% 181 to 365 days 60% legal contract too and it’s
180 days 366 to 455 days 25% 366 to 455 days 50% based on trust.

456 to 545 days 12% 456 t‑o 545 days 25%

Fraud is an action by
Exceeding 545 0% 545 to 720 days you or anyone acting on
12%
days your behalf where you
Exceeding 720 0%
receive benefits, financial
days
or otherwise, for which
ii. The Company may cancel the policy at any time on grounds of misrepresentation you are either not eligible
non-disclosure of material facts, fraud by the insured person by giving 15 days’ at all or not to the extent
written notice. There would be no refund of premium on cancellation on grounds of under the policy.
misrepresentation, non-disclosure of material facts or fraud.
In case of death of an Insured, pro-rate refund of the premium for the deceased insured will
be refunded, provided there is no history of claim.

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

III. Renewal of Policy Pay your renewal
premium before end of
The policy shall ordinarily be renewable except on grounds of fraud, misrepresentation by policy period to maintain
the insured person. continuity of benefits. A
i. The Company shall endeavor to give notice for renewal. However, the Company is not grace period of 30 days
under obligation to give any notice for renewal. is also available to pay
ii. Renewal shall not be denied on the ground that the insured person had made a claim the premium after policy
or claims in the preceding policy years. expiry.
NOTE: You are NOT
iii. Request for renewal along with requisite premium shall be received by the Company
insured during the grace
before the end of the policy period.
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.

IV. Possibility of Revision of Terms of the Policy Including the Premium Rates

The Company, with prior approval of IRDAI, 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.

V. 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.

VI. Fraud
We will cancel your
lf any claim made by the insured person, is in any respect fraudulent, or if any false policy, will not pay any
statement, or declaration is made or used in support thereof, or if any fraudulent means claim, will not refund any
or devices are used by the insured person or anyone acting on his/her behalf to obtain premium paid and have
any benefit under this policy, all benefits under this policy and the premium paid shall be right to take all possible
forfeited. legal action against you
including for recovery of
Any amount already paid against claims made under this policy but which are found benefits paid earlier, if
fraudulent later shall be repaid by all recipient(s)/policyholder(s), who has made that • You withheld any
particular claim, who shall be jointly and severally liable for such repayment to the insurer. information from us,
whole or part that
would have invited
any decision other
than a ‘standard
acceptance’ of your
application for
insurance.

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

 For the purpose of this clause, the expression “fraud” means any of the following acts Note: Non standard
committed by the insured person or by his agent or the hospital/doctor/any other party decisions are:
acting on behalf of the insured person, with intent to deceive the insurer or to induce the o Loading – We
insurer to issue an insurance policy: ask for additional
a) the suggestion, as a fact of that which is not true and which the insured person premium
does not believe to be true; o Exclusions – We
apply a additional
b) the active concealment of a fact by the insured person having knowledge or belief waiting period for
of the fact; health conditions
c) any other act fitted to deceive; and or treatments
d) any such act or omission as the law specially declares to be fraudulent o Rejection – We
hate to do this.
The Company shall not repudiate the claim and / or forfeit the policy benefits on the But sometimes are
ground of Fraud, if the insured person / beneficiary can prove that the misstatement was compelled to say
true to the best of his knowledge and there was no deliberate intention to suppress the no to a customer
fact or that such misstatement of or suppression of material fact are within the knowledge IMPORTANT: We
of the insurer. understand you may not
know how important is
the information on your
health and it’s impact
on your policy. Hence
it’s very important that
you disclose all health
information and we would
decide how important
(we call it ‘material’) it is.
• Cause fraud of any
kind
VII. Withdrawal of Policy
If we withdraw any
i. ln the likelihood of this product being withdrawn in future, the Company will intimate product, we will
the insured person about the same 90 days prior to expiry of the policy. inform you at least
90 days before.
ii. lnsured Person will have the option to migrate to similar health insurance product You will also have
available with the Company at the time of renewal with all the accrued continuity the option to shift
benefits such as cumulative bonus, waiver of waiting period as per IRDAI guidelines, your policy with all
provided the policy has been maintained without a break. accrued benefits to
another similar health
insurance product
available with us.

VIII. Redressal of Grievance: You can contact us

ln case of any grievance the Insured Person may contact the company through: anytime for any service
Website: www.nivabupa.com related to your policy,
claim or complaint.
Toll free: 1860-500-8888
E-mail: Email us through our service platform https://rules.nivabupa.com/
customer-service/ (Senior citizens may write to us at:
[email protected])
Fax: 011-4174-3397
Courier: Customer Services Department
D-5, 2nd Floor, Logix Infotech Park
opp. Metro Station, Sector 59, Noida, Uttar Pradesh, 201301

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

 lnsured person may also approach the grievance cell at any of the company's
branches with the details of grievance. If lnsured person is not satisfied with the
redressal of grievance through one of the above methods, Insured Person may
contact the grievance officer at:
Head – Customer Services
D-5, 2nd Floor, Logix Infotech Park
opp. Metro Station, Sector 59, Noida,Uttar Pradesh, 201301
Contact No: 1860-500-8888
Fax No: 011-4174-3397
Email ID: Email our Grievance officer through our Grievance Redressal platform
https://transactions.nivabupa.com/pages/grievance-redressal.aspx
For updated details of grievance officer, kindly refer the link https://
www.nivabupa.com/customer-care/health-services/grievance-redressal.aspx
If the Insured Person is not satisfied with the above, they can escalate to our
Grievance Redressal officer through our platform https://
transactions.nivabupa.com/pages/grievance-redressal.aspx.

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 (Refer below Annexure).
Grievance may also be lodged at IRDAI lntegrated Grievance Management
System –www.bimabharosa.irdai.gov.in

IX. Claim settlement (Provision for Penal interest)

We will provide our
I. The Company shall settle or reject a claim, as the case may be, within 30 days from the
decision on claim within
date of receipt of last necessary document.
30 days (45 days for
II. ln the case of delay in the payment of a claim, the Company shall be liable to pay investigated cases)
interest to the policyholder from the date of receipt of last necessary document to the from submission of
date of payment of claim at a rate 2% above the bank rate. all necessary claim
documents. For any delay
III. However, where the circumstances of a claim warrant an investigation in the opinion
in payment of claim, we
of the Company, it shall initiate and complete such investigation at the earliest, in any
will pay interest on the
case not later than 30 days from the date of receipt of last necessary document- ln
claim amount at a rate 2%
such cases, the Company shall settle or reject the claim within 45 days from the date
above bank rate.
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.
(Explanation: “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)

X. Moratorium Period

After completion of eight continuous years under the Policy no look back to be applied. This After 8 years, no health
period of eight years is called as moratorium period. The moratorium would be applicable insurance claim shall
for the sums insured of the first Policy and subsequently completion of 8 continuous years be contestable except
would be applicable from date of enhancement of sums insured only on the enhanced for proven fraud and
limits. After the expiry of Moratorium Period no health insurance claim shall be contestable permanent exclusions.
except for proven fraud and permanent exclusions specified in the Policy contract. The
policies would however be subject to all limits, sub limits, co-payments, deductibles as per
the Policy contract.

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

 XI. Multiple Policies

I. ln case of multiple policies taken by an insured person during a period from one or In case you have multiple
more insurers to indemnify treatment costs, the insured person shall have the right policies, you can choose
to require a settlement of his/her claim in terms of any of his/her policies. ln all such the policy from which you
cases the insurer chosen by the insured person shall be obliged to settle the claim as want to claim first.
long as the claim is within the limits of and according to the terms of the chosen policy.
II. If claim amount exceeds
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 the Sum Insured of first
sum insured is not exhausted. Then the insurer shall independently settle the claim policy you claim from;
subject to the terms and conditions of this policy. then you can claim the
balance amount from the
III. lf the amount to be claimed exceeds the sum insured under a single policy, the insured second policy.
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.

XII. Migration

The Insured Person will have the option to migrate the Policy to other health insurance You can shift your policy
products / plans offered by the Company policy by applying for migration of the policy at to any other health
least 30 days before the policy renewal date as per IRDAI guidelines on Migration. If such insurance product / plan
person is presently covered and has been continuously covered without any lapses under offered by us as per
any health insurance product / plan offered by the Company, the insured person will get migration guidelines.
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/whatsNew_Layout.aspx?page=PageNo3987&flag=1

XIII. Portability

The Insured Person will have the option to port the Policy to other insurers by applying You can also shift your
to such insurer to port the entire Policy along with all the members of the family, if any, policy to any other
at least 45 days before, but not earlier than 60 days from the policy renewal date as per insurer as per portability
IRDAI guidelines related to portability. If such person is presently covered and has been guidelines.
continuously covered without any lapses under any health insurance policy with an Indian
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/whatsNew_Layout.aspx?page=PageNo3987&flag=1

XIV. Disclosure of Information

The Policy shall be void and all premium paid thereon shall be forfeited to the Company in The policy shall be
the event of misrepresentation, mis-description or non-disclosure of any material fact by considered void in case
the policyholder. of misrepresentation,
mis-description or non-
(Explanation: “Material facts” for the purpose of this policy shall mean all relevant disclosure of any material
information sought by the company in the proposal form and other connected documents fact.
to enable it to take informed decision in the context of underwriting the risk)

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

 XV. 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.

XVI. 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.

6.2. Specific terms and clauses

I. Automatic Cancellation:
The Policy shall automatically terminate in the event of death of the all Insured Person(s).
A refund in accordance with the table in Section 6.1 (II) shall be payable provided that no
claim has been admitted or lodged or not benefit has been availed by the insured person
under the policy.

II. Additional premium (Risk Loading)

i. We may ask for additional premium after due risk evaluation (it’s what referred to as
Underwriting) based on all information provided by you. We will issue policy to you
only after you pay us the additional premium and provide us consent.
ii. We will never ask for more than 100% for any particular health condition and never
more than 150% for any individual.
iii. Once applied, Risk loading continues even for all renewals

III. Other Renewal Conditions:

a. Renewal Premium:
Renewal premium will alter based on Age. For Family Floater policies, the age of
eldest insured person will be considered for calculating the premium.
b. Addition of Insured Persons on Renewal:
If a new member is added in the Policy, either by way of endorsement or at the time
of Renewal, the Pre-existing Disease clause, exclusions, loading (if any) and Waiting
Periods will be applicable afresh for that member.
c. Changes to Sum Insured on Renewal:
You may opt for enhancement of Sum Insured at the time of Renewal, subject to
underwriting. All Waiting Periods as defined in the Policy shall apply afresh for this
enhanced limit from the effective date of such enhancement.

IV. Policy Disputes

Any dispute concerning the interpretation of the terms, conditions, limitations and/or
exclusions contained herein shall be governed by Indian law and shall be subject to the
jurisdiction of the Indian Courts.

V. Territorial Jurisdiction

All claims shall be payable in India in Indian Rupees only.

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

 VI. Notices

Any notice, direction or instruction given under this Policy shall be in writing and delivered
by hand, post, or facsimile to:
i. You/the Insured Person at the address specified in the Policy Schedule or at the
changed address of which We must receive written notice.
ii. Us at the following address:
Niva Bupa Health Insurance Company Limited
D-5, 2nd Floor, Logix Infotech Park
opp. Metro Station, Sector 59, Noida, Uttar Pradesh, 201301
Fax No.: +91 11 41743397
iii. No insurance agents, brokers or other person/entity is authorized to receive any notice
on Our behalf.
iv. In addition, We may send You/the Insured Person other information through electronic
and telecommunications means with respect to Your Policy from time to time.

VII. Alteration to the Policy

This Policy constitutes the complete contract of insurance. Any change in the Policy will
only be evidenced by a written endorsement signed and stamped by Us. No one except Us
can within the permission of the IRDAI change or vary this Policy.

VIII. Zonal pricing

For the purpose of calculating premium, the country has been divided into the following
2 zones:
i. Zone 1: Delhi NCR, Mumbai (including Navi Mumbai and Thane), Kolkata and Gujarat
State
ii. Zone 2: Rest of India

Your premium depends upon your residential city. Please inform us immediately in case of
change in your city.

IX. Assignment

The Policy can be assigned subject to applicable laws.

X. Claims
a. Cashless claim facility is available at our network hospitals ONLY. As list of network
hospitals is dynamic, for the latest list, refer to our website www.nivabupa.com.
b. Documents required with claim form:
Hospital / Medical records:
• Original Discharge summary with first and subsequent consultation papers.
• Original Final Hospital bill with detailed break-up and payment receipt (including
pharmacy bills).
• Laboratory investigation reports with supporting prescriptions.
• MLC/First Information Report (FIR) (in accident cases).
Policyholder documents (Nominee in case of death of Policyholder):
• KYC documents
• Cancelled cheque

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

 IMPORTANT:
• All documents MUST be submitted within 30 days from discharge.
• For any delay in submission, You MUST provide the reasons in writing. We will
condone such delay on merits (i.e. reasons beyond your control).
• You MUST submit all claim related documents for expenses within the Deductible
amount (if applicable).
• We reserve the right to check and investigate the hospital / medical records from
any doctor, Hospital, clinic, individual or institution.
c. The expenses that are not covered or subsumed into room charges / procedure
charges / costs of treatment are placed as Annexure I.
d. For any hospitalization, we will pay for items included in the bill by the Hospital during
the duration of hospitalization. Items not included in the bill will not be paid.

Disclaimer: Niva Bupa Health Insurance Company Limited (formerly known as Max Bupa Health Insurance Company Limited) (IRDAI Registration No. 145). ‘Bupa’ and
‘HEARTBEAT’ logo are registered trademarks of their respective owners and are being used by Niva Bupa Health Insurance Company Limited under license. Registered
Office Address: C-98, First Floor, Lajpat Nagar, Part 1, New Delhi-110024, Customer Helpline No.: 1860-500-8888. Fax: +91 11 41743397. Website: www.nivabupa.com.
CIN: U66000DL2008PLC182918. For more details on risk factors, terms and conditions, please read sales brochure carefully before concluding the sale.

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

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

Sl. No. Item Sl. No. Item Sl. No. Item

1 Baby Food 24 Attendant Charges 47 Lumbo Sacral Belt
Extra Diet of Patient (Other than
Nimbus Bed or Water or Air Bed
2 Baby Utilities Charges 25 that which forms part of bed 48
Charges
charge)
3 Beauty Services 26 Birth Certificate 49 Ambulance Collar
4 Belts/ Braces 27 Certificate Charges 50 Ambulance Equipment
5 Buds 28 Courier Charges 51 Abdominal Binder
Private Nurses Charges- Special
6 Cold Pack/Hot Pack 29 Conveyance Charges 52
Nursing Charges
7 Carry Bags 30 Medical Certificate 53 Sugar Free Tablets
Creams Powders Lotions
(Toiletries are not Payable,
8 Email / Internet Charges 31 Medical Records 54
only Prescribed Medical
Pharmaceuticals Payable)
Food Charges (Other than
9 Patient's Diet Provided by 32 Photocopies Charges 55 ECG Electrodes
Hospital)
10 Leggings 33 Mortuary Charges 56 Gloves
11 Laundry Charges 34 Walking Aids Charges 57 Nebulisation Kit
Any Kit with no Details
Oxygen Cylinder (For Usage
12 Mineral Water 35 58 Mentioned [Delivery Kit, Orthokit,
Outside The Hospital)
Recovery Kit, etc]
13 Sanitary Pad 36 Spacer 59 Kidney Tray
14 Telephone Charges 37 Spirometre 60 Mask
15 Guest Services 38 Nebulizer Kit 61 Ounce Glass
16 Crepe Bandage 39 Steam Inhaler 62 Oxygen Mask
17 Diaper Of Any Type 40 Armsling 63 Pelvic Traction Belt
18 Eyelet Collar 41 Thermometer 64 Pan Can
19 Slings 42 Cervical Collar 65 Trolly Cover
Blood Grouping And Cross
20 43 Splint 66 Urometer, Urine Jug
Matching of Donors Samples
Service Charges Where Nursing
21 44 Diabetic Foot Wear 67 Ambulance
Charge also Charged
Knee Braces (Long/ Short/
22 Television Charges 45 68 Vasofix Safety
Hinged)
Knee Immobilizer/Shoulder
23 Surcharges 46
Immobilizer

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

 List II – Items that are to be subsumed into Room Charges

Sl. No. Item Sl. No. Item Sl. No. Item

Baby Charges (Unless Specified/
1 14 Bed Pan 27 Admission Kit
Indicated)
2 Hand Wash 15 Face Mask 28 Diabetic Chart Charges
Documentation Charges /
3 Shoe Cover 16 Flexi Mask 29
Administrative Expenses
4 Caps 17 Hand Holder 30 Discharge Procedure Charges
5 Cradle Charges 18 Sputum Cup 31 Daily Chart Charges
Entrance Pass / Visitors Pass
6 Comb 19 Disinfectant Lotions 32
Charges
Eau-De-Cologne / Room Expenses Related to Prescription
7 20 Luxury Tax 33
Freshners on Discharge
8 Foot Cover 21 HVAC 34 File Opening Charges
Incidental Expenses / Misc.
9 Gown 22 House Keeping Charges 35
Charges (Not Explained)
Patient Identification Band /
10 Slippers 23 Air Conditioner Charges 36
Name Tag
11 Tissue Paper 24 IM IV Injection Charges 37 Pulseoxymeter Charges
12 Tooth Paste 25 Clean Sheet
13 Tooth Brush 26 Blanket/Warmer Blanket

List III – Items that are to be subsumed into Procedure Charges

Sl. No. Item Sl. No. Item Sl. No. Item
Ward and Theatre Booking
1 Hair Removal Cream 9 17 Boyles Apparatus Charges
Charges
Disposables Razors Charges Arthroscopy And Endoscopy
2 10 18 Cotton
(For Site Preparations) Instruments
3 Eye Pad 11 Microscope Cover 19 Cotton Bandage
Surgical Blades,
4 Eye Sheild 12 20 Surgical Tape
Harmonicscalpel,Shaver
5 Camera Cover 13 Surgical Drill 21 Apron
6 DVD, CD Charges 14 Eye Kit 22 Torniquet
7 Gause Soft 15 Eye Drape 23 Orthobundle, Gynaec Bundle
8 Gauze 16 X-Ray Film

List IV – Items that are to be subsumed into costs of treatment

Sl. No. Item Sl. No. Item Sl. No. Item

1 Admission/Registration Charges 7 Infusion Pump – Cost 13 Mouth Paint
Hospitalisation for Evaluation/ Hydrogen Peroxide\Spirit\
2 8 14 Vaccination Charges
Diagnostic Purpose Disinfectants etc
Nutrition Planning Charges -
3 Urine Container 9 15 Alcohol Swabes
Dietician Charges - Diet Charges
Blood Reservation Charges and
4 10 HIV Kit 16 Scrub Solution/Sterillium
Ante Natal Booking Charges
5 Bipap Machine 11 Antiseptic Mouthwash 17 Glucometer & Strips
6 CPAP/ CAPD Equipments 12 Lozenges 18 Urine Bag

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

 ANNEXURE II
List of Insurance Ombudsmen

Office Details Jurisdiction

AHMEDABAD - Shri Kuldip Singh
Office of the Insurance Ombudsman,
Jeevan Prakash Building, 6th floor,
Tilak Marg, Relief Road, Gujarat, Dadra & Nagar Haveli, Daman and Diu
AHMEDABAD – 380 001.
Tel.: 079 - 25501201/02/05/06
Email: [email protected]
BENGALURU - Mr Vipin Anand
Office of the Insurance Ombudsman,
Jeevan Soudha Building,PID No. 57-27-N-19
Ground Floor, 19/19, 24th Main Road, Karnataka
JP Nagar, Ist Phase, Bengaluru – 560 078.
Tel.: 080 - 26652048 / 26652049
Email: [email protected]
BHOPAL - Shri R. M. Singh
Insurance Ombudsman
Office of the Insurance Ombudsman,
Janak Vihar Complex, 2nd Floor,
Madhya Pradesh, Chhattisgarh
6, Malviya Nagar, Opp. Airtel Office,
Near New Market, Bhopal – 462 003.
Tel.: 0755 - 2769201 / 2769202
Email: [email protected]
BHUBANESWAR - Shri Suresh Chandra Panda
Office of the Insurance Ombudsman,
62, Forest park,
Odisha
Bhubaneswar – 751 009.
Tel.: 0674 - 2596461 /2596455
Email: [email protected]
CHANDIGARH - Mr Atul Jerath
Office of the Insurance Ombudsman,
S.C.O. No. 101, 102 & 103, 2nd Floor, Punjab, Haryana (excluding Gurugram, Faridabad, Sonepat and
Batra Building, Sector 17 – D, Bahadurgarh), Himachal Pradesh, Union Territories of Jammu &
Chandigarh – 160 017. Kashmir,Ladakh & Chandigarh
Tel.: 0172 - 2706196 / 2706468
Email: [email protected]
CHENNAI - Shri Segar Sampathkumar
Office of the Insurance Ombudsman,
Fatima Akhtar Court, 4th Floor, 453,
Tamil Nadu, PuducherryTown and Karaikal
Anna Salai, Teynampet,
(which are part of Puducherry)
CHENNAI – 600 018.
Tel.: 044 - 24333668 / 24335284
Email: [email protected]
DELHI - Shri Sudhir Krishna
Office of the Insurance Ombudsman,
2/2 A, Universal Insurance Building,
Delhi & following Districts of Haryana -
Asaf Ali Road,
Gurugram, Faridabad, Sonepat & Bahadurgarh
New Delhi – 110 002.
Tel.: 011 - 23232481/23213504
Email: [email protected]

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

GUWAHATI - Shri Somnath Ghosh
Office of the Insurance Ombudsman,
Jeevan Nivesh, 5th Floor,
Assam, Meghalaya, Manipur, Mizoram, Arunachal Pradesh,
Nr. Panbazar over bridge, S.S. Road,
Nagaland and Tripura
Guwahati – 781001(ASSAM).
Tel.: 0361 - 2632204 / 2602205
Email: [email protected]
HYDERABAD - Shri N. Sankaran
Office of the Insurance Ombudsman,
6-2-46, 1st floor, “”Moin Court””,
Andhra Pradesh, Telangana, Yanam and part of
Lane Opp. Saleem Function Palace,
Union Territory of Puducherry
A. C. Guards, Lakdi-Ka-Pool, Hyderabad - 500 004.
Tel.: 040 - 23312122
Email: [email protected]
JAIPUR - Shri Rajiv Dutt Sharma
Office of the Insurance Ombudsman,
Jeevan Nidhi – II Bldg., Gr. Floor,
Bhawani Singh Marg, Rajasthan
Jaipur - 302 005.
Tel.: 0141 - 2740363
Email: [email protected]
ERNAKULAM - Shri G. Radhakrishnan
Office of the Insurance Ombudsman,
2nd Floor, Pulinat Bldg.,
Kerala, Lakshadweep, Mahe-a part of
Opp. Cochin Shipyard, M. G. Road,
Union Territory of Puducherry
Ernakulam - 682 015.
Tel.: 0484 - 2358759 / 2359338
Email: [email protected]
KOLKATA - Shri P. K. Rath
Office of the Insurance Ombudsman,
Hindustan Bldg. Annexe, 4th Floor,
4, C.R. Avenue, West Bengal, Sikkim, Andaman & Nicobar Islands
KOLKATA - 700 072.
Tel.: 033 - 22124339 / 22124340
Email: [email protected]
LUCKNOW Districts of Uttar Pradesh : Lalitpur, Jhansi, Mahoba, Hamirpur, Banda,
Office of the Insurance Ombudsman, Chitrakoot, Allahabad, Mirzapur, Sonbhabdra, Fatehpur, Pratapgarh,
6th Floor, Jeevan Bhawan, Phase-II, Jaunpur,Varanasi, Gazipur, Jalaun, Kanpur, Lucknow, Unnao, Sitapur,
Nawal Kishore Road, Hazratganj, Lakhimpur, Bahraich, Barabanki, Raebareli, Sravasti, Gonda, Faizabad,
Lucknow - 226 001. Amethi, Kaushambi, Balrampur, Basti, Ambedkarnagar, Sultanpur,
Tel.: 0522 - 2231330 / 2231331 Maharajgang, Santkabirnagar, Azamgarh, Kushinagar, Gorkhpur,
Email: [email protected] Deoria, Mau, Ghazipur, Chandauli, Ballia, Sidharathnagar
MUMBAI - Shri Bharatkumar S. Pandya
Office of the Insurance Ombudsman,
3rd Floor, Jeevan Seva Annexe,
S. V. Road, Santacruz (W), Goa, Mumbai Metropolitan Region (excluding Navi Mumbai & Thane)
Mumbai - 400 054.
Tel.: 69038821/23/24/25/26/27/28/28/29/30/31
Email: [email protected]

Product Name: Senior First | Product UIN: MAXHLIP21575V012021

 NOIDA - Shri Chandra Shekhar Prasad
State of Uttarakhand and the following Districts of Uttar Pradesh:
Office of the Insurance Ombudsman,
Agra, Aligarh, Bagpat, Bareilly, Bijnor, Budaun, Bulandshehar, Etah,
Bhagwan Sahai Palace
Kannauj, Mainpuri, Mathura, Meerut, Moradabad, Muzaffarnagar,
4th Floor, Main Road, Naya Bans, Sector 15,
Oraiyya, Pilibhit, Etawah, Farrukhabad, Firozbad, Gautam Buddh
Distt: Gautam Buddh Nagar, U.P-201301.
nagar, Ghaziabad, Hardoi, Shahjahanpur, Hapur, Shamli, Rampur,
Tel.: 0120-2514252 / 2514253
Kashganj, Sambhal, Amroha, Hathras, Kanshiramnagar, Saharanpur
Email: [email protected]
PATNA - Shri N. K. Singh
Office of the Insurance Ombudsman,
2nd Floor, Lalit Bhawan,
Bailey Road, Bihar, Jharkhand
Patna 800 001.
Tel.: 0612-2547068
Email: [email protected]
PUNE - Shri Vinay Sah
Office of the Insurance Ombudsman,
Jeevan Darshan Bldg., 3rd Floor,
Maharashtra, Areas of Navi Mumbai and Thane (excluding Mumbai
C.T.S. No.s. 195 to 198, N.C. Kelkar Road,
Metropolitan Region)
Narayan Peth, Pune – 411 030.
Tel.: 020-41312555
Email: [email protected]

Council for Insurance Ombudsmen,

3rd Floor, Jeevan Seva Annexe,
S. V. Road, Santacruz (W),
Mumbai - 400 054.
Tel.: 022 -69038800/69038812
Email: [email protected]

Product Name: Senior First | Product UIN: MAXHLIP21575V012021