PLUS WORDING

SBI General Insurance Company Limited
CUSTOMER INFORMATION SHEET
(Description is illustrative and not exhaustive)

S. TITLE DESCRIPTION REFER TO
NO POLICY
CLAUSE
NUMBER
1 Product Arogya Plus Policy
Name
2 What am I Following are covered as basic cover up to the limit specified in the Policy IV. Scope of
covered for 1. Hospitalisation expenses Cover
2. OPD treatment and Teleconsultation
3. Pre-hospitalisation expenses
4. Post-hospitalisation expenses
5. Day care expenses
6. Ambulance expenses
7. Alternative treatment
8. Domiciliary hospitalization
9. Maternity Expenses covered under the OPD sublimit traceable to
childbirth
10. HIV/AIDS Cover upto Sum Insured
11. Mental Illness Cover upto Sum Insured (Sub limit - Rs. 50,000 whichever
is lower, applicable for few conditions)
12. Genetic Disorders upto Rs.50,000
13. Internal Congenital Anomaly upto Rs. 10% of Sum Insured
14. 12 Specific Procedures upto 50% of Sum Insured
Note: Insurer’s Liability in respect of all claims admitted during the period of
insurance shall not exceed the Sum Insured for the Insured person as
mentioned in the schedule.
3 What are Following is a partial list of the policy exclusions. Please refer to the V. Exclusions
the major policy document for the complete list of exclusions:
Exclusions
1. Admission primarily for investigation & evaluation
in the policy
2. Admission primarily for rest Cure, rehabilitation and respite care
3. Expenses related to the surgical treatment of obesity that do not fulfill
certain conditions
4. Change-of-Gender treatments
5. Expenses for cosmetic or plastic surgery
6. Expenses related to any treatment necessitated due to participation in
hazardous or adventure sports
(Note: the above is a partial listing of the policy exclusions. Please refer to
the policy clauses for the full listing).
4 Waiting 1. Initial waiting period: 30 days for all illnesses (not applicable on renewal or V. Exclusions
period for accidents)
2. 90 days for specified disease and procedures.
3. Specified surgeries/treatments/diseases are covered after specific waiting
period of 12 months
SBI General Insurance Company Limited Arogya Plus Policy UIN: SBIHLIP22135V032122 Page 1 of 41
4. Pre-existing diseases: Covered after 48 months unless otherwise provided

5 Payout Indemnity basis for covered expenses up to specified sum insured. IV. Scope of
basis Benefit basis for the expenses covered under OPD and Maternity Cover
6 Cost sharing No cost sharing
7 Renewal The policy shall ordinarily be renewable except on misrepresentation by the VI.
Conditions insured person. grounds of fraud, Conditions
i. The Company shall endeavor to give notice for renewal. However, Precedent
the Company is not under obligation to give any notice for (Condition
renewal. no.16)
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
.
8 Renewal Nil
Benefits
9 Cancellation i. The policyholder may cancel this policy by giving 1Sdays'written notice VI.
and in such an event, the Company shall refund premium for the Conditions
unexpired policy period as detailed below.
Period on risk Rate of premium refunded
Up to one month 75% of annual rate
Up to three months 50%of annual rate
Up to six months 25% of annual rate
Exceeding six Nil
months
Notwithstanding anything contained herein or otheruise, 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 or misrepresentation, non-disclosure
of material facts or fraud.
10 Claims IV.
a. For Cashless Service:
Conditions
Refer link for Hospital Network details –
http://www.sbigeneral.in/portal/contact-us/hospital
b. For Reimbursement of Claim: For reimbursement of claims the insured
person may submit the necessary documents to TPA/Company within

the prescribed time limit as specified hereunder.
Sl Type of Claim Prescribed Time limit
No
1 Reimbursement of Within fifteen days of date of
hospitalization, day care and pre- discharge from hospital
hospitalization expenses
2 Reimbursement of post Within fifteen days from
hospitalization expenses completion of post
hospitalization treatment
For details on claim procedure please refer the policy document.
11 Policy
Servicing If You/Insured Person may have a grievance that requires to be
redressed, You/Insured Person may contact Us with the details of the
grievance through:
• Level 1
Call us on our Toll Free for any queries that you may have @
1800221111, 18001021111
Email your queries to [email protected]
Visit our website www.sbigeneral.in to register for your queries
Please walk into any of our branch office or corporate office during
business hours
You may also fax us your queries at _1800227244, 18001027244
• Level 2
If you still are not happy about the resolution provided then you may
please write to our [email protected]
• Level 3
If you are dissatisfied with the resolution provided in the Steps as
indicated above on your Complaint, you may send your ‘Appeal’
addressed to the Chairman of the Grievance Redressal Committee.
The Committee will look into the appeal and decide the same
expeditiously on merits.
You can write to Head – Compliance, Legal & CS on the id -
[email protected]
• Level 4
If your issue remains unresolved you may approach IRDA by calling on
the Toll Free no. 155255 or you can register an online complaint on
the website http://igms.irda.gov.in
• Senior Citizens: Senior Citizens can also write to
[email protected]
If after having followed the above steps you are not happy with the
resolution and your issue remains unresolved, you may approach the
Insurance Ombudsman for Redressal.
12 Grievances/ a. Details of Grievance redressal officer - IV.Conditions
Complaints https://www.sbigeneral.in/portal/grievance-redressal
b. IRDAI Integrated Grievance Management System -
https://igms.irda.gov.in/
Insurance Ombudsman — The contact details of the Insurance

Ombudsman offices have been provided as Annexure-B of Policy
document
13 Insured's 1. Free Look period of 15 days from the date of receipt of the IV.Conditions
Rights policy shall be applicable at the inception.
2. Right to migrate from one product to another product of the
company
For Queries related to migration contact below:-
Toll free no. – 1800-22-1111
Email Id- [email protected]
3. Right to port the from one company to another company.
For Queries related to portability contact below:-
Toll free no. – 1800-22-1111
Email Id- [email protected]
14 Please disclose all pre-existing disease/s or condition/s before buying

Insured's
a policy. Non-disclosure may result in claim not being paid.
Obligations
Benefit illustration :
AROGYA PLUS
Coverage opted on Coverage opted on individual basis Coverage opted on family floater
individual basis covering multiple members of the basis with overall Sum Insured (Only
covering each family under a single policy (Sum one Sum Insured is available for the
member of the Insured is available for each member entire family)
family separately of the family)
(at a single point in
time)
Premi
um or
Discou
consoli
nt, if Premi
Premi dated
Age of any Floater um
Sum Premi um Sum premi Sum
the Premiu Family discou after
Insured um after Insured um for Insured
members m (Rs.) memb nt if discou
(Rs.) (Rs.) Discou (Rs.) all (Rs.)
insured er any nt
nt (Rs.) memb
discou (Rs.)
ers of
nt)
family
(Rs.)
35 yrs 8900 3,00,000 8900 7.50% 8232.5 3,00,000
30 yrs 8900 3,00,000 8900 7.50% 8232.5 3,00,000
8900 0 8900 3,00,000
15 yrs 8900 3,00,000 8900 7.50% 8232.5 3,00,000
10 yrs 8900 3,00,000 8900 7.50% 8232.5 3,00,000
Total Premium for all members

of the Family is Rs. 35600/- Total Premium for all members of
when each member is covered the Family is Rs. 32,930/- when they Total Premium when policy is opted
separately. are covered under a single policy. on floater basis is Rs. 8900/-
Sum Insured available for each Sum Insured available for each Sum Insured of Rs. 3,00,000/- is
individual is Rs.3,00,000/- family member is Rs. 3,00,000/- available for the entire family.
Note:
considering any loading. Also, the premium rates are exclusive of taxes applicable.
(LEGAL DISCLAIMER) NOTE: The information must be read in conjunction with the product brochure and Policy
document. In case of any conflict between the Customer Information Sheet and the Policy document the terms
and conditions mentioned in the Policy document shall prevail.
AROGYA PLUS POLICY
I. PREAMBLE
This Policy is issued to the Insured based on the proposal and declaration together with any statement, report or
other document which shall be the basis of this contract and shall be deemed to be incorporated herein, upon
payment of the premium to Insurer and the realisation thereof by the Insurer. This Policy records the agreement
between Insurer and Insured and sets out the terms of Insurance and the obligations of each party.
II. OPERATIVE CLAUSE

Subject to the terms, conditions, exclusions and definitions contained herein or endorsed or otherwise expressed
hereon, Insurer undertakes to indemnify the Insured the medical expenses which are medically necessary and
mentioned in scope of cover up to the Sum Insured for the Insured as mentioned in the schedule of the Policy.
III. DEFINITIONS
The following words or terms shall have the meaning ascribed to them wherever they appear in this Policy, and
references to the singular or to the masculine shall include references to the plural and to the feminine and vice
versa, wherever the context so permits:
1. Accident
An accident is a sudden, unforeseen and involuntary event caused by external, visible and violent means.
2. An 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 clocks;
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.
3. 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.
4. Alternative treatments
Alternative treatments are forms of treatments other than treatment "Allopathy" or "modem medicine"
and includes Ayurveda, Unani, Sidha and Homeopathy in the Indian context
5. Any one illness
Any one illness means continuous period of illness and it includes relapse within 45 days from the date of
last consultation with the Hospital/Nursing Home where treatment may have been taken.
6. Cashless facility
"Cashless facility” means a facility extended by the Insurer to the Insured where the payments, of the
costs of treatment undergone by the Insured in accordance with the policy terms and conditions, are
directly made to the network provider by the Insurer to the extent pre-authorization approved.
7. Condition Precedent
Condition Precedent shall mean a policy term or condition upon which the Insurer's liability under the
Policy is conditional upon.
8. Congenital Anomaly
Congenital Anomaly refers to a condition(s) which is present since birth, and which is abnormal with
reference to form, structure or position.
a. Internal Congenital Anomaly
Congenital anomaly which is not in the visible and accessible parts of the body
b. External Congenital Anomaly
Congenital anomaly which is in the visible and accessible parts of the body
9. Co-payment
A co-payment is a cost-sharing requirement under a health insurance policy that provides that the
policyholder/Insured will bear a specified percentage of the admissible claim amount. A co-payment does
not reduce the Sum Insured.
10. Cumulative Bonus
Cumulative Bonus shall mean any increase in the Sum Insured granted by the Insurer without an
associated increase in premium.
11. Day Care Centre
A day care centre means any institution established for day care treatment of illness and/or injuries or a
medical setup 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—
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
12. Day Care Treatment
Day care treatment refers to medical treatment, and/or surgical procedure which is:
a. undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 hrs
because of technological advancement, and
b. which would have otherwise required a hospitalization of more than 24 hours.
Treatment normally taken on an out-patient basis is not included in the scope of this definition.
13. Deductible
Deductible is cost-sharing requirement under a health insurance policy that provides that the Insurer will
not be liable for a specified rupee amount in case of indemnity policies and for a specified number of
days/hours in case of hospital daily cash policy which will apply before any benefits are payable by the
Insurer. A deductible does not reduce the sum Insured.
Deductible will be applicable as specified under the Policy.
14. Dental Treatment
Dental treatment is treatment carried out by a dental practitioner including examinations, fillings (where
appropriate), crowns, extractions and surgery excluding any form of cosmetic surgery/implants.
15. Disclosure to information norm
The Policy shall be void and all premium paid hereon shall be forfeited to the Company, in the event of
misrepresentation, mis-description or non-disclosure of any material fact.
16. Domiciliary Hospitalisation
Domiciliary hospitalisation 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.
17. Emergency Care
Emergency care means management for a severe 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.
18. Grace Period
Grace period means the specified period of time immediately following the premium due date during
which a payment can be made to renew or continue a policy in force without loss of continuity benefits
such as waiting periods and coverage of pre existing diseases. Coverage is not available for the period for
which no premium is received.
19. Hospital
A hospital means any institution established for in-patient care and day care treatment of illness and/or
injuries and which has been registered as a hospital with the local authorities under the Clinical
Establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the
Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under:
a. has qualified nursing staff under its employment round the clock;
b. has at least 10 in-patient beds in towns having a population of less than 10,00,000 and at least 15
in-patient beds in all other places;
c. has qualified medical practitioner(s) in charge round the clock;
d. has a fully equipped operation theatre of its own where surgical procedures are carried out;
e. maintains daily records of patients and makes these accessible to the insurance company’s
authorized personnel.
20. Hospitalisation
Means admission in a Hospital for a minimum period of 24 In patient Care consecutive ‘In-patient Care’
hours except for specified procedures/ treatments, where such admission could be for a period of less
than 24 consecutive hours.
21. Illness
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.
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:—
1. it needs ongoing or long-term monitoring through consultations, examinations, check-
ups, and / or tests—
2. it needs ongoing or long-term control or relief of symptoms—
3. it requires your rehabilitation or for you to be specially trained to cope with it—
4. it continues indefinitely—
5. it recurs or is likely to recur
22. Injury
Injury means accidental physical bodily harm excluding illness or disease solely and directly caused by
external, violent and visible and evident means which is verified and certified by a Medical Practitioner.
23. Inpatient Care
Inpatient care means treatment for which the Insured person has to stay in a hospital for more than 24
hours for a covered event.
24. Intensive Care Unit

Intensive care unit means an identified section, ward or wing of a hospital which is under the constant
supervision of a dedicated medical practitioner(s), and which is specially equipped for the continuous
monitoring and treatment of patients who are in a critical condition, or require life support facilities and
where the level of care and supervision is considerably more sophisticated and intensive than in the
ordinary and other wards.
25. Maternity Expenses
Maternity expenses shall include—
a. medical treatment expenses traceable to childbirth ( including complicated deliveries and
caesarean sections incurred during hospitalization).
b. expenses towards lawful medical termination of pregnancy during the Policy Period.
26. Medical Advise
Any consultation or advice from a Medical Practitioner including the issue of any prescription or repeat
prescription.
27. Medical expenses
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.
28. Medical Practitioner
A Medical Practitioner is 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 licence.’
29. Medically Necessary
Medically necessary treatment is defined as any treatment, tests, medication, or stay in hospital or part
of a stay in hospital which
a. is required for the medical management of the illness or injury suffered by the Insured;
b. must not exceed the level of care necessary to provide safe, adequate and appropriate medical
care in scope, duration, or intensity;
c. must have been prescribed by a medical practitioner,
d. must conform to the professional standards widely accepted in international medical practice or
by the medical community in India.
30. Migration” means, the right accorded to health insurance policyholders (including all members under
family cover and members of group health insurance policy), to transfer the credit gained for pre-existing
conditions and time bound exclusions, with the same insurer.
31. Newborn baby
Newborn baby means baby born during the Policy Period and is aged between 1 day and 90 days, both days
inclusive.
32. Network Provider
"Network Provider” means hospitals or health care providers enlisted by an Insurer or by a TPA and
Insurer together to provide medical services to an Insured on payment by a cashless facility.
33. Non- Network
Any hospital, day care centre or other provider that is not part of the network.
34. Notification of Claim
Notification of claim means the process of intimating a claim to the insurer or TPA through any of the
recognized modes of communication.
35. OPD treatment
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.
36. Portability
Portability” means, the right accorded to 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.
37. Post-hospitalization Medical Expenses
Post-hospitalization Medical Expenses means medical expenses incurred during predefined
number of days immediately after the insured person is discharged from the hospital provided that:
i. Such Medical Expenses are for the same condition for which the insured person’s hospitalization
was required, and
ii. The inpatient hospitalization claim for such hospitalization is admissible by the
insurance company.
38. 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.
39. Pre-hospitalization Medical Expenses
Pre-hospitalization Medical Expenses means medical expenses incurred during predefined
number of days preceding the hospitalization of the Insured Person, provided that:
i. Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalization
was required, and
ii. The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.
40. Qualified Nurse
Qualified nurse is a person who holds a valid registration from the Nursing Council of India or the Nursing
Council of any state in India.
41. Reasonable and Customary Charges
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 .
42. Renewal
Renewal defines 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.
43. Room Rent
Room Rent means the amount charged by a Hospital towards Room and Boarding expenses and shall
include the associated medical expenses.
44. Surgery or Surgical Procedure
Surgery or Surgical Procedure means manual and / or operative procedure (s) required for treatment of
an illness or injury, correction of deformities and defects, diagnosis and cure of diseases, relief of
suffering or prolongation of life, performed in a hospital or day care centre by a medical practitioner
45. Unproven/Experimental treatment
Treatment including drug experimental therapy which is not based on established medical practice in
India, is treatment experimental or unproven.
46. Administrator
means any third party administrator (TPA) engaged by the Insurer for providing policy and claims
facilitation services to the Insured as well as to the Insurer and who is duly licensed by IRDA for the said
purpose.
47. Age
means completed years as at the commencement date of the Policy Period.
48. Diagnostic centre
means the diagnostic centrewhich have been empanelled by Insurer (or administrator) as per the latest
version of the schedule of diagnostic centre maintained by Insurer, which is available to Insured on
request.
49. Epidemic disease
means a disease which occurs when new cases of a certain disease, in a given human population, and
during a given period, substantially exceed what is the normal "expected" incidence rate based on recent
experience (the number of new cases in the population during a specified period of time is called the
"incidence rate").
50. Family
means the legal spouse, dependent children, parents and parents in law.
51. Family Cover
Family floater cover means the cover under the Policy which is available in aggregate not separately for
all members of family who are specified as Insureds in policy schedule and which can be used by all or
any of them.
Family non floater cover means the cover under the Policy which is available separately for all members
of family who are specified as Insureds in policy schedule.
52. Group
means any association of persons who assemble together with a commonality of purpose or engaging in
a common economic activity like employees of a company. Non-employer-employee groups, like
employee associations, holders of credit cards issued by a specific company, customers of a particular
business where Insurance is offered as an add on benefit, borrowers of a bank, professional associations
or societies may also be treated as a group. However, an association of persons coming together with a
purpose of availing an insurance cover, will not be treated as a group for the purpose of this Policy.
53. Insured
means a person named as Insured in the policy schedule.
54. Insurer
means SBI General Insurance Company Limited.
55. Mental illness/ disease
means any mental disease or bodily condition marked by disorganization of personality, mind, and
emotions to impair the normal psychological, social or work performance of the individual regardless of
its cause or origin.
56. Other Insurer
means any of the registered Insurers in India other than SBI General Insurance Company Limited.
57. Package service expenses
means expenses levied by the hospital/nursing home for treatment of specific surgical
procedures/medical ailments as a lump sum amount under agreed package charges based on the room
criteria as defined in the tariff schedule of the hospital.
58. Policy
means the complete documents consisting of the policy wording, schedule and endorsements and
attachments if any.
59. Policy period
means the period commencing with the commencement date of the Policy and terminating with the
expiry date of the Policy as stated in the policy schedule.
60. Proposal
means application form which the Insured duly fills in and signs for this insurance and any other
information Insured provides in the said form or otherwise to Insurer.
61. Proposer
means the person furnishing complete details and information in the proposal form for availing the
benefits either for himself and/or towards the person to be covered under the Policy and consents to the
terms of the contract of insurance by way of signing the same.
62. Schedule
means that portion of the Policy which sets out Insured’s details, the type of insurance cover in force, the
Policy period and the sum insured. Any annexure and/or endorsement to the schedule shall also be a
part of the schedule.
63. Sum insured
means the specified amount mentioned in the schedule to this policy which represents the Insurer’s
maximum liability for any or all claims under this policy during the currency of the policy subject to terms
and conditions.
64. Tele-consultation
means engagement between licensed tele-consultation service provider/ professional and the insured/
covered member that is provided via a range of technology enabled communication media other than face-
to-face interactions, such as telephone, internet, and others.
IV. SCOPE OF COVER

If the Insured suffers an illness/ disease and/ or injury during the Policy period, this Policy covers below
medical expenses incurred for medical treatment arising out of that illness/ disease and/ or injury:
1. Eligible hospitalisation expenses: - while the Insured was under inpatient care medical expenses incurred
for:
a. Room rent, boarding expenses
b. Medical practitioners fees, (including consultation through telemedicine ) Intensive care unit
c. Nursing expenses
d. Anesthesia, blood, oxygen, operation theatre expenses, surgical appliances, medicines &
consumables, diagnostic expenses and x-ray, dialysis, chemotherapy, radiotherapy, cost of
pacemaker, prosthesis/internal implants and any medical expenses incurred which is integral
part of the operation
e. Physiotherapy as inpatient care and being part of the treatment.
f. Drugs, medicines and consumables consumed during hospitalization period.
g. Diagnostic procedures
h. Dressing, ordinary splints and plaster casts.
2. OPD treatment and Teleconsultation : - expenses for OPD consultation or Teleconsultation and
treatment up to limit specified in policy schedule on advice of a medical practitioner because of
illness/disease and/or injury sustained or contracted during the Policy.
3. Pre-hospitalisation expenses: - the maximum amount that can be claimed under this head is limited to
60 days for each of the admitted hospitalisation and domicilary hospitalisation claim under the Policy.
4. Post-hosptalisation expenses: - the maximum amount that can be claimed under this head is limited to
90 days for each of the admitted hospitalisation and domicilary hospitalisation claim under the Policy.
5. Day care expenses: Insurer shall pay for day care expenses incurred on technological surgeries and
procedures requiring less than 24 hours of hospitalisation up to the sum insured.
6. Ambulance expenses: - Actual ambulance expenses or INR 1500 whichever is lower will be reimbursed
for per valid hospitalization claim for transferring insured to or between Hospitals in the Hospital’s
ambulance or in an ambulance provided by any ambulance service provider.
7. Alternative treatment: - taken in a government hospital or in any institute recognized by government
and/or accredited by quality council of India/national accreditation board on health.
8. Domiciliary hospitalisation: - Insurer will cover reasonable and customary charges towards domiciliary
hospitalisation including pre and post hospitalization expenses.
9. Maternity Expenses: - are covered but only under OPD section and up to OPD Limit specified in policy
schedule.
10. Admissibility of certain incidental expenses will be as per Standard List of Excluded expenses in
Hospitalisation indemnity policies ( as per IRDA health Insurance guidelines) - (Annexure B )
11. HIV/AIDS Cover: We will cover expenses incurred for Inpatient treatment due to any condition caused
by or associated with human immunodeficiency virus or variant/mutant viruses and or any syndrome or
condition of a similar kind commonly referred to as AIDS upto the Sum Insured as specified in Policy
Schedule, except for the conditions which are permanently excluded.
12. Mental Illness Cover: If Insured is hospitalized for any Mental Illness contracted during the Policy Period,
We will pay Medical Expenses -upto the limit as specified in Policy Schedule, under Section 1 in
accordance with The Mental Health Care Act, 2017, subsequent amendments and other applicable laws
and Rules provided that;
i. The Hospitalization is prescribed by a Medical Practitioner for Mental Illness
ii. The Hospitalization is done in Mental Health Establishment
Sub-limit:
a. The following disorders / conditions shall be covered only up to Rs. 50,000/-. This sub-limit shall
apply for all the following disorders / conditions on cumulative basis.
b. Pre-hospitalization and Post-hospitalization Medical Expenses are also covered within the overall
benefit sub-limit as specified above in point (a).
Disorder / Condition Description
Severe depression is characterized by a persistent feeling of sadness or a
Severe Depression lack of interest in outside stimuli. It affects the way one feels, thinks, and
behaves.
Schizophrenia is mental disorder, that distorts the way a person thinks,
acts, expresses emotions, perceives reality, and relates to others.
Schizophrenia Schizophrenia result in combination of hallucinations, delusions, and
extremely disordered thinking and behaviour that impairs daily
functioning,
Bipolar disorder is a mental illness that brings severe high and low
Bipolar Disorder moods and changes in sleep, energy, thinking, and behaviour. It includes
periods of extreme mood swings with emotional highs and lows.
Post-traumatic stress disorder is an anxiety disorder caused by very
Post-traumatic stress disorder stressful, frightening, or distressing events. It includes flashbacks,
nightmares, severe anxiety and uncontrollable thoughts about the event.
Eating disorder is a mental condition where people experience severe

Eating disorder disturbances in their eating behaviours and related thoughts and
emotions.
Generalized Anxiety Disorder is a mental health disorder characterized
Generalized anxiety disorder
by a perpetual state of worry, fear, apprehension, inability to relax.
Obsessive-compulsive disorder is an anxiety disorder in which people
Obsessive compulsive disorders have recurring, unwanted thoughts, ideas or sensations (obsessions) that
make them feel driven to do something repetitively (compulsions).
Panic disorder is an anxiety disorder characterized by reoccurring
unexpected panic attacks with sudden periods of intense fear. It may
Panic disorders
include palpitations, sweating, shaking, shortness of breath, numbness,
or a feeling that something terrible is going to happen.
Personality disorder is a type of mental disorder in which people have a
Personality disorders rigid and unhealthy pattern of thinking, functioning and behaving. It
includes trouble in perceiving and relating to situations and people.
Conversion disorder is a type of mental disorder where mental or
Conversion disorders emotional distress causes physical symptoms without the existence of an
actual physical condition.
Dissociative disorders are mental disorders that involve experiencing a
Dissociative disorders disconnection and lack of continuity between thoughts, memories,
surroundings, actions and identity
*ICD codes for the above disorders / conditions are provided below.
What is not covered:
a. Treatment related to intentional self-inflicted Injury or attempted suicide by any means.

b. Treatment and complications related to disorders of intoxication, dependence, abuse, and
withdrawal caused by drugs and other substances such as alcohol, opioids or nicotine.
*
ICD Codes Disorder / Condition
F33.0, F33.1, F33.2, F33.4, F33.5, F33.6, F33.7, F33.8,

F33.9, O90.6, F34.1, F32.81, F32.0, F32.1, F32.2,
F32.4, F32.5, F32.6, F32.7, 32.8, F32.9, F33.9, F30.0, Severe Depression
F30.1, F30.2, F30.4, F30.5, F30.6, F30.7, F30.8,

F30.9, F32.3, F33.3, F43.21, F32.8, F33.40, F32.9
F20.0, F20.1, F20.2, F20.3, F20.5, F21, F22, F23, F24,
Schizophrenia
F20.8, F25.0, F25.1, F25.8, F25.9
F31.0, F31.1, F31.2, F31.4, F31.5, F31.6, F31.7, F31.8,
Bipolar Disorder
F31.9
F43.0, F43.1, F43.2, F43.8, F43.9 Post-traumatic stress disorder
F40.1, F41.0, F40.2, F40.8, F40.9, F41.1, F41.3, F41.8 Generalized anxiety disorder
F50.0, F50.2, F50.8, F98.3, F98.21, F50.8 Eating disorder
F42 Obsessive compulsive disorders
F41.1, F40.1, F60.7, F93.0, F94.0 Panic disorders
F60.0, F60.1, F60.2, F60.3, F60.4, F60.8, F60.6, F60.7, F60.5 Personality disorders
F44.4, F44.5, F44.6, F44.7 Conversion disorders
F44.5, F44.8, F48.1, F44.1, F44.2 Dissociative disorders
13. Genetic Disorders or Diseases are covered up to the Limit Rs. 50,000
14. Internal Congenital Diseases are Covered upto the Limit Rs. 10% of Sum Insured.
15. 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 50% of -of Sum Insured, specified in the policy schedule, during the
policy period:
A. Uterine Artery Embolization and HIFU (High Intensity Focused Ultrasound)
B. Balloon Sinuplasty
C. Deep Brain Stimulation
D. Oral Chemotherapy
E. Immunotherapy - Monoclonal Antibody to be given as injection
F. Intra Vitreal Injections
G. Robotic Surgeries
H. Stereotactic Radio Surgeries
I. Bronchial Thermoplasty
J. Vaporisation of the Prostrate ( Green Laser Treatment or Holmium Laser Treatment)
K. IONM - (lntra Operative Neuro Monitoring)
L. Stem Cell Therapy: Hematopoietic stem cells for bone marrow transplant for haematological
conditions to be covered
V. EXCLUSIONS: -
Following exclusions will apply on the claim arising under hospitalisation.
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 48 months of continuous coverage after the date of inception of the
first policy with insurer.
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 48 months for any pre-existing disease is subject to
the same being declared at the time of application and accepted byInsurer
2. 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 90 Days/12 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.
f) List of specific diseases/procedures
i. 12 Months waiting period
• Any types of gastric or duodenal ulcers;
• Tonsillectomy, Adenoidectomy, Mastoidectomy, Tympanoplasty;
• Surgery on all internal or external tumor /cysts/nodules/polyps of any kind including breast
lumps;
• All types of Hernia and Hydrocele;
• Anal Fissures, Fistula and Piles;
• Cataract;
• Benign Prostatic Hypertrophy;
• Hysterectomy/ myomectomy for menorrhagia or fibromyoma or prolapse of uterus;
• Non infective Arthritis, Treatment of Spondylosis / Spondylitis, Gout & Rheumatism;
• Surgery of Genitourinary tract;
• Calculus Diseases;
• Sinusitis, nasal disorders and related disorders;
• Surgery for prolapsed intervertebral disc unless arising from accident;
• Vertebro-spinal disorders (including disc) and knee conditions;
• Surgery of varicose veins and varicose ulcers;

• Chronic Renal failure;
• Medical Expenses incurred in connection with joint replacement surgery due to Degenerative
condition, Age related osteoarthritis and Osteoporosis unless such Joint replacement surgery
unless necessitated by Accidental Bodily Injury.
ii. 90 Days Waiting Period
• Hypertension, Heart Disease and related complications;
• Diabetes and related complications;
3. 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.
4. Treatment taken outside India.

5. War, invasion, acts of foreign enemies, hostilities (whether war be declared or not), civil war, commotion,
unrest, rebellion, revolution, insurrection, military or usurped power or confiscation or nationalisation or
requisition of or damage by or under the order of any government or public local authority.
6. Injury or disease directly or indirectly caused by or contributed to by nuclear weapons/materials.
7. Circumcision unless necessary for treatment of a disease, illness or injury not excluded hereunder, or, as
may be necessitated due to an accident
8. Refractive Error:Code- (Excl15)
Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5
dioptres.
9. 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.hh
10. cost of spectacles, contact lenses, hearing aids, crutches, wheelchairs, artificial limbs, dentures, artificial
teeth and all other external appliances , prosthesis and/or devices.
11. Expenses incurred on items for personal comfort like television, telephone, etc. Incurred during
hospitalization and which have been specifically charged for in the hospitalisation bills issued by the
hospital/nursing home.
12. External medical equipment of any kind used at home as post hospitalisation care including cost of
instrument used in the treatment of sleep apnoea syndrome (C.P.A.P), continuous ambulatory peritoneal
dialysis (C.A.P.D) and oxygen concentrator for bronchial asthmatic condition.
13. Dental treatment or surgery of any kind unless required as a result of accidental bodily injury to natural
teeth requiring hospitalization treatment.
14. Convalescence, general debility, “run-down” condition, rest cure, external congenital anomaly.
15. Intentional self-injury (including but not limited to the use or misuse of any intoxicating drugs or alcohol)
16. Breach of law:Code- (Excl10)
Expenses tor treatment directly arising from or consequent upon any Insured Person committing or
attempting to commit a breach of law with criminal intent.
17. Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences
thereof.Code-( Excl12)
18. Venereal disease or any sexually transmitted disease or sickness (excluding HIV / AIDS as mentioned under
scope of cover )
19. Sterility and Infertility: (Code- Excl17)
Expenses related to sterility and infertility this includes:
i. Any type of sterilization
ii. Assisted Reproduction services including artificial insemination and advanced reproductive
technologies such as IVF, ZIFT, GIFT ICSI
iii. Gestational Surrogacy
iv. Reversal of sterilization
20. Vaccination or inoculation except as part of post-bite treatment for animal bite.
21. 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)
22. Surgery to correct deviated septum and hypertrophied turbinate unless necessitated by an accidental body
injury.
23. Medical practitioner’s home visit expenses during pre and post hospitalization period, attendant nursing
expenses.
24. Change-of-Gendertreatments:Code-( Excl07)
Expenses related to any treatment, including surgical management, to change characteristics of the body
to those of the opposite sex.
25. 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.
26. Stay in a hospital without undertaking any active regular treatment by the medical practitioner, which
ordinarily cannot be given without hospitalization.
27. 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)
28. Rest Cure, rehabilitation and respite care (Code- Excl05)
b) Expenses related to any admission primarily for enforced bed rest and not for receiving
treatment. This also includes:
i. Custodial care either at home or in a nursing facility for personal care such as help with
activities of daily living such as bathing, dressing, moving around either by skilled nurses or
assistant or non-skilled persons.
ii. Any services for people who are terminally ill to address physical, social, emotional and
spiritual needs.
29. Investigation & Evaluation (Code- Excl04)

a) Expenses related to any admission primarily tor diagnostics and evaluation purposes.
b) Any diagnostic expenses which are not related or not incidental to the Current diagnosis and
treatment
30. Hospitalization for donation of any body organs by an Insured including complications arising from the
donation of organs.
31. Obesity/ Weight Control:Code- (Code-Excl06)
Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:
1) Surgery to be conducted is upon the advice of the Doctor

2) The surgery/Procedure conducted should be supported by clinical protocols
3) The member has to be 18 years of age or older and
4) Body Mass Index (BMI);
a) greater than or equal to 40 or
b) greater than or equal to 35 in conjunction with any of the following severe co-morbidities
following failure of less invasive methods of weight loss:
i. Obesity-related cardiomyopathy
ii. Coronary heart disease
iii. Severe Sleep Apn
iv. Uncontrolled Type2 Diabetes
32. . 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.
33. Disease / illness or injury whilst performing duties as a serving member of a military or police force.
34. Any kind of, surcharges, admission fees / registration charges etc levied by the hospital.
35. In respect of the existing diseases, disclosed by the insured and mentioned in the policy schedule (based
on insured's consent), policyholder is not entitled to get the coverage for specified ICD codes.
VI. CONDITIONS:
1. 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.
2. Disclosure to Information Norm:

The policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of
misrepresentation, mis description or non-disclosure ofany 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)
3. Due care: where this Policy requires Insured to do or not to do something, then the complete satisfaction of
that requirement by Insured or someone claiming on Insured’s behalf is a condition precedent to any
obligation under this Policy. If Insured or someone claiming on Insured’s behalf fails to completely satisfy
that requirement, then Insurer may refuse to consider Insured’s claim. Insured will cooperate with Insurer at
all times.
4. 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. 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.
If 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 coveror
iii. Where only a part of the insurance coverage has commenced, such proportionate premium
commensurate with the insurance coverage during such period;
6. Notices: Any notice, direction or instruction under this Policy shall be in writing and if it is to:
Any Insured, then it shall be sent to Proposer’s address specified in the Schedule to this Policy and
Proposer shall act for all Insureds for these purposes.
Insurer, it shall be delivered to Insurer’s address specified in the Schedule to this Policy. No insurance
agents, brokers or other person or entity is authorised to receive any notice, direction or instruction on
Insurer’s behalf unless Insurer has expressly stated to the contrary in writing.
Insured must notify Insurer of any change in address.

7. Mis-description: - this Policy shall be void and premium paid shall be forfeited to Insurer in the event of
misrepresentation, mis-description or non-disclosure of any materials facts pertaining to the proposal form,
written declarations or any other communication exchanged for the sake of obtaining the insurance policy by
the Insured. Nondisclosure shall include non-intimation of any circumstances which may affect the Insurance
cover granted. The misrepresentation, mis-description and non-disclosure is related to the information
provided by the proposer/Insured to the Insurer at any point of time starting from seeking the insurance
cover in the form of submitting the filled in proposal form, written declarations or any other communication
exchanged for the sake of obtaining the insurance policy and ends only after all the contractual obligations
under the Policy are exhausted for both the parties under the contract.
8. Reasonable Care: We are not obliged to make payment for any claim or that part of any claim that could have
been avoided or reduced if the Insured had taken reasonable care, or that is brought about or contributed to
by the Insured failing to follow the directions, advice or guidance provided by a Medical Practitioner.
9. Package service expenses: as defined under the Policy will be payable only if prior approval for the said
package service is provided by administrator / Insurer upon the request of the Insured.
10. Unhindered access: the Insured shall extend all possible support & co-operation including necessary
authorisation to the Insurer for accessing the medical records and medical practitioners who have attended
to the patient.
11. Claims Procedures :
a. Claims Procedure for Reimbursement :
ii) The Insured shall without any delay consult a doctor and follow the advice and treatment
recommended, take reasonable step to minimize the quantum of any claim that might be made
under this Policy and intimation to this effect must be forwarded to Insurer accordingly.
Insured must provide intimation to Insurer immediately and in any event within 48 hours from the
date of Hospitalisation. However the Insurer at his sole discretion may relax this condition subject to
a justifiable reason/evidence being produced by the Insured on the reasons for such a delay beyond
the stipulated 48 hours up to a maximum period of 7 days.
iii) Insured has to file the claim with all necessary documentation within 15 days of discharge from the
hospital, provide Insurer with written details of the quantum of any claim along with all the original
bills, receipts and other documents upon which a claim is based and shall also give Insurer such
additional information and assistance as Insurer may require in dealing with the claim. In case of
delayed submission of claim and in absence of a justified reason for delayed submission of claim, the
Insurer would have the right of not considering the claim for reimbursement.
iv) In respect of post hospitalization claims, the claims must be lodged within 15 days from the
completion of post hospitalisation treatment subject to maximum of 105 days from the date of
discharge from hospital.
v) The Insured shall submit himself for examination by the Insurer’s medical advisors as often as may be
considered necessary by the Insurer for establishing the liability under the Policy. The Insurer will
reimburse the amount towards the expenses incurred for the said medical examination to the
Insured.
vi) Insured must submit all original bills, receipts, certificates, information and evidences from the
attending medical practitioner /hospital /diagnostic laboratory as required by Insurer.
vii) On receipt of intimation from Insured regarding a claim under the Policy, Insurer/administrator is
entitled to carry out examination and obtain information on any alleged Injury or disease requiring
hospitalisation if and when Insurer may reasonably require.
b. Claims procedure for Cashless:
i) Prior to taking treatment and/or incurring medical expenses at a network hospital, Insured must call
Insurer and request pre-authorisation by way of the written form Insurer will provide.
ii) After considering Insured’s request and after obtaining any further information or documentation
Insurer has sought, Insurer may if satisfied send Insured or the network hospital, an authorisation
letter. The authorisation letter, the ID card issued to Insured along with this Policy and any other
information or documentation that Insurer has specified must be produced to the network hospital
identified in the pre-authorisation letter at the time of Insured’s admission to the same.
iii) If the procedure above is followed, Insured will not be required to directly pay for the medical
expenses in the network hospital that Insurer is liable to indemnify under cover IV.1 above and the
original bills and evidence of treatment in respect of the same shall be left with the network hospital.
Pre-authorisation does not guarantee that all costs and expenses will be covered. Insurer reserves
the right to review each claim for medical expenses and accordingly coverage will be determined
according to the terms and conditions of this Policy. Insured will, in any event, be required to settle
all other expenses directly.
c. Claims Submission:
Insured will submit the claim documents to administrator. Following is the document list for claim
submission:
i) Duly filled Claim form,
ii) Valid Photo Identity Card, residence proof and 2 recent photos of Insured and/or his nominee.
iii) Original Discharge card/certificate/ death summary
iv) Copies of prescription for diagnostic test, treatment advise, medical references
v) Original set of investigation reports
vi) Itemized original hospital bill and receipts Hospital and related original medical expense receipt
Pharmacy bills in original with prescriptions
d. Claims processing: on receipt of claim documents from Insured, Insurer/administrator shall assess the
admissibility of claim as per policy terms and conditions. Upon satisfactory completion of assessment
and admission of claim, the Insurer will make the payment of claim as per the contract only in Indian
Rupees and within India only. In case if the claim is repudiated Insurer will inform the claimant about the
same in writing with reason for repudiation.
e. Penal interest provision:
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 oreceipt of last necessary document to
the date of payment of claim.
f. Position after a claim: As from the day of receipt of the claim amount by the Insured, the Sum insured for
the remainder of the Policy Period shall stand reduced by a corresponding amount. In case claim is made
for maternity benefit or OPD, then both Sum insured and OPD limit will get reduced by corresponding
amount.
12. 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 pa(y acting on behalf of the insured
person, with intent to deceive the insurer or to induce the insurer to issue an insurance policy:
a) the suggestion, as a fact of that which is not true and which the insured
person does not believe to be true;
b) the active concealment of a fact by the insured person having knowledge
or belief of the fact;
c) any other act fitted to deceive; and
d) 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.
13. if the Insured or any of their family members make or progress any claim knowing it to be false or fraudulent
in any way, then the coverage for this Insured and his family members will be void and all claims or payments
due under it shall be lost and the premium paid shall become forfeited.
14. 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.
15. Multiple Policies
i. In case of multiple policies taken by an insured person during a period from one or more insurers
toindemnify treatment costs, the insured person shall have the right to require a settlement of
his/herclaim in terms of any of his/her policies. In all such cases the insurer chosen by the insured
person shall be obliged to settle theclaim as long as the claim is within the limits of and according to the
terms of the chosen policy.
ii. Insured 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 insurershall 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 whomhe/she wants to claim the balance amount.
iv. Where an insured person has policies from more than one insurer to cover the same risk onindemnity
basis, the insured person shall only be indemnified the treatment costs in accordancewith the terms
and conditions of the chosen policy.
16. Cancellation:
i. The policyholder may cancel this policy by giving 1Sdays'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 refunded
Up to one month 75% of annual rate
Up to three months 50%of annual rate
Up to six months 25% of annual rate
Exceeding six Nil
months
Notwithstanding anything contained herein or otheruise, 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 or misrepresentation, non-disclosure of material facts or fraud.
17. Termination of policy: this Policy terminates on earliest of the following events-
a. Cancellation of policy as per the cancellation provision.
b. On the policy expiry date.
18. Arbitration & conciliation: if any dispute or difference shall arise as to the quantum to be paid under this
Policy (liability being otherwise admitted) such difference shall independently of all other questions be
referred to the decision of a sole arbitrator to be appointed in writing by the parties to the
dispute/difference, or if they cannot agree upon a single arbitrator within 30 days of any party invoking
arbitration, the same shall be referred to a panel of 3 arbitrators, comprising of two arbitrators and one to be
appointed by each of the parties to the dispute/difference and the third arbitrator to be appointed by such
two arbitrators and the arbitration shall be conducted under and in accordance with the provisions of the
arbitration and conciliations act 1996.
It is hereby agreed and understood that no dispute or difference shall be referable to arbitration, as
hereinbefore provided, if the Insurer has disputed or not accepted liability under or in respect of this policy.
It is expressly stipulated and declared that it shall be a condition precedent to any right of action or suit upon
this Policy that the award by such arbitrator/arbitrators of the amount of the loss shall be first obtained.
The law of the arbitration shall be Indian law and the seat of the arbitration and venue for all the hearings
shall be within India.
19. Renewal:
The policy shall ordinarily be renewable except on misrepresentation by the insured person. grounds of
fraud,
i. The Company shall endeavor to give notice for renewal. However, the Company is not under obligation to
give any notice for renewal.
ii. Renewal shall not be denied on the ground that the insured person had made a claim or claims in the
preceding policy years.
iii. Request for renewal along with requisite premium shall be received by the Company before the end of the
policy period.
iv. At the end of the policy period, the policy shall terminate and can be renewed within the Grace Period of
30 days to maintain continuity of benefits without break in policy. Coverage is not available during the
grace period.
v. No loading shall apply on renewals based on individual claims experience
20. Withdrawal of product:
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. Insured 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.
21. Migration
The insured person will have the option to migrate the policy to other health insurance products/plans
offered by the company by applying for migration of the policyatleast30 days before the policy renewal date
as per IRDAI guidelineson Migration. If such person is presently covered and has been continuously covered
without any lapses under any health insurance product/plan offered by the company,the insured person will
get the accrued continuity benefits in waiting periods as per IRDAI guidelines on migration.
For DetailedGuidelines on migration, kindly refer the link
https://www.irdai.gov.in/ADMINCMS/cms/whatsNew_Layout.aspx?page=PageNo3987&flag=1
22. Portability:
The insured person 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. lf such person is presently covered and
has been continuously covered without any lapses under any health insurance policy with an lndian
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
23. Possibility of Revision of Terms of the Policy lncluding the Premium Rates
The Company, with prior approval of lRDAl, may revise or modify the terms of the policy including the
premium rates. The insured person shall be notified three months before the changes are effected.
24. Moratorium Period

After completion of eight continuous years under the policy no look back to 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 8 continuous years would be applicable from date of enhancement of
sums insured only on the enhanced limits. After the expiry of Moratorium Period no health insurance claim
shall be contestable except for proven fraud and permanent exclusions specified in the policy contract. The
policies would however be subject to all limits, sub limits, co-payments, deductibles as per the policy
contract.
25. Disclaimer: if Insurer shall disclaim liability to the Insured for any claim hereunder and if the Insured shall not
within 12 calendar months from the date of receipt of the notice of such disclaimer notify Insurer in writing
that he does not accept such disclaimer and intends to recover his claim from Insurer then the claim shall for
all purposes be deemed to have been abandoned and shall not thereafter be recoverable hereunder.
26. Jurisdiction: - The Policy constitutes the complete contract of insurance. No change or alteration shall be
valid or effective unless approved in writing by Insurer, which approval shall be evidenced by an endorsement
on the schedule.
The construction, interpretation and meaning of the provisions of this Policy shall be determined in
accordance with Indian law. The section headings of this Policy are included for descriptive purposes only
and do not form part of this Policy for the purpose of its construction or interpretation.
25. Loading and Discount: -In case family is covered on non floater basis maximum 7.5% discount will be given.
Maximum 7.5% discount will also be given for long term policy. Premium will be loaded by 5% each for
habit of smoking, alcohol and any other type of tobacco including betel nut in any form.
26. Deduction under section 80D income-tax act – deduction under section 80D income-tax act will be allowed
on premium and amount eligible of deduction under section 80D income-tax is separately specified in
policy schedule.
27. Redressal of Grievance
In case of any grievance the insured person may contact the company through
Website: www.sbigeneral.in
Toll free: 1800 22 1111 / 1800 102 1111 Monday to Saturday (8 am - 8 pm).
E-mail: [email protected]
Fax : 1800 22 7244 / 1800 102 7244
Courier:
Insured person may also approach the grievance cell at any of the company’s branches with the details of
grievance
If Insured person is not satisfied with the redressal of grievance through one of the above methods, insured
person may contact the grievance officer at [email protected]
For updated details of grievance officer, kindly refer the link https://www.sbigeneral.in/portal/grievance-
redressal
If Insured person is not satisfied with the redressalof grievance through above methods, theinsured person
may also approach the office of Insurance Ombudsman of the respective area/region for redressal of
grievanceas per Insurance Ombudsman Rules 2017.
Office of Insurance the Areas of Jurisdiction

Ombudsman
AHMEDABAD - Shri Kuldip Singh
Gujarat, Dadra & Nagar
Office of the Insurance Ombudsman,
Haveli,Daman and Diu.
Jeevan Prakash Building, 6th floor,
Tilak Marg, Relief Road,
Ahmedabad – 380 001.
Tel.: 079 - 25501201/02/05/06
Email: [email protected]
BENGALURU - Smt. Neerja Shah

Karnataka.
Jeevan Soudha Building,PID No. 57-27-N-19
Ground Floor, 19/19, 24th Main Road,
JP Nagar, Ist Phase,
Bengaluru – 560 078.
Tel.: 080 - 26652048 / 26652049
BHOPAL - Shri Guru Saran Shrivastava

Madhya Pradesh,
Chhattisgarh.
JanakVihar Complex, 2nd Floor,
6, Malviya Nagar, Opp. Airtel Office,
Near New Market,
Bhopal – 462 003.
Tel.: 0755 - 2769201 / 2769202
Fax: 0755 - 2769203
BHUBANESHWAR - Shri Suresh Chnadra Panda Orissa.

62, Forest park,
Bhubneshwar – 751 009.
Tel.: 0674 - 2596461 /2596455
Fax: 0674 - 2596429
CHANDIGARH - Dr. Dinesh Kumar Verma Punjab,Haryana,

Office of the Insurance Ombudsman, Himachal Pradesh,
S.C.O. No. 101, 102 & 103, 2nd Floor, Jammu & Kashmir,
Batra Building, Sector 17 – D, Chandigarh.
Chandigarh – 160 017.
Tel.: 0172 - 2706196 / 2706468
Fax: 0172 - 2708274
CHENNAI - Shri M. Vasantha Krishna Tamil Nadu,

Office of the Insurance Ombudsman, Pondicherry Town and
Fatima Akhtar Court, 4th Floor, 453, Karaikal (which are part of UT of Pondicherry).
Anna Salai, Teynampet,
CHENNAI – 600 018.
Tel.: 044 - 24333668 / 24335284
Fax: 044 - 24333664
DELHI - Shri Sudhir Krishna Delhi.

2/2 A, Universal Insurance Building,
Asaf Ali Road,
New Delhi – 110 002.
Tel.: 011 - 23232481/23213504
GUWAHATI - Shri Kiriti .B. Saha Assam, Meghalaya,
Office of the Insurance Ombudsman, Manipur, Mizoram,
Jeevan Nivesh, 5th Floor, Arunachal Pradesh,
Nr. Panbazar over bridge, S.S. Road, Nagaland and Tripura.
Guwahati – 781001(ASSAM).
Tel.: 0361 - 2632204 / 2602205
HYDERABAD - Shri I. Suresh Babu Andhra Pradesh,

Office of the Insurance Ombudsman, Telangana,
6-2-46, 1st floor, "Moin Court", Yanam and
Lane Opp. Saleem Function Palace, part of Territory of UT of Pondicherry.
A. C. Guards, Lakdi-Ka-Pool,
Hyderabad - 500 004.
Tel.: 040 - 67504123 / 23312122
Fax: 040 - 23376599
JAIPUR - Smt. Sandhya Baliga Rajasthan.

Jeevan Nidhi – II Bldg., Gr. Floor,
Bhawani Singh Marg,
Jaipur - 302 005.
Tel.: 0141 - 2740363
ERNAKULAM - Ms. Poonam Bodra Kerala, UT of (a) Lakshadweep, (b)

Office of the Insurance Ombudsman, Mahe-a part of UT of Pondicherry.
2nd Floor, Pulinat Bldg.,
Opp. Cochin Shipyard, M. G. Road,
Ernakulam - 682 015.
Tel.: 0484 - 2358759 / 2359338
Fax: 0484 - 2359336
KOLKATA - Shri P. K. Rath West Bengal,

Office of the Insurance Ombudsman, Sikkim,
Hindustan Bldg. Annexe, 4th Floor, UT of Andaman & Nicobar Islands.
4, C.R. Avenue,
KOLKATA - 700 072.
Tel.: 033 - 22124339 / 22124340
Fax : 033 - 22124341
LUCKNOW -Shri Justice Anil Kumar Srvastava Districts of Uttar Pradesh :
Office of the Insurance Ombudsman, Laitpur, Jhansi, Mahoba, Hamirpur, Banda,
6th Floor, Jeevan Bhawan, Phase-II, Chitrakoot, Allahabad, Mirzapur, Sonbhabdra,
Nawal Kishore Road, Hazratganj, Fatehpur, Pratapgarh, Jaunpur,Varanasi, Gazipur,
Lucknow - 226 001. Jalaun, Kanpur, Lucknow, Unnao, Sitapur,
Tel.: 0522 - 2231330 / 2231331 Lakhimpur, Bahraich, Barabanki, Raebareli,
Fax: 0522 - 2231310 Sravasti, Gonda, Faizabad, Amethi, Kaushambi,
Email: [email protected] Balrampur, Basti, Ambedkarnagar, Sultanpur,
Maharajgang, Santkabirnagar, Azamgarh,
Kushinagar, Gorkhpur, Deoria, Mau, Ghazipur,
Chandauli, Ballia, Sidharathnagar.
MUMBAI - Shri Milind A. Kharat Goa,
Office of the Insurance Ombudsman, Mumbai Metropolitan Region
3rd Floor, Jeevan SevaAnnexe, excluding Navi Mumbai & Thane.

S. V. Road, Santacruz (W),
Mumbai - 400 054.
Tel.: 022 - 26106552 / 26106960
Fax: 022 - 26106052
NOIDA - Shri Chandra Shekhar Prasad State of Uttaranchal and the following Districts of
Office of the Insurance Ombudsman, Uttar Pradesh:
BhagwanSahai Palace Agra, Aligarh, Bagpat, Bareilly, Bijnor, Budaun,
4th Floor, Main Road, Bulandshehar, Etah, Kanooj, Mainpuri, Mathura,
Naya Bans, Sector 15, Meerut, Moradabad, Muzaffarnagar, Oraiyya,
Distt: Gautam Buddh Nagar, Pilibhit, Etawah, Farrukhabad, Firozbad,
U.P-201301. Gautambodhanagar, Ghaziabad, Hardoi,
Tel.: 0120-2514250 / 2514252 / 2514253 Shahjahanpur, Hapur, Shamli, Rampur, Kashganj,
Email: [email protected] Sambhal, Amroha, Hathras, Kanshiramnagar,
Saharanpur.
PATNA - Shri N. K. Singh Bihar,
Office of the Insurance Ombudsman, Jharkhand.
1st Floor,Kalpana Arcade Building,,
Bazar Samiti Road,
Bahadurpur,
Patna 800 006.
Tel.: 0612-2680952
PUNE - Shri Vinay Sah Maharashtra,
Office of the Insurance Ombudsman, Area of Navi Mumbai and Thane
Jeevan Darshan Bldg., 3rd Floor, excluding Mumbai Metropolitan Region.
C.T.S. No.s. 195 to 198,
N.C. Kelkar Road, Narayan Peth,
Pune – 411 030.
Tel.: 020-41312555
Grievance may also be lodged at IRDAI Integrated Grievance Management System - https://igms.irda.gov.in/
Annexure B
List I — Items for which coverage is not available in the policy
Sr Item
No
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

Sl Item
No
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 subsumed into procedure charges.
Sl Item
No.
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 Cost of Treatment
Sl Item
No.
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 C - Day Care List

The following are the listed Day care procedures and such other Surgical Procedures that necessitate less than 24
hours Hospitalisation due to medical/technological advancement/ infrastructure facilities and the coverage of
which is subject to the terms, conditions and exclusions of the policy
Microsurgical operations on the middle ear

1. Stapedectomy
2. Revision of a stapedectomy
3. Other operations on the auditory ossicles
4. Myringoplasty (Type -I Tympanoplasty)
5. Tympanoplasty (closure of an eardrum perforation/reconstruction of the auditory ossicles)
6. Revision of a tympanoplasty
7. Other microsurgical operations on the middle ear
Other operations on the middle & internal ear

8. Myringotomy
9. Removal of a tympanic drain
10. Incision of the mastoid process and middle ear
11. Mastoidectomy
12. Reconstruction of the middle ear
13. Other excisions of the middle and inner ear
14. Fenestration of the inner ear
15. Revision of a fenestration of the inner ear
16. Incision (opening) and destruction (elimination) of the inner ear
17. Other operations on the middle and inner ear
Operations on the nose & the nasal sinuses

18. Excision and destruction of diseased tissue of the nose
19. Operations on the turbinates (nasal concha)
20. Other operations on the nose
21. Nasal sinus aspiration
Operations on the eyes

22. Incision of tear glands
23. Other operations on the tear ducts
24. Incision of diseased eyelids
25. Excision and destruction of diseased tissue of the eyelid
26. Incision of diseased eyelids
27. Operations on the canthus and epicanthus
28. Corrective surgery for entropion and ectropion
29. Corrective surgery for blepharoptosis
30. Removal of a foreign body from the conjunctiva
31. Removal of a foreign body from the cornea
32. Incision of the cornea
33. Operations for pterygium
34. Other operations on the cornea
35. Removal of a foreign body from the lens of the eye
36. Removal of a foreign body from the posterior chamber of the eye
37. Removal of a foreign body from the orbit and eyeball

38. Operation of cataract
Operations on the skin & subcutaneous tissues

39. Incision of a pilonidal sinus
40. Other incisions of the skin and subcutaneous tissues
41. Surgical wound toilet (wound debridement) and removal of diseased tissue of the skin and subcutaneous
tissues
42. Local excision of diseased tissue of the skin and subcutaneous tissues
43. Other excisions of the skin and subcutaneous tissues
44. Simple restoration of surface continuity of the skin and subcutaneous tissues
45. Free skin transplantation, donor site
46. Free skin transplantation, recipient site
47. Revision of skin plasty
48. Other restoration and reconstruction of the skin and subcutaneous tissues
49. Chemosurgery to the skin
50. Destruction of diseased tissue in the skin and subcutaneous tissues
Operations on the tongue

51. Incision, excision and destruction of diseased tissue of the tongue
52. Partial glossectomy
53. Glossectomy
54. Reconstruction of the tongue
55. Other operations on the tongue
Operations on the salivary glands & salivary ducts

56. Incision and lancing of a salivary gland and a salivary duct
57. Excision of diseased tissue of a salivary gland and a salivary duct
58. Resection of a salivary gland
59. Reconstruction of a salivary gland and a salivary duct
60. Other operations on the salivary glands and salivary ducts
Other operations on the mouth & face

61. External incision and drainage in the region of the mouth, jaw and face
62. Incision of the hard and soft palate
63. Excision and destruction of diseased hard and soft palate
64. Incision, excision and destruction in the mouth
65. Plastic surgery to the floor of the mouth
66. Palatoplasty
67. Other operations in the mouth
Operations on the tonsils & adenoids

68. Transoral incision and drainage of a pharyngeal abscess
69. Tonsillectomy without adenoidectomy
70. Tonsillectomy with adenoidectomy
71. Excision and destruction of a lingual tonsil
72. Other operations on the tonsils and adenoids
Trauma surgery and orthopaedics
73. Incision on bone, septic and aseptic
74. Closed reduction on fracture, luxation or epiphyseolysis with osteosynthesis

75. Suture and other operations on tendons and tendon sheath
76. Reduction of dislocation under GA
77. Arthroscopic knee aspiration
Operations on the breast

78. Incision of the breast
79. Operations on the nipple
Operations on the digestive tract

80. Incision and excision of tissue in the perianal region
81. Surgical treatment of anal fistulas
82. Surgical treatment of haemorrhoids
83. Division of the anal sphincter (sphincterotomy)
84. Other operations on the anus
85. Ultrasound guided aspirations
86. Sclerotherapy etc.
87. Laparoscopic cholecystectomy
Operations on the female sexual organs

88. Incision of the ovary
89. Insufflation of the Fallopian tubes
90. Other operations on the Fallopian tube
91. Dilatation of the cervical canal
92. Conisation of the uterine cervix
93. Other operations on the uterine cervix
94. Incision of the uterus (hysterotomy)
95. Therapeutic curettage
96. Culdotomy
97. Incision of the vagina
98. Local excision and destruction of diseased tissue of the vagina and the pouch of Douglas
99. Incision of the vulva
100. Operations on Bartholin’s glands (cyst)
Operations on the prostate & seminal vesicles

101. Incision of the prostate
102. Transurethral excision and destruction of prostate tissue
103. Transurethral and percutaneous destruction of prostate tissue
104. Open surgical excision and destruction of prostate tissue
105. Radical prostatovesiculectomy
106. Other excision and destruction of prostate tissue
107. Operations on the seminal vesicles
108. Incision and excision of periprostatic tissue
109. Other operations on the prostate
Operations on the scrotum & tunica vaginalis testis

110. Incision of the scrotum and tunica vaginalis testis
111. Operation on a testicular hydrocele
112. Excision and destruction of diseased scrotal tissue
113. Plastic reconstruction of the scrotum and tunica vaginalis testis

114. Other operations on the scrotum and tunica vaginalis testis
Operations on the testes

115. Incision of the testes
116. Excision and destruction of diseased tissue of the testes
117. Unilateral orchidectomy
118. Bilateral orchidectomy
119. Orchidopexy
120. Abdominal exploration in cryptorchidism
121. Surgical repositioning of an abdominal testis
122. Reconstruction of the testis
123. Implantation, exchange and removal of a testicular prosthesis
124. Other operations on the penis
Operations on the spermatic cord, epididymis und ductus deferens

125. Surgical treatment of a varicocele and a hydrocele of the spermatic cord
126. Excision in the area of the epididymis
127. Epididymectomy
128. Reconstruction of the spermatic cord
129. Reconstruction of the ductus deferens and epididymis
130. Other operations on the spermatic cord, epididymis and ductus deferens
Operations on the penis

131. Operations on the foreskin
132. Local excision and destruction of diseased tissue of the penis
133. Amputation of the penis
134. Plastic reconstruction of the penis
135. Other operations on the penis
Operations on the urinary system

136. Cystoscopical removal of stones
Other Operations
137. Lithotripsy
138. Coronary angiography
139. Haemodialysis
140. Radiotherapy for Cancer
141. Cancer Chemotherapy

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SBI General Insurance Company Limited

CUSTOMER INFORMATION SHEET

(Description is illustrative and not exhaustive)

4. Pre-existing diseases: Covered after 48 months unless otherwise provided

Notwithstanding anything contained herein or otheruise, no refunds of

person may submit the necessary documents to TPA/Company within

Insurance Ombudsman — The contact details of the Insurance

14 Please disclose all pre-existing disease/s or condition/s before buying

Total Premium for all members

AROGYA PLUS POLICY

II. OPERATIVE CLAUSE

2. An AYUSH Hospital is a healthcare facility wherein medical/surgical/para-surgical treatment

a) Central or State Government AYUSH Hospital or

i. Having at least 5 in-patient beds;

i. Having qualified registered AYUSH Medical Practitioner(s) in charge;

24. Intensive Care Unit

IV. SCOPE OF COVER

Eating disorder is a mental condition where people experience severe

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

F33.0, F33.1, F33.2, F33.4, F33.5, F33.6, F33.7, F33.8,

F30.1, F30.2, F30.4, F30.5, F30.6, F30.7, F30.8,

F50.0, F50.2, F50.8, F98.3, F98.21, F50.8 Eating disorder

F42 Obsessive compulsive disorders

F41.1, F40.1, F60.7, F93.0, F94.0 Panic disorders

F44.4, F44.5, F44.6, F44.7 Conversion disorders

F44.5, F44.8, F48.1, F44.1, F44.2 Dissociative disorders

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

• Surgery of varicose veins and varicose ulcers;

3. 30-day waiting period- Code- (Excl03)

4. Treatment taken outside India.

9. Cosmetic or plastic Surgery:Code- (Excl08)

29. Investigation & Evaluation (Code- Excl04)

1) Surgery to be conducted is upon the advice of the Doctor

32. . Unproven Treatments: (Code- Excl16)

1. Condition Precedent to Admission of Liability

2. Disclosure to Information Norm:

5. Free look period

Insured must notify Insurer of any change in address.

15. Multiple Policies

For Detailed Guidelines on portability, kindly refer the link

24. Moratorium Period

Fax : 1800 22 7244 / 1800 102 7244

Office of Insurance the Areas of Jurisdiction

BENGALURU - Smt. Neerja Shah

BHOPAL - Shri Guru Saran Shrivastava

BHUBANESHWAR - Shri Suresh Chnadra Panda Orissa.

CHANDIGARH - Dr. Dinesh Kumar Verma Punjab,Haryana,

CHENNAI - Shri M. Vasantha Krishna Tamil Nadu,

DELHI - Shri Sudhir Krishna Delhi.

HYDERABAD - Shri I. Suresh Babu Andhra Pradesh,

JAIPUR - Smt. Sandhya Baliga Rajasthan.

ERNAKULAM - Ms. Poonam Bodra Kerala, UT of (a) Lakshadweep, (b)

KOLKATA - Shri P. K. Rath West Bengal,

3rd Floor, Jeevan SevaAnnexe, excluding Navi Mumbai & Thane.

20 BLOOD GROUPING AND CROSS MATCHING OF DONORS SAMPLES

52 PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES

List II— Items that are to be subsumed into Room charges

List III. Items that are subsumed into procedure charges.

23 ORTHOBUNDLE, GYNAEC BUNDLE

List IV— Items that are to be subsumed into Cost of Treatment