Revised Reliance Health Gain Policy Wordings

RELIANCE HEALTH GAIN - POLICY WORDINGS
SECTION-1 PREAMBLE i. Central or State Government AYUSH Hospital; or

This Policy is a contract of insurance issued by Reliance General ii. Teaching Hospital attached to AYUSH colleges recognized
Insurance Company Limited (hereinafter called the 'Company') to by the Central Government/Central Council of Indian
the Proposer mentioned in the Policy Schedule to cover the person(s) Medicine/Central Council for Homeopathy; or
named in the Policy Schedule (hereinafter called the 'Insured
iii. AYUSH Hospital, standalone or co-located with in-patient
Person(s)'). The Policy is based on the statements, declarations
healthcare facility of any recognized system of medicine,
provided in the Proposal Form and any other information provided by
registered with the local authorities, wherever applicable,
the Proposer to the Company for issuance of this Policy, and is subject
and is under the supervision of a qualified registered
to receipt of the requisite premium.
AYUSH Medical Practitioner and must comply with all the
SECTION-2 DEFINITIONS following with all the following criterion:
The terms defined below have the meanings ascribed to them • Having at-least 05 in-patient beds;
wherever they appear in this Policy and, where appropriate, references
• Having qualified AYUSH Medical Practitioner in charge
to the singular include references to the plural; references to the male
round the clock;
include the female and references to any statutory enactment include
subsequent changes to the same and vice versa. • Having dedicated AYUSH therapy sections as required
and/or has equipped operation theatre where surgical
2.1 STANDARD DEFINITIONS
procedure are to be carried out;
1) Accident/ Accidental means a sudden, unforeseen and
• Maintaining daily records of the patients and making
involuntary event caused by external, visible and violent means.
them accessible to the insurance Company’s authorized
2) Act means the Insurance Act 1938. representative.
3) Anyone Illness means Continuous period of Illness and includes 8) Bank Rate: means bank rate fixed by the Reserve Bank of India
relapse within 45 days from the date of last consultation with (RBI) at the beginning of the financial year in which claim has
the Hospital/Nursing Home centre where treatment was taken. fallen due.
4) Authority means the Insurance Regulatory and Development 9) Break in Policy means the period of gap that occurs at the end
Authority of India established under sub section 1 of section 3 of of the existing policy term/installment premium due date, when
the IRDA Act 1999. the premium due for renewal on a given policy or installment
premium due is not paid on or before the premium renewal
5) AYUSH Treatment means the medical and / or Hospitalization
date or grace period
treatments given under ‘Ayurveda, Yoga and Naturopathy,
Unani, Siddha and Homeopathy systems. 10) Cashless Facility means a facility extended by the Company
to the Insured where the payments, of the costs of treatment
6) AYUSH Day Care Centre means and includes Community
undergone by the Insured in accordance with the Policy Terms
Health Centre (CHC) , Primary Health Centre (PHC) ,Dispensary,
and Conditions, are directly made to network provider by the
Clinic, Polyclinic or any such health centre which is registered
Company to the extent pre-authorization is approved.
with the local authorities, wherever applicable and having
facilities for carrying out treatment procedures and medical 11) Complainant means a Policyholder or prospect or any
or surgical/para-surgical interventions or both under the beneficiary of an insurance policy who has filed a Complaint or
supervision of registered AYUSH Medical Practitioner(s) on Grievance against the Company or a Distribution Channel.
day care basis without in-patient services and must comply
12) Complaint or Grievance means written expression (includes
with all the following criterion:
communication in the form of electronic mail or other electronic
i. Having qualified registered AYUSH Medical Practitioner(s) scripts), of dissatisfaction by a Complainant with insurer,
in charge,
13) Distribution Channels, intermediaries, insurance intermediaries
ii. Having dedicated AYUSH therapy sections as required or other regulated entities about an action or lack of action
and /or has equipped operation theatre where surgical about the standard of service or deficiency of service of such
procedures are to be carried out; insurer, Distribution Channels, intermediaries, insurance
intermediaries or other regulated entities.
iii. Maintaining daily records of the patients and making
them accessible to the insurance Company’s authorized Explanation: An inquiry or request would not fall within the
representative. definition of the “Complaint” or “Grievance”.
7) AYUSH Hospital is a healthcare facility wherein medical/ 14) Condition Precedent means a Policy term or condition upon
surgical/para-surgical treatment and procedures and which the Company’s liability under the policy is conditional
interventions are carried out by AYUSH Medical Practitioner(s) upon.
comprising of any of the following:
15) Congenital Anomaly means a condition which is present
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IRDAI Registration No. 103. Reliance General Insurance Company Limited. An ISO 9001:2015 Certified Company
For complete details on the benefits, coverage, terms & conditions and exclusions, do read the sales brochure, prospectus and policy wordings
carefully before concluding sale. Registered & Corporate Office: 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off.
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belongs to Anil Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance Company Limited under License.
Reliance
Reliance Health
Health Gain
Gain Policy.
Policy. UIN:
UIN: RELHLIP22229V032122.
RELHLIP22229V032122. RGI/MCOM/CO/RHGP-PW/Ver. 2.0/290924.
since birth and which is abnormal with reference to form, 24) Domiciliary Hospitalization means medical treatment for an
structure or position. illness/disease/injury which in the normal course would require
care and treatment at a hospital but is actually taken while
i. Internal Congenital Anomaly
confined at home under any of the following circumstances:
Congenital Anomaly which is not in the visible and
accessible parts of the body. i. The condition of the patient is such that he/she is not in a
condition to be removed to a hospital, or
ii. External Congenital Anomaly
Congenital Anomaly which is in the visible and accessible ii. The patient takes treatment at home on account of non-
parts of the body. availability of room in a hospital.
16) Co-payment means a cost sharing requirement under this 25) Emergency/Emergency Care means management for
Policy that provides that the Policyholder/Insured will bear a an illness or injury which results in symptoms which occur
specified percentage of the admissible claims amount. A co- suddenly and unexpectedly and requires immediate care by
payment does not reduce the Sum Insured. a Medical practitioner to prevent death or serious long-term
impairment of the Insured person’s health.
17) Cumulative Bonus means any increase or addition in Base
Sum Insured granted by the Insurer without an associated 26) Grace period means the specified period of time, immediately
increase in premium. following the premium due date during which premium
payment can be made to renew or continue a policy in force
18) Day Care Centre means any institution established for Day
without loss of continuity benefits pertaining to waiting periods
Care Treatment of illness and/or injuries or a medical set-up
and coverage of pre-existing diseases. Coverage need not be
with a Hospital and which has been registered with the local
available during the period for which no premium is received.
authorities, wherever applicable, and is under supervision of a
The grace period for payment of the premium for all types
registered and qualified medical practitioner AND must comply
of insurance policies shall be: fifteen days where premium
with all minimum criteria as under.
payment mode is monthly and thirty days in all other cases.
i. Has qualified nursing staff under its employment.
27) Home Care Treatment means treatment availed by the Insured
ii. Has qualified Medical Practitioner/s in charge; Person at home which in normal course would require care
and treatment at a Hospital but is actually taken at home
iii. Has a fully equipped Operation theatre of its own, where provided that:
surgical procedures are carried out;
i. The Medical Practitioner advices the Insured Person to
iv. Maintains daily records of patients and will make these undergo treatment at home.
accessible to the Insurance company’s authorized
personnel. ii. There is a continuous active line of treatment with monitoring
of the health status of a Medical Practitioner for each day
19) Day Care Treatment means medical treatment, and/ or through the duration of the home care treatment.
surgical procedure which is:
iii. Daily monitoring chart including records of treatment
i. Undertaken under general or local anesthesia in a administered duly signed by the treating doctor is
Hospital/ Day Care center in less than 24 hours because of maintained
technological advancement, and
28) Hospital means any institution established for In-patient care
ii. Which would have otherwise required Hospitalization of and Day Care Treatment of Illness and / or Injuries and which
more than 24 consecutive hours. has been registered as a Hospital with the local authorities,
iii. Treatment normally taken on an out-patient basis is not under the Clinical Establishments (Registration & Regulation)
included in the scope of this definition. Act, 2010 or under enactments specified under the schedule
of section 56(1) of the said Act or complies with all with all
20) Deductible means a cost sharing requirement under a health minimum criteria as under :
insurance policy that provides that the insurer will not be liable
for a specified rupee amount in case of indemnity policies and i. Has qualified nursing staff under its employment round the
for a specified number of days/hours in case of hospital cash clock;
policies which will apply before any benefits are payable by the ii. Has at least 10 in-patient beds, in towns having a population
insurer. A deductible does not reduce the Sum Insured. of less than 10,00,000 and 15 in-patient beds in all other
21) Dental treatment means a treatment related to teeth or places;
structures supporting teeth including examinations, fillings iii. Has qualified Medical Practitioner(s) in charge round the
(where appropriate), crowns, extractions and surgery. clock;
22) Disclosure to information norm: The policy shall be void and iv. Has a fully equipped Operation theatre of its own, where
all premium paid thereon shall be forfeited to the Company surgical procedures are carried out;
in the event of misrepresentation, mis-description or non-
disclosure of any material fact. v. Maintains daily records of patients and makes these
accessible to the Insurance company’s authorized
23) Distribution Channels means persons and entities authorized personnel.
by the Authority to involve in sale and service of insurance
products. For the purpose of this Policy, it means the Distribution 29) Hospitalization means admission in a Hospital for a minimum
Channels who is an Intermediary of the Company. period of 24 consecutive ‘In-patient Care’ hours except for

Reliance Health Gain Policy. UIN: RELHLIP22229V032122.
specified procedures/ treatments, where such admission could and no more than other Hospitals or doctors in the same
be for a period of less than 24 consecutive hours (Day Care locality would have charged for the same medical treatment.
Treatment).
38) Medically Necessary Treatment means any treatment, tests,
30) Illness means a sickness or a disease or pathological condition medication or stay in Hospital or part of a stay in Hospital
leading to the impairment of normal physiological function and which
requires medical treatment.
i. Is required for the medical management of the illness/injury
i. Acute condition - Acute condition is a disease, Illness or suffered by the Insured.
Injury that is likely to respond quickly to treatment which
ii. Must not exceed the level of care necessary to provide safe,
aims to return the person to his or her state of health
adequate and appropriate medical care in scope, duration
immediately before suffering the disease/ illness/ injury
or intensity.
which leads to full recovery
iii. Must have been prescribed by a Medical Practitioner;
ii. Chronic condition - A chronic condition is defined as
a disease, Illness, or Injury that has one or more of the iv. Must conform to the professional standards widely
following characteristics: accepted in international medical practice or by the medical
community in India.
• It needs ongoing or long-term monitoring through
consultations, examinations, check-ups, and /or tests" 39) Medical Practitioner/Physician means a person who holds
a valid registration from the Medical Council of any State or
• It needs ongoing or long-term control or relief of symptoms
Medical Council of India or Council for Indian Medicine or for
• It requires rehabilitation for the patient or for the patient to Homeopathy set up by the Government of India or a State
be specially trained to cope with it Government and is thereby entitled to practice medicine within
its jurisdiction; and is acting within its scope and jurisdiction of
• It continues indefinitely
license.
• It recurs or is likely to recur
Medical Practitioner for Mental Illness shall be in accordance
31) Injury means accidental physical bodily harm excluding illness with The Mental Healthcare Act, 2017.
or disease solely and directly caused by external, violent, visible
The registered practitioner should not be the Policyholder/
and evident means which is verified and certified by a Medical
Insured or their close family member.
Practitioner.
40) Migration means a facility provided to policyholders (including
32) In-Patient Care/ In-Patient Treatment means treatment for
all members under family cover and group policies), to transfer
which the Insured Person has to stay in a Hospital for more
the credits gained for pre-existing diseases and specific
than 24 hours for a covered event.
waiting periods from one health insurance policy to another
33) Intensive / Critical Care Unit (ICU/CCU) means an identified with the same insurer.
section, ward or wing of a Hospital which is under the constant
41) Network Provider
supervision of dedicated Medical Practitioner(s), and which
means hospitals or health care providers enlisted by an insurer,
is specially equipped for the continuous monitoring and
TPA or jointly by an Insurer and TPA to provide medical services
treatment of patients who are in a critical condition, or require
to an insured by a cashless facility
life support facilities and where the level of care and supervision
is considerably more sophisticated and intensive than in the 42) Newborn baby means baby born during the Policy Period and
ordinary and other wards. is aged upto 90 days
34) ICU (Intensive Care Unit) Charges means the amount charged 43) Non-Network Provider/Hospital means any Hospital, Day
by a Hospital towards ICU expenses which shall include the Care center or other provider that is not part of the Network.
expenses for ICU bed, general medical support services
44) Notification of claim means the process of intimating a claim
provided to any ICU patient including monitoring devices,
to the insurer or TPA through any of the recognized modes of
critical care nursing and intensivist charges.
communication.
35) Maternity Expenses means
45) OPD treatment means the one in which the Insured visits a
i. Medical Treatment Expenses traceable to childbirth clinic / Hospital or associated facility like a consultation room
(including complicated deliveries and caesarean sections for diagnosis and treatment based on the advice of a Medical
incurred during hospitalization). Practitioner. The Insured is not admitted as a Day Care or In-
patient.
ii. Expenses towards lawful medical termination of pregnancy
during the Policy Period. 46) Post Hospitalization Medical Expenses means Medical
Expenses incurred during pre-defined number of days
36) Medical Advice means any consultation or advice from a
immediately after the Insured Person is discharged from the
Medical Practitioner including the issuance of any prescription
Hospital provided that:
or follow-up prescription.
i. Such medical expenses are incurred for the same condition
37) Medical Expenses means those expenses that that an Insured
for which the Insured Person’s hospitalization was required
Person has necessarily and actually incurred for medical
and
treatment on account of Illness or Accident on the advice of a
Medical Practitioner, as long as these are no more than would ii. The In-patient hospitalization claim for such Hospitalization
have been payable if the Insured Person had not been insured is admissible by the Company

47) Portability means a facility provided to the health insurance 57) Senior citizen means any person who has completed sixty
policyholders (including all members under family cover), or more years of Age as on the date of commencement or
to transfer the credits gained for, pre-existing diseases and renewal of the Policy.
specific waiting periods from one insurer to another insurer
58) Surgery / Surgical Procedure / Surgical Operation means
48) Pre-existing Disease means any condition, ailment, Injury or manual and/or operative procedure(s) required for treatment
disease: of an Illness or Injury, correction of deformities and defects,
diagnosis and cure of diseases, relief of suffering or
i. That is/are diagnosed by a physician not more than 36 months
prolongation of life, performed in a Hospital or Day Care
prior to the date of commencement of the policy issued by the
centre by a Medical Practitioner.
insurer; or
59) Unproven/ Experimental Treatments means the treatment
ii. For which medical advice or treatment was recommended by,
including drug experimental therapy which is not based on
or received from, a physician, not more than 36 months prior to
established medical practice in India, is treatment experimental
the date of commencement of the policy.
or unproven.
49) Pre-hospitalization Medical Expenses means Medical
2.2 SPECIFIC DEFINITIONS
expenses incurred during pre-defined number of days
preceding the hospitalization of the Insured Person, provided 1) Age means means “Age as on last birthday” as determined
that: on the date of first Policy issuance or at Renewal. In case of
change in Age during the proposal stage then “Age” shall be
i. Such Medical Expenses are incurred for the same condition
determined on the date of Proposal Form submission would
for which the Insured Person’s hospitalization was required
be considered for premium calculation.
and
1) Ambulance means a road vehicle or an aircraft operated by
ii. The In-patient hospitalization claim for such Hospitalization
a licensed / authorized service provider and equipped for the
is admissible by the Company
transport and paramedical treatment of the person requiring
50) Proposal Form means a form to be filled in by the Prospect in medical attention.
written or electronic or any other format as approved by the
2) Annexure means document attached and marked as
Authority, for furnishing all material information as required by
Annexure to this Policy.
the insurer in respect of a risk, in order to enable the insurer
to take informed decision in the context of underwriting the 3) Base Sum Insured means the amount specified as Base Sum
risk, and in the event of acceptance of the risk, to determine Insured in the Policy Schedule. Calculation of bonus and sub-
the rates, advantages, terms and conditions of the cover to be limits mentioned under the Policy shall be on basis of the Base
granted. Sum Insured.
Explanation: “Material Information” shall mean all important, 4) Child means Insured Person’s biological or legally adopted son
essential and relevant information sought by the Company in or daughter, whose completed age is between 3 months to 25
the proposal form and other connected documents to enable years as on Policy Period Start Date, and who is financially
him to take informed decision in the context of underwriting the dependent on the Insured Person and does not have an
risk independent source of income.
51) Prospect means any person who is potential customer of an 5) Claim means a demand made by the Policyholder or on his
insurer and is likely to enter into an insurance contract either behalf, for payment of Medical Expenses under any other
directly with the insurer or through a Distribution Channel. Benefit, as covered under the Policy.
52) Prospectus means a document either in physical or electronic 6) Companion, For the purposes of this Policy, Companion
or any other format issued by the insurer to sell or promote the means Insured Person’s family member/ relative above 18
insurance products years of age who is accompanying the Insured Person during
the Hospitalization.
53) Qualified Nurse means a person who holds a valid registration
from the Nursing Council of India or the Nursing Council of any 7) Company means Reliance General Insurance Company
state in India. Limited.
54) Reasonable & Customary Charges means the charges for 8) Cosmetic Surgery/Treatment means Surgery/ treatment
services or supplies, which are the standard charges for the which is primarily done for the enhancement of appearance
specific provider and consistent with the prevailing charges in through surgical and medical techniques.It concerns with
the geographical area for identical or similar services, taking maintaining normal appearance, restoring or enhancing it.
into account the nature of the illness / injury involved
9) Dependent means financially dependent on the Policyholder
55) Renewal means the terms on which the contract of insurance and does not have independent source of income.
can be renewed on mutual consent with a provision of Grace
10) Family means as defined in the Policy Schedule. For the
Period for treating the renewal continuous for the purpose of
purposes of this Policy, it shall include the Policyholder and
gaining credit for pre-existing diseases, time-bound exclusions
anyone or more of the family members as mentioned below:
and for all waiting periods.
i. legally wedded spouse
56) Room Rent means the amount charged by a Hospital towards
Room and Boarding expenses and shall include the associated ii. Parents and/or Parents- in law
medical expenses.
iii. maximum six dependent children(i.e. biological or adopted)

between the age of 3 months to 25 years. If the child is benefits under the Policy are subject to.
above 18 years of age is financially independent, he or she
18) Policyholder means the person who is the Proposer and
shall be ineligible for coverage in the subsequent renewals.
whose name specifically appears in the Policy Schedule as
11) Insured Person/Insured means a person accepted by the such.
Company to be Insured under this Policy and who meets and
19) Policy Period means the period commencing from the Policy
continues to meet all the eligibility requirements and whose
Period Start Date as specified in Policy Schedule and ending
name specifically appears under Insured /Insured Person in
on the Policy Period End Date as specifically appearing in the
the Policy Schedule and with respect to whom the premium
Policy Schedule or on the date of cancellation of the Policy,
has been received by the Company.
whichever is earlier.
12) Life Threatening Medical Condition means a medical
20) Policy Period End Date means the date and time at which the
condition suffered by the Insured Person which has any of the
Policy Period ends as specified in the Policy Schedule.
following characteristics:
21) Policy Period Start Date means the date and time at which the
i. Markedly unstable vital parameters (blood pressure, pulse,
Policy Period commences as specified in the Policy Schedule.
temperature and respiratory rate); or
22) Policy Year means a period of 12 consecutive months starting
ii. Acute impairment of one or more vital organ systems
from the Policy Period Start Date and ending on the last day
(involving brain, heart, lungs, liver, kidneys and pancreas);
of such 12 month period. For the purpose of subsequent years,
or
Policy Year shall mean a period of 12 months commencing
iii. Critical care being provided, which involves highly complex from the end of previous Policy Year and lapsing on the last
decision making to assess, manipulate and support day of such 12month period, till the Policy Period End Date, as
vital system function(s) to treat single or multiple vital mentioned in the Policy Schedule.
organ failure(s) and requires interpretation of multiple
23) Rehabilitation means assisting an Insured Person who,
physiological parameters and application of advanced
following a medical condition, requires assistance in physical,
technology; or
vocational, independent living and educational pursuits to
iv. Critical Care being provided in critical care areas such as restore him to the position in which he was in, prior to such
coronary care unit, intensive care unit, respiratory care unit, medical condition occurring.
or the emergency department; and
24) Second Opinion means an additional medical opinion obtained
v. is certified by the attending Medical Practitioner as a Life from a Medical Practitioner solely on the Policyholder’s or
Threatening Medical Condition. Insured Person’s express request in relation to listed Critical
Illness (specified in Benefit no-3.7.10.3 Second Opinion) which
13) Mental Illness means a substantial disorder of thinking,
the Insured Person has been diagnosed with during the Policy
mood, perception, orientation or memory that grossly impairs
Year.
judgment, behavior, capacity to recognize reality or ability
to meet the ordinary demands of life, mental conditions 25) Sub-limit means a cost sharing requirement under a health
associated with the abuse of alcohol and drugs, but does not insurance policy in which an insurer would not be liable to pay
include mental retardation which is a condition of arrested any amount in excess of the pre-defined limit
or incomplete development of mind of a person, specially
26) Sum Insured means the maximum, total and cumulative
characterized by sub normality of intelligence.
liability of the Company to pay the claims made under the
14) Migration means a facility provided to policyholders (including Policy in respect of that Insured Person (on Individual basis)
all members under family cover and group policies), to transfer or all Insured Persons (on Floater basis) during the Policy Year
the credits gained for pre-existing diseases and specific basis, for the following covers and in this order:
waiting periods from one health insurance policy to another
i. Base Sum Insured
with the same insurer.
ii. Benefit- 3.2.2-Extra Sum Insured or Benefit-3.7.2-Double
15) Nominee means the person whose name specifically appears
Cover(whichever is applicable)
as such in the Policy Schedule and is the person to whom the
proceeds under this Policy, if any, shall become payable in the iii. Benefit-3.5.1-Cumulative bonus
event of the death of the Policyholder. Nominee for all other
Insured Person(s) shall be the Policyholder himself. iv. Benefit-3.6.3-Policy Service Guaranteed Sum Insured(if
applicable)
16) Policy means these Policy wordings, the Policy Schedule and
any applicable endorsements or extensions attaching to or v. Benefit-3.2.1 Reinstated Sum Insured or Benefit-3.7.1.2
forming part thereof. The Policy contains details of the extent Unlimited Reinstatement of Base Sum(which ever is
of cover available to the Insured person, what is excluded from applicable)
the cover and the terms & conditions on which the Policy is 27) Survival Period means the period that the Insured Person has
issued to the Insured Person. to survive before a claim becomes valid, commencing from the
17) Policy Schedule/Schedule means the Policy Schedule date of First Diagnosis.
attached to and forming part of this Policy mentioning apart 28) Telemedicine means Medical consultation service availed via
from other details, Policyholder’s details, details of the Insured telecommunications and digital communication technologies
Person, coverage, sections and benefits applicable, the Base by the Insured Person from a Medical Practitioner while
Sum Insured, the Policy Period, Premium paid (including taking treatment for the health condition that has resulted
duties, taxes and levies thereon) and the limits to which

in an admissible Claim under a cover in this Policy. Such The Company shall indemnify the Policyholder/Insured Person for
Telemedicine services shall be delivered in compliance with the the Medical Expenses incurred during the Policy Year, if the Insured
Medical Council of India’s ‘Telemedicine Practice Guidelines’ Person undergoes a Day Care Treatment as defined under this
dated March 2020 or its subsequent amendments, if any. Policy, on the written advice of a Medical Practitioner.
29) Total Liability means the sum total of Sum Insured and below 3.1.1.3 ACCOMMODATION BONUS
listed covers
The Company shall pay a fixed daily amount of Rs 1000 to the
i. Benefit-3.1.1.3-Accomodation Bonus Policyholder/Insured Person, if during the Policy Year, the Insured
Person undergoes Hospitalization for In-Patient Treatment and
ii. Benefit-3.3.1 -Accidental Death Cover
occupies the following Room Categories:
iii. Benefit-3.4.1-Waiver of Premium
i. For Plus and Power: Twin sharing Room or below
iv. Benefit-3.5.3-Loyalty Cover
ii. For Prime: Single Private Air-Conditioned Room or below
v. Benefit-3.7.7-Hospital Cash (if opted)
Provided that:
vi. Benefit-3.7.8.4-Convalescence Cover (if opted)
a. The above mentioned fixed daily amount shall be payable
vii. Benefit-3.7.9.1-Health Check Up (if opted) for each continuous and completed 24 hours of such
Hospitalization
viii. Benefit-3.7.9.2-Vaccination Cover (if opted)
b. The daily amount mentioned above shall not be payable
ix. Benefit-3.7.11.2-Companion Cover (if opted) for the number of completed days the Insured Person is
x. Benefit-3.7.11.3-Child Care Cover (if opted) admitted into an ICU Room.
SECTION-3 SCOPE OF COVER c. If the Policyholder has opted Benefit-3.7.3 Change in Room
Rent Limits, then daily amount mentioned above shall be
The Company hereby agrees subject to the terms, conditions and payable only on occupying a category of Room lower than
exclusions contained or expressed herein, to compensate the that selected under optional Benefit-3.7.3 Change in Room
Insured Person as per the covers and limits specified in the Policy Rent Limits
Schedule.
d. The daily amount mentioned above shall not be payable
3.1 HOSPITALIZATION COVERS for the Room Category opted by the Insured Person Benefit
3.1.1 HOSPITALIZATION EXPENSES - 3.7.3 Change in Room Rent Limits
If any of the Insured Person is diagnosed with any Illness or suffers e. The Company has accepted the claim under Benefit -
any Injury that requires Hospitalization, (including Hospitalization 3.1.1.1. In Patient Treatment
under AYUSH Treatment), during the Policy Period, then the 3.1.2 DOMESTIC ROAD AMBULANCE
Company shall pay Medical Expenses incurred by the Policyholder/
Insured Person, subject to the limits, terms, conditions and exclusions The Company shall indemnify the Policyholder/Insured Person up
mentioned under this Policy. to the amount specified in the Policy Schedule, per Hospitalization,
for expenses incurred on availing Road Ambulance services offered
The Medical Expenses as mentioned above shall mean the by a Hospital or by an Ambulance service provider, provided that
Reasonable and Customary Charges which include the following:
i. Company has accepted the Inpatient Hospitalization claim
i. Room Rent under Benefit 3.1.1.1 In Patient Treatment.
ii. Nursing expense ii. The coverage includes the cost of the transportation of
iii. Intensive care Unit (ICU) charges, the Insured Person to the nearest Hospital in case of an
emergency Life Threatening Medical condition, or from
iv. Medical Practitioner(s) fees, one Hospital to another Hospital which is prepared to
admit the Insured Person and provide the necessary
v. Anesthesia, blood, oxygen, operation theatre charges,
medical services
surgical appliances expenses,
iii. Such Life-Threatening Medical Condition is certified by the
vi. Medicines, drugs and Consumables expenses
Medical Practitioner
vii. Diagnostic procedures expenses
iv. The transportation from one Hospital to another Hospital
viii. The cost of prosthetic and other devices or equipment if has been prescribed by a Medical Practitioner and is
implanted internally during a Surgical Procedure, unless medically necessary.
specifically excluded.
v. Subject to all other conditions mentioned above, in case
3.1.1.1 IN-PATIENT TREATMENT where such transportation is required ‘intercity’ (beyond
100km in distance), the coverage limit under this benefit
The Company shall indemnify the Policyholder/Insured Person for
shall be extended upto the amount specified in the Policy
the Medical Expenses incurred during the Policy Year, if the Insured
Schedule for ‘Intercity Ambulance cost’ (beyond 100km in
Person undergoes Hospitalization for In-Patient Treatment, on the
distance).
written advice of a Medical Practitioner.
3.1.3 DOMICILIARY HOSPITALIZATION
3.1.1.2 DAY CARE TREATMENT
The Company shall indemnify the Policyholder/Insured Person

up to an amount specified in the Policy Schedule, for the Medical the Medical Expenses incurred in the 60 days immediately before
Expenses incurred for Domiciliary Hospitalization during the Policy the Insured Person was Hospitalized, provided that:
Year, provided that the condition for which the medical treatment
i. Such Medical Expenses are incurred in respect of the
is required continues for at least three continuous and completed
same condition for which the Insured Person has taken
days, in which case the Company shall pay the Reasonable and
Hospitalization, and
Customary Charges for necessary medical treatment for the entire
period. ii. The Company has accepted the claim for these
Hospitalization expenses under any one of the following
The Company shall not be liable for payment of any Claim under
Benefits: 3.1.1,3.1.3,3.1.4
this Benefit in relation to treatment of any of the following diseases:
3.1.6 POST-HOSPITALIZATION
i. Asthma
The Company shall indemnify the Policyholder/Insured Person for
ii. Bronchitis
the Medical Expenses incurred in the 60 or 90 days (as specified
iii. Chronic Nephritis and Chronic Nephritic Syndrome in the Policy Schedule) immediately after the Insured Person was
discharged post Hospitalization, provided that:
iv. Diarrhea and all types of Dysenteries including Gastro-
enteritis i. Such costs are incurred in respect of the same condition for
which the Insured Person has taken Hospitalization, and
v. Diabetes Mellitus and Insipidus
ii. The Company has accepted the claim for these
vi. Epilepsy
Hospitalization expenses under any one of the following
vii. Hypertension Benefits: 3.1.1,3.1.3,3.1.4
viii. Influenza, Cough and Cold 3.1.7 ORGAN DONOR EXPENSES
ix. All Psychiatric or Psychosomatic Disorders The Company shall indemnify the Policyholder/Insured Person
up to an amount specified in the Policy Schedule for the Medical
x. Pyrexia of unknown origin for less than 10 days Expenses incurred, during In Patient Treatment, in respect of donor
xi. Tonsillitis and Upper Respiratory Tract Infection including of any organ transplant surgery conducted on the Insured Person
Laryngitis and Pharyngitis during the Policy Year, provided that:
Arthritis, Gout and Rheumatism i. The organ donated is for the Insured Person’s use.
3.1.4 MODERN TREATMENT ii. The Company has accepted In-Patient Hospitalization
Claim under Benefit 3.1.1.1 In Patient Treatment.
The Company shall indemnify the Insured Person up to the limit
as specified in the Policy Schedule for the Medical Expenses iii. The Company shall not pay the donor’s Pre and Post
incurred during the Policy Year on Inpatient Treatment or Day Care Hospitalization Expenses
Treatment or Domiciliary Treatment of below mentioned Modern An organ donor is any person whose organ has been made available
Treatment Methods: in accordance and compliance with The Transplantation of Human
i. Uterine Artery Embolization and HIFU Organs Act, 1994 (amended).
ii. Balloon Sinuplasty 3.2 EXTRA COVER
iii. Deep Brain Stimulation 3.2.1 REINSTATEMENT OF BASE SUM INSURED
iv. Oral Chemotherapy The Company shall carry out one reinstatement, upto the Base
Sum Insured, after the Base Sum Insured, Double Cover or Extra
v. Immunotherapy-Monoclonal Antibody to be given as Sum Insured (whichever is applicable), Cumulative Bonus and Policy
injection Service Guarantee Sum Insured (if any) have been utilized completely
vi. Intra Vitreal injections for claims incurred under the Policy, for the particular Policy Year,
provided that:
vii. Robotic surgeries
i. For a claim to be admissible under Re-instated Sum Insured
viii. Stereotactic radio surgeries it should be admissible under the Benefits- 3.1 Hospitalization
Covers
ix. Bronchical Thermoplasty
ii. The limits of claims in aggregate under Re-instated Sum
x. Vaporization of the prostrate (Green laser treatment or
Insured during a Policy Year shall be as per follows:
holmium laser treatment)
a. Up to 100% of Base Sum Insured
xi. IONM- (Intra Operative Neutro Monitoring)
• For subsequent claims for unrelated illness or injury.
xii. Stem Cell therapy: including Hematopoietic stem cells for
bone marrow transplant for hematological conditions b. Upto 20% of Base Sum Insured
The claim under this benefit shall be subject to all other terms under • for subsequent claim which has arisen out of or is a
Benefits 3.1.1, 3.1.3, 3.1.5, 3.1.6 and3.1.7 consequence of or its related to or is a complication of an
illness/injury for which a claim has already been admitted
3.1.5 PRE-HOSPITALIZATION
under the current or any previous Policy in relation to an
The Company shall indemnify the Policyholder/Insured Person for Insured Person.

iii. The Re-instated Sum Insured for a particular Policy Year can benefit directly or indirectly arising out of or relating to:
be utilized only after the Base Sum Insured, Double Cover or
i. Any pre-existing injury or physical condition
Extra Sum Insured (whichever is applicable), Cumulative Bonus
and Policy Service Guarantee Sum Insured (if applicable)have ii. Whilst engaging in aviation or ballooning, or whilst mounting
been completely exhausted in that Policy Year. into, or dismounting from or travelling in any balloon or aircraft
other than as a passenger (fare-paying or otherwise) in any
iv. The Reinstated Sum Insured shall be available only for all
Scheduled Airlines in the world.
subsequent claims.
iii. An Insured Person flying in an aircraft other than as a fare
v. The Company’s overall liability for all claims, in aggregate,
paying passenger in any Scheduled Airlines in the world.
within a Policy Year under this cover shall not exceed the Base
Sum Insured iv. Any intentional self-inflicted Injury unless in self-defense or to
save life, suicide or attempted suicide, sexually transmitted
vi. While calculating Cumulative Bonus, Re-instated Sum Insured
conditions, mental and nervous, insanity, disorder, anxiety,
shall not be considered.
stress or depression.
vii. The Reinstatement of Sum Insured shall be done on Individual
v. Whilst under the influence of intoxicating liquor or drugs or
basis for Individual Policies and on Floater basis for Floater
other intoxicants except where the insured is not directly
policies
responsible for the injury/accident through under influence of
viii. The unutilized Re-instated Sum Insured cannot be carried intoxication.
forward to any subsequent Policy Year.
vi. Insured Person engaging in sporting activities in so far as
3.2.2 EXTRA SUM INSURED they involve the training for or participation in competitions of
professional sports, unless declared beforehand and agreed
The Company shall provide an additional 20% of Base Sum Insured
by the Company subject to additional premium being paid and
as Extra Sum Insured on the same claim, which can be utilized
incorporated accordingly in the Policy.
after the Base Sum Insured has been utilized completely for claims
incurred under the Policy, for the particular Policy Year, provided vii. Insured Person serving in any branch of the Military, Navy or
that: Air-force or any branch of Armed Forces or any paramilitary
forces except during peace time
i. For a claim to be admissible under this benefit it should be
admissible under the Benefit- 3.1 Hospitalization Covers viii. Insured person working in/with mines, tunneling or explosives
or involving electrical installation with high tension supply or
ii. The Extra Sum Insured shall be available only for the same
conveyance testing or oil rigs work or ship crew services or as
claim, which is payable under the Base Sum Insured during a
jockeys or circus personnel or aerial photography or engaged
single hospitalization.
in Hazardous Activities
iii. The Extra Sum Insured for a particular Policy Year can be
ix. Results from pregnancy or child-birth
utilized only after the Base Sum Insured has been completely
exhausted in that Policy Year. x. Impairment of an Insured’s intellectual faculties by abuse of
stimulants or depressants or by the illegal use of any solid,
iv. The Company’s overall liability for all claims, in aggregate,
liquid or gaseous substance.
within a Policy Year under this benefit shall be limited to 20%
of the Base Sum Insured 3.4 CRITICAL ILLNESS COVER
v. The benefit can be utilized once in Policy Year. 3.4.1 WAIVER OF PREMIUM
vi. While calculating Cumulative Bonus, Extra Sum Insured shall If the Policyholder (who is also an Insured Person) as covered under
not be considered. the Policy is diagnosed for the first time, with any of the listed Critical
Illness which is admissible and payable under this cover, during the
vii. The Extra Sum Insured shall be available on Individual basis for
Policy Year, then the renewal Policy premium for a period of one
Individual Policies and on Floater basis for Floater policies
year shall be waived off. For a long-term Policy, the Company shall
viii. Any unutilized Extra Sum Insured shall not be carried forward waive one year proportionate renewal Policy premium. This is subject
to any subsequent Policy Year. to following:
3.3 PERSONAL ACCIDENT COVER i. This benefit is provided once in the lifetime to the Policyholder.
3.3.1 ACCIDENTAL DEATH COVER ii. The Critical Illness has been diagnosed for the first time during
the Policy Year.
If the Insured Person, sustains an injury, from an Accident during the
Policy Year and if such injury shall within twelve calendar months of iii. Such Renewal shall be done on the same basis as the expiring
its occurrence be the sole and direct cause of death of the Insured Policy.
Person, then the Company shall be liable to pay 5% of the Base Sum
iv. The Cumulative Bonus will not be accrued in the year claim
Insured subject to a minimum of Rs 1 lakh to Nominee /Legal Heir/
has been made under the Policy.
Assignee as stated in the Policy Schedule.
For the purpose of this Benefit, Critical illness is as defined below: -
The payment under this benefit shall not reduce the Base Sum
Insured. “Critical Illness” means disease / illness / surgery limited to the
following.
Exclusions applicable to Benefit-3.3.1 Accidental Death Cover
i. Cancer of specified severity
The Company shall not be liable for payment of any claim under this

A malignant tumour characterized by the uncontrolled growth & confirmed and evidenced by all of the following:
spread of malignant cells with invasion & destruction of normal
a. Investigations including typical MRI findings which unequivocally
tissues. This diagnosis must be supported by histological
confirm the diagnosis to be multiple sclerosis and
evidence of malignancy & confirmed by a pathologist. The
term cancer includes leukemia, lymphoma and sarcoma. b. There must be current clinical impairment of motor or sensory
function, which must have persisted for a continuous period of
The following are excluded —
at least 6 months.
a. All tumors which are histologically described as carcinoma
Other causes of neurological damage such as SLE and HIV are
in situ, benign, pre-malignant, borderline malignant, low
excluded.
malignant potential, neoplasm of unknown behavior, or non-
invasive, including but not limited to: Carcinoma in situ of 3.5 RENEWAL BENEFITS
breasts, Cervical dysplasia CIN-1, CIN -2 and CIN-3.
3.5.1 CUMULATIVE BONUS
b. Any non-melanoma skin carcinoma unless there is evidence of
metastases to lymph nodes or beyond; The Company shall provide 33.33 % (one third) of the Base Sum
Insured as Cumulative Bonus at the end of each completed and
c. Malignant melanoma that has not caused invasion beyond the continuous Policy Year, provided that no Claim has been made in
epidermis; the expiring Policy Year. This benefit is subject to the following:
d. All tumors of the prostate unless histologically classified as i. In any Policy Year, the accrued Cumulative Bonus, including
having a Gleason score greater than 6 or having progressed to the one credited under Portability if any, shall not exceed 100%
at least clinical TNM classification T2N0M0 of the of Base Sum Insured available in this renewed Policy.
e. All Thyroid cancers histologically classified as T1N0M0 (TNM ii. The Cumulative Bonus shall not enhance the available Room
Classification) or below; Category limit and other such limits which are a function of
Sum Insured which shall always be applicable on the Base
f. Chronic lymphocytic leukaemia less than RAI stage 3
Sum Insured.
g. Non-invasive papillary cancer of the bladder histologically
iii. In relation to a Floater, the Cumulative Bonus, shall be available
described as TaN0M0 or of a lesser classification,
on Floater basis. The Cumulative Bonus which accrued during
h. All Gastro-Intestinal Stromal Tumors histologically classified as a claim-free Policy Year will only be available to those Insured
T1N0M0 (TNM Classification) or below and with mitotic count of Person(s) who were insured in such claim-free Policy Year and
less than or equal to 5/50 HPFs; continue to be insured in the subsequent Policy Year.
i. All tumors in the presence of HIV infection. iv. If the Insured Persons in the expiring Policy are covered on
an Individual basis and the expiring Policy has been Renewed
ii. Open chest Coronary Artery Bypass Graft (CABG)
on a Floater basis, then the Cumulative Bonus to be carried
The actual undergoing of heart surgery to correct blockage or forward for such Renewed Policy shall be the one that is the
narrowing in one or more coronary artery(s), by coronary artery bypass lowest among all the Insured Persons.
grafting done via a sternotomy (cutting through the breast bone) or
v. In case of Floater Policy where Insured Persons renew their
minimally invasive keyhole coronary artery bypass procedures. The
expiring Policy by splitting the Policy in to two or more Floater
diagnosis must be supported by a coronary angiography and the
Policies/Individual Policies, the Cumulative Bonus shall be split
realization of surgery has to be confirmed by a cardiologist.
equally amongst Insured Persons; except where the Policy is
The following are excluded: split due to the child attaining the age of 25 years, in which
case both the renewed Policies shall carry the full accrued
a. Angioplasty and/or any other intra-arterial procedures Cumulative Bonus.
iii. Stroke resulting in permanent symptoms vi. If the Policyholder opts to reduce the Base Sum Insured at the
Any cerebrovascular incident producing permanent neurological time of Renewal, the applicable Cumulative Bonus shall be
sequelae. This includes infarction of brain tissue, thrombosis in reduced in the same proportion to the Base Sum Insured in
an intracranial vessel, haemorrhage and embolisation from an renewed Policy.
extracranial source. Diagnosis has to be confirmed by a specialist vii. If a claim is made in the expiring Policy Year and is notified to
medical practitioner and evidenced by typical clinical symptoms as the Company after the acceptance of Renewal premium, any
well as typical finding in CT scan or MRI of the brain. Evidence of incremental Cumulative Bonus awarded basis the expiring
permanent neurological deficit lasting at least 3 months has to be Policy Year shall be withdrawn.
produced.
viii. Entire Cumulative Bonus will be lost if Policy is not continued /
The following are excluded: renewed on or before expiry of Grace Period.
a. Transient ischemic attacks (TIA) ix. Cumulative Bonus shall be applicable on an annual basis
b. Traumatic injury of the brain subject to continuation of the Policy.
c. Vascular disease affecting only the eye or optic nerve or x. In case of a claim in any given Policy Year the Cumulative
vestibular functions Bonus shall be decreased by 33.33% (one third) of the Base
Sum Insured in the subsequent year. However, the reduction
iv. Multiple Sclerosis with persisting symptoms in Cumulative Bonus shall not reduce the Base Sum Insured.
The unequivocal diagnosis of Definite Multiple Sclerosis xi. Cumulative Bonus shall decrease to the extent (in-part or

whole) of Cumulative Bonus amount utilized for settlement of before expiry of Grace Period.
claim.
viii. In case the Insured Person(s) in the expiring 4 consecutive and
xii. The accrued Cumulative Bonus will be carried forward to the continuous Policy Years are covered on individual basis and
renewed Policy. This shall apply even if the Policyholder avails desire to renew such expiring policy with the Company on a
the Benefit -3.5.2 (Call Option for Enhancement of Base Sum Floater basis and are eligible for Call option then the amount
Insured) available for call option shall be basis the lowest of the Base
Sum Insured amongst all the Insured Person(s).
xiii. For a claim to be admissible under Cumulative Bonus it should
be admissible under the Benefit3.1 Hospitalization Covers. ix. In case where the Insured Person(s) in the expiring 4 consecutive
and continuous Policy Years are covered on a floater basis
3.5.2 CALL OPTION FOR ENHANCEMENT OF BASE SUM
and desire to renew such expiring Policy with the Company on
INSURED
an Individual/floater basis and are eligible for Call option then
At the end of four consecutive and continuous Policy Years, if no the Base Sum Insured available as call option shall be split into
claim has been made under Benefit -3.1-Hospitalization Covers and 2 or more Floater / individual covers in the proportion of the
Benefit - 3.4 Critical Illness Cover in respect of any of the Insured number of lives insured under such renewed policies,except
Persons in the Policy, the Company shall provide the Policyholder, where the Policy is split due to the child attaining the age of
the Call option for enhancement of Base Sum Insured by an amount 25 years in which casethe Base Sum Insured available as call
equal to the accumulated Cumulative Bonus. If the Policyholder option shall be carried forward in full to both policies.
chooses to exercise this option, and make appropriate payment for
x. If the Policyholder chooses to forgo this option then the same
such option, the Base Sum Insured of the renewed Policy shall be
would be available at time of next renewal, provided that the
the sum total of:
Policy was in force for four consecutive and continuous years
¥ Expiring Policy’s Base Sum Insured immediately preceding such renewal and no claim has been
made under Benefit - 3.1 Hospitalization Covers and Benefit
¥ Accumulated Cumulative Bonus -3.4 Critical Illness Cover during this period.
This is subject to the following: xi. In case of multiple Insured Persons covered under individual
i. The enhanced Base Sum Insured on exercising the call option Base Sum Insured under the same Policy then all those who
shall not exceed four times the Base Sum Insured limit under become eligible for Call option would have to opt for or forgo
the first Policy Year with the Company. the Call option without selection.
ii. The enhanced Base Sum Insured on exercising the Call Option xii. On exercising of the Call option, Insured Person will be offered
shall not exceed Rupees one crore, irrespective of expiring continuity of coverage to the extent of the full amount of the
Policy’s Base Sum Insured. enhanced Sum Insured, in terms of Waiting Period with
respect to Pre-Existing Diseases and time bound exclusions
iii. The call option shall cease to be available: as specified in Section-4 of this Policy.
a. In relation to an individual cover, once the Insured Person xiii. This benefit will not affect the accumulated Cumulative Bonus.
attains the Age of 60 years.
xiv. If Call Option is exercised, then the Cumulative Bonus shall be
b. In relation to a floater cover, once the eldest Insured Person carried forward including any Cumulative Bonus earned for
attains the Age of 60 years. the expiring Policy Year.
iv. In relation to a Floater, the enhanced Base Sum Insured after 3.5.3 LOYALTY COVER
exercising the Call option shall be available on Floater basis.
At the end of each completed and continuous Policy Year, the
v. Under a Floater Policy the Call option shall be available only Company shall provide Loyalty Cover to the Policyholder (who is also
if all the Insured Person(s) who are to be insured under the an Insured Person) as per below:
enhanced Base Sum Insured were also continuously covered
in the immediate preceding 4 Policy Years, and had no claim
under any of the benefits listed in Benefit-3.1-Hospitalization
Covers and Benefit -3.4 Critical Illness Cover during this period
and continue to be insured under the subsequent Policy Year-wise availability of Sum Insured for Loyalty Cover
Year. However, if a new member is to be added at the time (‘Earned’ Loyalty Cover Sum Insured)
of renewal, the Company may cover that particular member
Policy Accidental Critical Hospital Cash Leave
under the renewed Policy subject to receipt of appropriate Year Death and Illness Compensation
premium, underwriting and applicability of Waiting Periods as Permanent Benefit
defined under clause 4.1.1, 4.1.2 & 4.1.3 and 4.2.1 of the Policy. Total
Disability
vi. Under an Individual Policy the Call option shall be available
only if the Insured Person(s) who is to be insured under the
enhanced Base Sum Insured was also continuously covered
in the immediate preceding 4 Policy Years and had no claim Year 2 10% of Base
Sum Insured
under any of the benefits listed in Benefit-3.1-Hospitalization
Covers and Benefit -3.4 Critical Illness Cover during this period Year 3 20% of Base 10% of
and continues to be insured in the subsequent Policy Year. Sum Insured Base Sum
Insured
vii. Call Option shall not be available if Policy is not renewed on or

Year 4 30% of Base 20% of Daily Cash ii. Immediate, permanent, total and absolute disablement of the
Sum Insured Base Sum amount (Plan Policyholder from engaging in, being occupied with or giving
Insured wise) of: attention to any employment or occupation of any description
Plus: Rs. 1000, whatsoever
Power:
Rs. 2000, then the Company shall be liable to pay the earned Loyalty Cover
Prime: Sum Insured to the Policyholder/Nominee /Legal Heir/Assignee as
Rs. 3000 stated in the Policy Schedule.
Year 5 40% of Base 30% of Daily Cash Rs. 1000 per Conditions applicable to Accidental Death and Permanent Total
Sum Insured Base Sum amount (Plan day Disability
Insured wise) of:
Plus: i. The benefit of claim under Accidental Death and Permanent
Rs. 1000, Total Disability shall be payable only once during the lifetime of
Power: the Policy.
Rs. 2000,
Prime: ii. If the Policyholder/ Nominee / Legal Heir / Assignee makes
Rs. 3000 a claim under either Accidental Death or Permanent Total
Year 6 50% of Base 40% of Daily Cash Rs. 1000 per Disability and the same is admitted by the Company, then no
Sum Insured Base Sum amount (Plan day further claim shall be payable under either of these benefits
Insured wise) of: (Accidental Death and Permanent Total Disability) to the
Plus: Rs. 1000, Policyholder or any of the other Insured Persons and these
Power: Rs.
benefits shall become inoperative.
2000, Prime:
Rs. 3000 iii. The Exclusions applicable to Benefit-3.3.1 Accidental Death
Year 7 50% of Base 50% of Daily Cash Rs. 1000 per Cover shall also be applicable on Benefit-3.5.3.1 Accidental
onward Sum Insured Base Sum amount (Plan day Death and Benefit-3.5.3.2 Permanent Total Disability benefits.
Insured wise) of:
Plus: Rs. 1000, 3.5.3.3 CRITICAL ILLNESS
Power: Rs.
If the Policyholder (who is also an Insured Person) as covered under
2000, Prime
Plus: Rs. 3000 the Policy is diagnosed for the first time, with any of the listed Critical
Illness which is admissible and payable under this cover, during the
Maximum 50% of Base 50% of 30 days of 30 days of Policy Year, then the Company shall be liable to pay the earned
limit Sum Insured Base Sum payment payment
Loyalty Cover Sum Insured (as specified in the Policy Schedule) to the
or 25 lakhs, Insured or
whichever is 25 lakhs, Policyholder. This is subject to following:
lower whichever • The Critical Illness has been diagnosed for the first time
is lower
• Such diagnosis is made during the Policy Year
The detailed coverage under each of these benefits shall be as
below: • The Insured Person survives the 30 days Survival Period
3.5.3.1 ACCIDENTAL DEATH • This benefit is claimable once in the lifetime of the Policyholder
If the Policyholder (who is also an Insured Person) as covered under For the purpose of this Benefit, Critical illness is as defined below: -
the Policy, sustains an injury, from an Accident during the Policy “Critical Illness” means disease / illness / surgery limited to the
Year and if such injury shall within twelve calendar months of its following and as defined under Section 3.4 Critical Illness Cover:
occurrence be the sole and direct cause of death of the Policyholder,
the Company shall be liable to pay the earned Loyalty Cover Sum i. Cancer of specified severity
Insured (as specified in the Policy Schedule) to the Nominee /Legal
ii. Open chest Coronary Artery Bypass Graft (CABG)
Heir/Assignee as stated in the Policy Schedule.
iii. Stroke resulting in permanent symptoms
3.5.3.2 PERMANENT TOTAL DISABILITY
iv. Multiple Sclerosis with persisting symptoms
If the Policyholder shall sustain any injury, resulting solely and
directly, from an Accident during the Policy Year and if such injury 3.5.3.4 HOSPITAL CASH
shall, within twelve calendar months of its occurrence, be the sole
and direct cause of A. IN-PATIENT CASH
i. The total and irrecoverable loss of: If the Company has accepted a claim under Benefit-3.1.1.1 In-Patient
Treatment, then the Company shall pay the Policyholder an amount
• sight of both eyes, or of the actual loss by physical separation equal to the Daily Cash amount specified in the Policy Schedule per
of two entire hands or two entire feet, or of one entire hand and day of Hospitalization, provided,
one entire foot, or of such loss of sight of one eye and such loss
of one entire hand or one entire foot, or i. The Daily Cash amount shall be payable for each 24 hours of
continuous and completed Hospitalization as In-Patient.
• Use of two hands or two feet, or of one hand and one foot,
or of such loss of sight of one eye and such loss of use of one ii. In a given Policy Year, the amount under this benefit shall be
hand or one foot, payable for a maximum of 30 days in a Policy Year
OR iii. Time Deductible: If the Hospitalization is for less than a

continuous and consecutive period of 72 hours, no amount

shall be payable under this benefit. If the Hospitalization Conditions Applicable to Benefit 3.5.3-Loyalty Cover
extends beyond a continuous and consecutive period of 72
a. The Loyalty Sum Insured shall be credited at the end of each
hours, the payment under this benefit shall be made from the
Policy Year as per the table provided, irrespective of claim
first day of Hospitalization.
under the Policy.
iv. Time Deductible shall be applicable on each and every In-
b. The payment under this benefit shall not reduce the Base Sum
Patient Treatment claim reported under the Policy.
Insured.
B. ICU CASH
c. In case the Policy is split due to the child attaining the age of 25
If the Company has accepted a claim under Benefit-3.1.1.1 In-Patient years in that case the earned Loyalty cover Sum Insured shall
Treatment where the Policyholder is admitted in an Intensive Care remain only with the Parent Policy.
Unit (ICU) of a Hospital on the written advice of a Medical Practitioner,
d. In case of merging of two or more Policies into one Policy,
then the Company shall pay the Policyholder additional 100% of
where the Policyholders (who are also an Insured Person)
Daily Cash amount as specified in the Policy Schedule per day of
were different, the Loyalty Cover shall be the higher count of
ICU Hospitalization provided,
Loyalty benefits of the two policies and granted only to the
i. The additional Daily Cash amount shall be payable for Policyholder of the renewal Policy.
each 24 hours of continuous and completed ICU In-Patient
3.6 VALUE ADDED COVERS
Hospitalization
3.6.1 WELLNESS SERVICES
ii. In a given Policy Year, the amount under this benefit shall be
payable for a maximum of 15 days in a Policy Year The Company shall provide the following Services under this benefit
either on its own or through a Service Provider:
iii. Time Deductible: If the Hospitalization is for less than a
continuous and consecutive period of 72 hours, no amount a. Doctor Anytime /Free Health Helpline: The Insured Person shall
shall be payable under this benefit. If the Hospitalization have the option of seeking medical advice from a Medical
extends beyond a continuous and consecutive period of 72 Practitioner through the telephonic or online mode.
hours, the payment under this benefit shall be made from the
first day of Hospitalization b. Health Portal: The Insured Person shall have the option to
access health related information and services through the
iv. Time Deductible shall be applicable on each and every In- Company’s/designated website.
Specific Conditions applicable to this Benefit:
3.5.3.5 LEAVE COMPENSATION BENEFIT
i. In case the Services are availed over phone or through online
If during the Policy Year, the Policyholder (who is also an Insured mode, the Insured Person will be required to provide the
Person) as covered under the Policy suffers an Illness or Injury for details as sought by the Company/ Service Provider in order
which Policyholder undergoes Hospitalization for a minimum to establish authenticity and validity prior to availing such
period of 7 continuous and consecutive days, then the Company services.
shall compensate the Policyholder (whether salaried or self-
employed),for availing leaves (for the period of Hospitalization) from ii. It is entirely for the Policyholder/Insured Person to decide
his/her place of work provided: whether to obtain these Services and also to decide the use (if
any) to which these Services is to be put for.
i. The Company has accepted the claim under Benefit-3.1.1.1 In-
Patient Treatment iii. The Service is intended for additional information purpose only
and does not substitute the Insured Person’s visit/ consultation
ii. The amount payable under this benefit shall be Rs. 1000, payable to an independent Medical Practitioner.
for each 24 hours of continuous and completed Hospitalization
as In-Patient, starting from the first day of Hospitalization. An The Company will have no liability on the availability and quality of
additional two days of payment shall be made to such Insured the Services.
Person post Hospitalization for recuperation. 3.6.2 CLAIM SERVICE GUARANTEE
iii. The amount under this benefit shall be payable maximum up to I. CASHLESS INTIMATION
30 days in a Policy Year.
If the Insured Person notifies a request for Cashless facility for
iv. The benefit shall be available to Policyholder until attainment Benefit 3.1.1 Hospitalization Expenses as per Section-6.1, along with
of 66 years of age. complete set of documents & information then the Company will
Exclusions related to Leave Compensation Benefit respond within 6 business hours of receipt of such information with
either
• It is imperative that the Policyholder stays employed as on the • Approval; or
Date of Discharge. If the Policyholder is not employed on the • Rejection; or
Date of Discharge, then no compensation is payable under this • Query seeking further information.
benefit.
In the event that the Company fails to respond within 6 business
• No consequential loss due to the leave availed during hours then the Company shall be liable to pay the Insured Person
Hospitalization apart from as provided above is payable for the delay in the following manner:
under this cover.
a. For delay beyond 6 business hours and upto 12 hours– 1% of
• Loss of Employment is not covered under this benefit Delayed Claim Amount. For delay beyond 12 hours additional
1% for every additional delay of 6 business hours. The total

liability under this clause shall be subject to a maximum of 6% i. In case of a claim in any given Policy Year the accrued
of Delayed Claim Amount. Cumulative Bonus amount shall not be reduced in the
subsequent year, except to the extent of the Cumulative Bonus
II. REIMBURSEMENT INTIMATION
amount utilized for settlement of claim.
The Company shall process the Claim for Benefit 3.1.1 Hospitalization
3.7.1.2 UNLIMITED REINSTATEMENT OF BASE SUM INSURED
Expenses within 21 days of the actual receipt of complete information
and all documents as specified in Section 6.1 (“Claims Intimation, The Company shall reinstate the Base Sum Insured unlimited
Assessment and Management”) times, during the Policy Year, after occurrence and payment of claim
amount under the Policy, subject to below mentioned terms and
In the event that the Company fails to send a response within 21 days
conditions.
then the Company shall be liable to pay the Insured Person for the
delay in the following manner: i. the Base Sum Insured shall be reinstated to full extent
immediately after settlement of a claim under Benefit-3.1
a. For delay beyond 21 days and upto 42 days – 1% of Delayed
Hospitalization Covers and such reinstated part shall become
Claim amount. For delay beyond 42 days, 1% for every
part of Reinstated Sum Insured
additional delay of 21 days. The total liability under this clause
shall be subject to a maximum of 6% of Delayed Claim Amount. ii. The Reinstated Sum Insured can be utilized in the following
manner:
SPECIFIC CONDITIONS APPLICABLE TO THIS BENEFIT
a. Unlimited utilization for subsequent claims for unrelated illness
• Delayed Claim Amount for the purposes of this benefit
or injury.
shall mean the minimum of authorization request amount,
authorization amount issued, final claim amount or balance b. Up to 100% of Base Sum Insured, for subsequent claim which
Sum Insured. has arisen out or is a consequence of or its related to or is a
complication of an illness/injury for which a claim has already
• The Company shall not be liable to pay under above mentioned
been admitted under the current or any previous Policy in
point i) and ii) in case of any force majeure, natural event or
relation to an Insured Person
manmade disturbances which impedes the Company’s ability
to make a decision or to communicate such decision to the iii. The Re-instated Sum Insured for a particular Policy Year can
Policyholder/Insured Person. be utilized only after the Base Sum Insured, Double Cover or
Extra Sum Insured (whichever is applicable), Cumulative Bonus
• Any amount paid under i) and ii) will not affect the Base Sum
and Policy Service Guarantee Sum Insured (if applicable) have
Insured as specified in the Policy Schedule. The Company’s
been completely exhausted.
maximum liability to make payment under this benefit shall not
exceed the amount specified in above point i) and ii) iv. The Reinstated Sum Insured shall be available only for all
subsequent claims.
• The payment under this benefit is over and above that payable
under Standard General Terms and Clauses, Clause-5.1.3 v. This benefit shall be available at each Policy Year.
Claim Settlement (provision for Penal Interest)
vi. The Reinstated Sum Insured at given time shall not exceed the
3.6.3 POLICY SERVICE GUARANTEE Base Sum Insured
In the event of delay in the process of issuing a Policy beyond 10 vii. Reinstatement of Base Sum Insured will be available on
Working days from the date of receipt of all completed documents individual basis for individual policies and on floater basis for
(including Medical reports, as applicable) and premium, the family floater policies.
Company shall provide a one-time additional amount of Sum
viii. While calculating Cumulative Bonus, Unlimited Re-instatement
Insured, as mentioned in Policy Schedule which shall be applicable
of Base Sum Insured shall not be considered.
only for the first Policy Year and shall not be applicable or carried
forward for subsequent Policy Years, renewals/auto-renewals. This ix. The unutilized Re-instated Sum Insured cannot be carried
Sum Insured shall not be taken into consideration for calculating the forward to any subsequent Policy Year.
Cumulative Bonus, Double Cover or Extra Sum Insured(whichever is
applicable)&/or the Re-instatement Sum Insured. x. This benefit supersedes the existing Benefit no-3.2.1
Reinstatement of Base Sum Insured.
3.7 OPTIONAL COVERS
3.7.1.3 CONSUMABLES COVER
The covers listed below are optional covers and are available to
the Insured Persons, on payment of additional premium, subject to The Company shall pay the Reasonable and Customary expenses
below mentioned terms, conditions, and exclusions. incurred by the Policyholder /Insured Person, during the Policy Year,
for items which are listed in ‘Annexure A- List I as Optional Items’ of
3.7.1 ENHANCED COVERS this Policy, provided:
3.7.1.1 GUARANTEED CUMULATIVE BONUS i. Such consumables or items are prescribed by the treating
Medical Practitioner and are medically necessary for the
This cover is an extension to Benefit no-3.5.1 Cumulative Bonus. The
treatment of the same condition for which Insured Person has
Company shall provide 33.33 % (one third) of the Base Sum Insured
taken In-Patient or Daycare Treatment, and
at the end of each completed and continuous Policy Year, provided
that no Claim has been made in the expiring Policy Year. ii. The Company has accepted Claim for Hospitalization expenses
under the Policy.
All the conditions and provisions stated under Benefit no-3.5.1
Cumulative Bonus shall also be applicable on this benefit, except for iii. The amount payable towards this benefit, in conjunction with
clause ix which shall stand modified as below: the other items under Hospitalization Expenses shall be within

the Sum Insured limit. iii. The annual Aggregate Deductible shall not be applicable on
Benefit-3.1.1.3-Accomodation Bonus, Benefit-3.3.1 Accidental
3.7.2 DOUBLE COVER
Death Cover, Benefit -3.4.1-Waiver of Premium, Benefit 3.5.3
Under this option, the Company shall provide an additional 100% of Loyalty Cover, Benefit-3.6 .1 Wellness Services, Benefit 3.7.7
Base Sum Insured as Double Cover on the same claim, which can Hospital Cash(if opted) ,Benefit-3.7.8.4 Convalescence Cover,
be utilized after the Base Sum Insured has been utilized completely Benefit-3.7.9.1 Health Check Up, Benefit-3.7.9.2 Vaccination
for claims incurred under the Policy, for the particular Policy Year, Cover, Benefit-3.7.11.2 Companion Cover, Benefit-3.7.11.3 Child
provided that: Care Cover.
i. The benefit shall be available only if the Company has accepted 3.7.6 REMOVAL OF CO-PAYMENT
the claim under Benefit-3.1 Hospitalization Covers.
Under this option, the Company shall waive off the Co-Payment
ii. The benefit shall be available only after full exhaustion of Base condition mentioned in Clause-6.2 Co-Payment Sub-section (i).
Sum Insured under the Policy. Such waiver, if allowed, shall be expressly mentioned in the Policy
Schedule.
iii. The Double Cover can be utilized only on the same claim,
which is payable under Base Sum Insured, during a single 3.7.7 HOSPITAL CASH
hospitalization.
Under this option, the Company shall compensate the Insured
iv. The benefit can be utilized once in Policy Year. Person, as per the following:
v. The Company’s overall liability for all claims, in aggregate, 3.7.7.1 IN-PATIENT CASH
within a Policy Year under this benefit shall be limited to 100%
If the Company has accepted and paid a claim under Benefit-3.1.1.1
of the Base Sum Insured
In-Patient Treatment, then the Company shall pay the Insured
vi. While calculating Cumulative Bonus, Double Cover shall not be Person an amount equal to the Daily Cash amount specified in the
considered. Policy Schedule per day of Hospitalization, provided,
vii. Any unutilized Double Cover Sum Insured, in whole or in part i. The Daily Cash amount shall be payable for each 24 hours of
shall not be carried forward to subsequent Policy Years. continuous and completed Hospitalization as In-Patient.
viii. The Double Cover will be available on individual basis for ii. The amount under this benefit shall be payable maximum up
individual policies and on floater basis for floater policies. to 30 days in a Policy Year.
ix. This benefit supersedes the existing Benefit no-3.2.2 Extra Sum iii. Time Deductible: If the Hospitalization is for less than a
Insured. continuous and consecutive period of 72 hours, no amount
shall be payable under this benefit. If the Hospitalization
3.7.3 CHANGE IN ROOM RENT LIMITS extends beyond a continuous and consecutive period of 72
Under this option, the Policyholder shall be allowed to opt the hours, the payment under this benefit shall be made from the
Room Rent category (as specified in the Coverage Summary) first day of Hospitalization.
for hospitalizations allowable under Section 3 of this Policy, if iv. Time Deductible shall be applicable on each and every In-
so requested by the Policyholder and explicitly accepted by the Patient Treatment claim reported under the Policy.
Company. The agreed Room Rent category shall beexpressly
mentioned in the Policy Schedule. 3.7.7.2 ICU CASH
3.7.4 REDUCTION IN PRE-EXISTING WAITING PERIOD If the Company has accepted and paid a claim under Benefit -
3.1.1.1 In-Patient Treatment where the Insured Person is admitted
Under this option, the Company shall reduce the 36 months Waiting in an Intensive Care Unit (ICU) of a Hospital on the written advice
Period for Pre-Existing Diseases as mentioned in Clause 4.1.1, to 24 of a Medical Practitioner, then the Company shall pay the Insured
or 12 months (as opted). Such reduction, if allowed, shall be expressly Person additional 100% of Daily Cash amount as specified in the
mentioned in the Policy Schedule. Policy Schedule per day of ICU Hospitalization provided,
3.7.5 VOLUNTARY AGGREGATE DEDUCTIBLE i. The additional Daily Cash amount shall be payable for
Under this option, the Company shall provide a discount in the each 24 hours of continuous and completed ICU In-Patient
premium, if the Policyholder opts for an annual Aggregate Hospitalization
Deductible under the Policy. The agreed limits of annual Aggregate ii. In a given Policy Year, the amount under this benefit shall be
Deductible shall be expressly mentioned in the Policy Schedule. payable for a maximum of 15 days
This benefit is subject to following: iii. Time Deductible: If the Hospitalization is for less than a
i. Deductible under this benefit is an annual Aggregate continuous and consecutive period of 72 hours, no amount
Deductible. For a claim to become payable, the sum of all shall be payable under this benefit. If the Hospitalization
admissible claims under the Policy, subject to Policy terms and extends beyond a continuous and consecutive period of 72
conditions, in a given Policy Year has to exceed the annual hours, the payment under this benefit shall be made from the
Aggregate Deductible as mentioned in the Policy Schedule. first day of Hospitalization
ii. Incase of Individual Policy, the Aggregate Deductible shall iv. Time Deductible shall be applicable on each and every In-
apply on individual basis and incase of a floater policy, shall Patient Treatment claim reported under the Policy.
apply on floater basis. 3.7.8 CONVENIENCE COVER

3.7.8.1 CHANGE IN PRE-POST HOSPITALIZATION LIMIT for individual policies and on floater basis for floater policies.
Under this benefit, the Policyholder shall be allowed to change iv. The payment under this benefit will be over and above the
the coverage period for Benefit - 3.1.5 Pre-Hospitalization to 90 payment made under Benefit-3.1.1.1 In-Patient Treatment.
days, and that for Benefit - 3.1.6 Post-Hospitalization to 180 days,
3.7.9 PREVENTIVE CARE COVER
if so requested by the Policyholder and explicitly accepted by the
Company. The agreed Pre-Hospitalization and Post-Hospitalization 3.7.9.1 HEALTH CHECK UP
limits shall beexpressly mentioned in the Policy Schedule.
At the end of every Policy Year, the Company shall provide expenses
3.7.8.2 AIR AMBULANCE for the listed diagnostic or preventive medical tests with respect to
the Insured Persons in the Policy. This benefit is subject to following:
The Company shall indemnify the Policyholder/Insured Person
upto an amount specified in the Policy Schedule, for the expenses i. The total amount payable towards medical tests in a given
incurred on availing Air Ambulance services during the Policy Year, Policy Year shall be limited to Rs 3000.
provided that:
ii. In case of a Floater Policy, the medical check-up limit mentioned
i. The Company has accepted the Inpatient Hospitalization claim above shall be available on Floater basis.
under Benefit 3.1.1.1 In Patient Treatment.
iii. The amount claimed under this Benefit shall not reduce the
ii. The coverage includes the cost of the transportation of the Base Sum Insured and Cumulative Bonus under the Policy.
Insured Person from the place of first occurrence of the Illness/
Accident to the nearest Hospital in case of an emergency Life iv. The Insured Person can undergo one or more of the listed
Threatening Medical condition, or from one Hospital to another medical tests anytime within a period of four months of
Hospital which is prepared to admit the Insured Person and becoming eligible.
provide the necessary medical services, only in case where v. The benefit shall be available on Cashless basis and arranged
the Insured Person requires immediate and rapid ambulance with Company’s Empaneled Service Providers. Where the
transportation which cannot be provided by a Road Ambulance. test(s) cannot be arranged with an Empaneled Service Provider
iii. Such Life-Threatening Medical Condition is certified by the the Company may provide Reimbursement facility on approval
Medical Practitioner basis.
iv. The transportation from one Hospital to another Hospital has vi. Utilizing this benefit alone shall not be considered as claim
been prescribed by a Medical Practitioner and is medically under the Policy.
necessary. vii. The benefit shall only be applicable to those Insured Persons
v. The Origin and Destination of Air Ambulance Service are within who were insured under the Policy in the expiring Policy Year.
the geographical boundaries of Republic of India Following are the list of medical tests:
vi. This benefit can be availed once in a Policy Year.
Organ/ Tests
vii. Such Air Ambulance should have been duly licensed for Disease
operation by the Competent Authorities of the Government of Specific
India.
Heart ECG,2D Echo, TMT, Lipid Profile
3.7.8.3 RADIO TAXI Liver Liver Profile, Sonography Abdomen
The Company shall indemnify the Policyholder/Insured Person up Kidney Kidney Profile, Sonography Abdomen
to the amount specified in the Policy Schedule, per Hospitalization,
Lungs Chest X-Ray, PFT
for the expenses incurred on availing registered Radio cab operator
services, provided that: Eyes Vision Test, Colour Vision Test, Eye Dilation Test,
Intraocular Pressure Measurement
i. The Company has accepted the Hospitalization claim under
Benefit- 3.1.1.Hospitalization Expenses Female PAP Smear, Sonography Abdomen and Pelvis,
Specific Mammography
ii. The coverage includes the cost of the transportation of the
Thyroid Thyroid Function Test
Insured Person for whom claim has been accepted under
Gland
Benefit- 3.1.1. Hospitalization Expenses to the nearest Hospital
and/or from Hospital to home. ENT ENT check Up, Audiometry Test
3.7.8.4 CONVALESCENCE COVER Dental OPG Dental (X Ray)
Diabetes Blood Sugar (PP/Fasting),HbA1c
The Company shall pay a lump sum amount as specified in the
Policy Schedule, if during the Policy Year, the Insured Person suffers General CBC,C-Reactive Protein, Urine Routine, Serum
an Illness or Injury for which Insured Person is Hospitalized for a Electrolytes (Calcium, Potassium, Sodium,
minimum period of 7 continuous and consecutive days, provided Phosphorus, Chloride), Vitamin D, Vitamin B-12
that:
3.7.9.2 VACCINATION COVER
i. The Company has accepted Inpatient Hospitalization Claim
At the end of every Policy Year, the Company shall provide expenses
under Benefit - 3.1.1.1 In Patient Treatment.
for the listed vaccines with respect to the Insured Persons in the
ii. This benefit is payable once in a Policy Year. Policy. This benefit is subject to following:
iii. The Convalescence Cover shall be available on individual basis i. The total amount payable under this benefit in a given Policy

Year shall be limited to the amount specified in the Policy Hospitalization Expenses.
Schedule.
iv. The treatment carried out for the cosmetic reasons shall not be
ii. In case of a Floater Policy, the vaccination limit specified in covered
Policy Schedule shall be available on Floater basis.
v. Pre-Hospitalization and Post-Hospitalization expenses shall
iii. The amount claimed under this Benefit shall not reduce the not be covered
Base Sum Insured and Cumulative Bonus under the Policy.
vi. This benefit waives the Standard Exclusion clause no-4.1.15
iv. Expenses related to doctor, nurses or any incidental expenses Refractive Error (Code: Excl 15)to the extent mentioned under
shall not be payable. point (i) above.
v. The benefit shall be available on Cashless basis and arranged 3.7.10.3 SECOND OPINION
with Company’s Empaneled Service Providers. Where the
The Company shall the indemnify the cost incurred for availing
vaccination cannot be arranged with an Empaneled Service
second medical opinion from a Medical Practitioner within India, if
Provider the Company may provide Reimbursement basis
the Insured Person, during the Policy Year is diagnosed with any of
facility on approval basis.
the listed Critical Illnesses provided that:
vi. Utilizing this benefit alone shall not be considered as claim
i. The benefit shall be provided on reimbursement basis.
under the Policy.
ii. By seeking the Second Opinion under this benefit the Insured
vii. The benefit shall only be applicable to those Insured Persons
Person is not prohibited or advised against visiting or
who were insured under the Policy in the expiring Policy Year.
consulting with any other independent Medical Practitioner or
List of vaccines covered: commencing or continuing any treatment advised by another
Medical Practitioner.
a. Diphtheria, Tetanus, Pertussis
iii. The Insured Person is free to choose whether to avail Second
b. Varicella Vaccine
opinion and if availed under this benefit, then whether or not to
c. Combined Measles, Mumps and Rubella (MMR)Vaccine act on it.
d. Influenza iv. The Second opinion shall be only for medical reason and not
be valid for medico-legal purposes.
e. Pneumonia
v. The Company does not assume any liability for and shall not
f. Typhoid be responsible for any actual or alleged errors, omissions or
g. Hepatitis B representations made by any Medical Practitioner or in any
expert opinion or for any consequences of actions taken or not
h. Hepatitis A taken in reliance thereon.
i. Haemophiles influenzae type b Vaccine (Hib) vi. This benefit can be availed once in a Policy Year.
j. Human Papillomavirus Vaccine (HPV) vii. Utilizing this benefit alone shall not be considered as claim
i. Anti-Rabies under the Policy.
3.7.10 SMART COVERS viii. For the purpose of this Cover, Critical Illnesses shall include:
3.7.10.1 CHANGE IN MODERN TREATMENT LIMITS I. CANCER OF SPECIFIED SEVERITY
Under this benefit, the Policyholder shall be allowed to change a. A malignant tumour characterized by the uncontrolled growth &
the coverage limit under Plans Plus and power for Benefit 3.1.4 spread of malignant cells with invasion & destruction of normal
Modern Treatment from 50% of Base Sum Insured to 100% of Base tissues. This diagnosis must be supported by histological
Sum Insured and if so requested by the Policyholder and explicitly evidence of malignancy & confirmed by a pathologist. The
accepted by the Company. The agreed coverage limit for Modern term cancer includes leukemia, lymphoma and sarcoma.
Treatment shall be expressly mentioned in the Policy Schedule. b. The following are excluded —
3.7.10.2 VISION CORRECTION • All tumors which are histologically described as carcinoma
The Company shall indemnify the Policyholder/Insured Person in situ, benign, pre-malignant, borderline malignant, low
up to an amount specified in the Policy Schedule for the Medical malignant potential, neoplasm of unknown behavior, or non-
Expenses incurred during the Policy Year, for undergoing medically invasive, including but not limited to: Carcinoma in situ of
necessary treatment under Benefit 3.1.1 Hospitalization Expenses for breasts, Cervical dysplasia CIN-1, CIN -2 and CIN-3.
correction of eyesight due to refractive error on the written advice of • Any non-melanoma skin carcinoma unless there is evidence of
the Medical Practitioner, provided that: metastases to lymph nodes or beyond;
i. The refractive error must be equal to or above-6.0/+6.0 • Malignant melanoma that has not caused invasion beyond the
dioptresat the time of taking the treatment epidermis;
ii. This benefit shall become available only after the expiry of 24 • All tumors of the prostate unless histologically classified as
months from the date of inception of the Insured Person’s first having a Gleason score greater than 6 or having progressed to
Policy with the Company. at least clinical TNM classification T2N0M0
iii. The Company has accepted claim under Benefit 3.1.1 • All Thyroid cancers histologically classified as T1N0M0 (TNM

Classification) or below; • Angiography (an x-ray of the blood vessels)
• Chronic lymphocytic leukaemia less than RAI stage 3 VI. BENIGN BRAIN TUMOR
• Non-invasive papillary cancer of the bladder histologically a. Benign brain tumor is defined as a life threatening, non-
described as TaN0M0 or of a lesser classification, cancerous tumor in the brain, cranial nerves or meninges
within the skull. The presence of the underlying tumor must be
• All Gastro-Intestinal Stromal Tumors histologically classified as
confirmed by imaging studies such as CT scan or MRI.
T1N0M0 (TNM Classification) or below and with mitotic count of
less than or equal to 5/50 HPFs; b. This brain tumor must result in at least one of the following and
must be confirmed by the relevant medical specialist.
• All tumors in the presence of HIV infection
• Permanent Neurological deficit with persisting clinical
II. OPEN HEART REPLACEMENT OR REPAIR OF HEART
symptoms for a continuous period of at least 90 consecutive
VALVES
days or
a. The actual undergoing of open-heart valve surgery is to replace
• Undergone surgical resection or radiation therapy to treat the
or repair one or more heart valves, as a consequence of defects
brain tumor.
in, abnormalities of, or disease- affected cardiac valve(s). The
diagnosis of the valve abnormality must be supported by an c. The following conditions are excluded:
echocardiography and the realization of surgery has to be
Cysts, Granulomas, malformations in the arteries or veins of the
confirmed by a specialist medical practitioner. Catheter based
brain, hematomas, abscesses, pituitary tumors, and tumors of skull
techniques including but not limited to, balloon valvotomy/
bones, and tumors of the spinal cord.
valvuloplasty are excluded.
VII. KIDNEY FAILURE REQUIRING REGULAR DIALYSIS
III. MAJOR ORGAN /BONE MARROW TRANSPLANT
a. End stage renal disease presenting as chronic irreversible
a. The actual undergoing of a transplant of:
failure of both kidneys to function, as a result of which either
• One of the following human organs: heart, lung, liver, kidney, regular renal dialysis (hemodialysis or peritoneal dialysis) is
pancreas, that resulted from irreversible end-stage failure of instituted or renal transplantation is carried out. Diagnosis has
the relevant organ, or to be confirmed by a specialist Medical Practitioner
• Human bone marrow using haematopoietic stem cells. The VIII. END STAGE LUNG FAILURE
undergoing of a transplant has to be confirmed by a specialist
a. End stage lung disease, causing chronic respiratory failure, as
medical practitioner
confirmed by a physician and evidenced by all of the following:
b. The following are excluded:
• FEV1 test results consistently less than 1 litre measured on 3
• Other stem-cell transplants occasions 3 months apart; and
• Where only islets of langerhans are transplanted • Requiring continuous permanent supplementary oxygen
therapy for hypoxemia; and
IV. COMA OF SPECIFIED SEVERITY
• Arterial blood gas analysis with partial oxygen pressure of
a. A state of unconsciousness with no reaction or response
55mmHg or less (PaO2 < 55mmHg); and
to external stimuli or internal needs. This diagnosis must be
supported by evidence of all of the following: • Dyspnea at rest.
• no response to external stimuli continuously for at least 96 IX. END STAGE LIVER FAILURE
hours;
a. Permanent and irreversible failure of liver function that has
• life support measures are necessary to sustain life; and resulted in all three of the following:
• Permanent neurological deficit which must be assessed at • Permanent jaundice; and
least 30 days after the onset of the coma.
• Ascites; and
b. The condition has to be confirmed by a Specialist Medical
• Hepatic encephalopathy.
Practitioner. Coma resulting directly from alcohol or drug abuse
is excluded. X. STROKE RESULTING IN PERMANENT SYMPTOMS
V. SURGERY OF AORTA a. Any cerebrovascular incident producing permanent neurological
sequelae. This includes infarction of brain tissue, thrombosis
a. The actual surgical repair of an aortic aneurysm (an abnormal
in an intracranial vessel, haemorrhage and embolization from
bulge in the wall of the aortic blood vessel causing the aorta to
an extracranial source. Diagnosis has to be confirmed by a
dilate or widen and the aortic valve to leak leading to bursting
specialist medical practitioner and evidenced by typical clinical
of arterial wall) for the first time by a surgeon. The diagnosis to
symptoms as well as typical findings in CT Scan or MRI of the
be evidenced by any two of the following:
brain. Evidence of permanent neurological deficit lasting for at
• Computerised tomography (CT) scan least 3 months has to be produced.
• Magnetic resonance imaging (MRI) scan b. The following are excluded:
• Echocardiography (an ultrasound of the heart) • Transient ischemic attacks (TIA)
• Abdominal ultrasound (for associated abdominal aneurysms) • Traumatic injury of the brain

• Vascular disease affecting only the eye or optic nerve or ii. The benefit can be availed on reimbursement basis only
vestibular
iii. The period of treatment shall be considered as the continuous
XI. PERMANENT PARALYSIS OF LIMBS period for which health status of the Insured Person was
monitored by a Medical Practitioner, supported by records
a. Total and irreversible loss of use of two or more limbs as a
of treatment and Daily Monitoring Chart duly signed by such
result of injury or disease of the brain or spinal cord. A
specialist medical practitioner must be of the opinion that the
paralysis will be permanent with no hope of recovery and must iv. No amount shall be payable towards Medical Expenses
be present for more than 3 months. incurred outside the period of treatment.
XII. MULTIPLE SCLEROSIS WITH PERSISTING SYMPTOMS v. The benefit can be availed for maximum 15 days, per Insured
Person, during the Policy Year
a. The unequivocal diagnosis of Definite Multiple Sclerosis
confirmed and evidenced by all of the following: vi. The following treatments or illnesses shall be covered under
Home Care Treatment:
• Investigations including typical MRI findings which unequivocally
confirm the diagnosis to be multiple sclerosis and a. Chemotherapy excluding any supporting medication
• There must be current clinical impairment of motor or sensory b. Dialysis
function, which must have persisted for a continuous period of
c. Gastroenteritis: Severe Gastroenteritis with dehydration level
at least 6 months.
>=10%
b. Other causes of neurological damage such as SLE and HIV are
d. Bronchopneumonia supported by radiological evidence
excluded.
e. Lower Respiratory tract infection supported by radiological
XIII. BLINDNESS
(X-ray) evidence
a. Total, permanent and irreversible loss of all vision in both eyes
f. Non-alcoholic Pancreatitis
as a result of illness or accident.
g. Dengue with platelet count less than 1 lakh and supported by
b. The Blindness is evidenced by:
positive Dengue Antigen report
• Corrected visual acuity being 3/60 or less in both eyes or ;
h. Hepatitis supported by positive diagnosis through blood
• The field of vision being less than 10 degrees in both eyes. reports
c. The diagnosis of blindness must be confirmed and must not be 3.7.11.2 COMPANION COVER
correctable by aids or surgical procedure.
The Company shall pay the Policyholder/Insured Person a fixed
XIV. THIRD DEGREE BURNS daily amount, as specified in the Policy Schedule towards the
expenses of a Companion during the Inpatient Treatment of the
a. There must be third-degree burns with scarring that cover
Insured Person, provided that:
at least 20% of the body’s surface area. The diagnosis must
confirm the total area involved using standardized, clinically i. The Company has accepted In-Patient Hospitalization Claim
accepted, body surface area charts covering 20% of the body under Benefit 3.1.1.1 In Patient Treatment.
surface area.
ii. The daily amount shall be payable for each 24 hours of
XV. BACTERIAL MENINGITIS continuous and completed In-patient Hospitalization of the
Insured Person.
a. Bacterial infection resulting in severe inflammation of
the membranes of the brain or spinal cord resulting in iii. The amount under this benefit shall be payable maximum up
significant, irreversible and permanent neurological deficit. to 30 days in a Policy Year.
The neurological deficit must persist for at least 6 weeks. This
iv. The amount shall be payable towards expenses incurred by
diagnosis must be confirmed by:
the Companion towards accommodation, transportation, food
• The presence of bacterial infection in cerebrospinal fluid by or any other miscellaneous expenses.
lumbar puncture; and
v. For a claim to be payable under this cover, the Companion/
• A consultant neurologist. Insured Person shall submit at minimum, the receipts of
paid accommodation availed by the Companion to assist the
Bacterial Meningitis in the presence of HIV infection is excluded.
Insured Person during Hospitalization.
3.7.11 FAMILY CARE COVER
vi. Time Deductible: If the Hospitalization is for less than a
3.7.11.1 HOME CARE TREATMENT continuous and consecutive period of 72 hours, no amount
shall be payable under this benefit. If the Hospitalization
The Company shall indemnify the Policyholder/Insured Person for extends beyond a continuous and consecutive period of 72
the Medical Expenses, incurred during the Policy Year, towards hours, the payment under this benefit shall be made from the
Home Care Treatment of any of the listed treatments taken by the first day of Hospitalization
Insured Person, on the written advice of a Medical Practitioner,
provided that: vii. Time Deductible shall be applicable on each and every In-
i. The services under this benefit shall be offered by registered
homecare provider. viii. The Company has accepted In-Patient Hospitalization Claim

under Benefit 3.1.1.1 In Patient Treatment. the two waiting periods shall apply.
3.7.11.3 CHILD CARE COVER iv. The waiting period for listed conditions shall apply even if
contracted after the Policy or declared and accepted without
The Company shall pay the Policyholder/Insured Person a fixed
a specific exclusion.
daily amount specified in the Policy Schedule towards the childcare
expenses of an Insured Child, if the Insured Person (Self or Spouse) v. If the Insured Person is continuously covered without
during the Policy Year, suffers an Illness or Injury for which Insured any Break as defined under the applicable norms on
Person is Hospitalized, provided that: portability stipulated by IRDAI, then waiting period for the
same would be reduced to the extent of prior coverage.
i. The benefit shall be payable toward any one dependent child
24 months waiting period:
covered under the Policy and aged up to 12 years.
ii. The amount under this benefit shall be payable maximum up Organ / Organ Illness /Diagnosis Surgeries / Surgical
to 30 days in a Policy Year. System ((irrespective of Procedure (irrespective of
treatment being any Illness / diagnosis)
iii. Time Deductible: If the Hospitalization is for less than a medical or surgical)
continuous and consecutive period of 72 hours, no amount
shall be payable under this benefit. If the Hospitalization Ear, Nose, ¥ Sinusitis ¥ Adenoidectomy
extends beyond a continuous and consecutive period of 72 Throat (ENT) ¥ Rhinitis ¥ Mastoidectomy
hours, the payment under this benefit shall be made from the ¥ Tonsillitis ¥ Tonsillectomy
first day of Hospitalization ¥ Tympanoplasty
iv. Time Deductible shall be applicable on each and every In- ¥ Surgery for nasal
Patient Treatment claim reported under the Policy. septum deviation
¥ Surgery for turbinate
v. The Company has accepted In-Patient Hospitalization Claim
under Benefit 3.1.1.1 In Patient Treatment. hypertrophy
¥ Nasal concha resection
vi. The amount payable under this benefit shall be over and above
¥ Nasal polypectomy
the amount payable under Benefit 3.1.1.1 In Patient Treatment.
SECTION-4 EXCLUSIONS Gynaecological ¥ Cysts, polyps, ¥ Hysterectomy unless
including breast necessitated by
The Company shall not be liable to make any payment under the lumps malignancy
Policy, in respect of any expenses incurred in connection with or in
¥ Polycystic ovarian
respect of the following:
diseases
4.1. STANDARD EXCLUSIONS ¥ Fibromyoma
4.1.1. PRE-EXISTING DISEASES (CODE- EXCL 01) ¥ Adenomyosis

¥ Endometriosis
i. Expenses related to the treatment of a Pre-existing Disease
(PED) and its direct complications shall be excluded until the ¥ Prolapsed uterus
expiry of 36months of continuous coverage after the date of Orthopaedic ¥ Non-infective ¥ Joint replacement
inception of the first policy with us. arthritis surgery
¥ Gout and
ii. In case of enhancement of Base Sum Insured the exclusion
rheumatism
shall apply afresh to the extent of Base Sum Insured increase.
¥ Osteoporosis
iii. If the Insured Person is continuously covered without any ¥ Ligament, tendon
Break as defined under the portability norms of the extant and meniscal tear
IRDAI (Health Insurance) Regulations, then waiting period for ¥ Prolapsed
the same would be reduced to the extent of prior coverage. intervertebral disk
iv. Coverage under the policy after the expiry of 36 months for any Gastrointestinal ¥ Cholelithiasis ¥ Cholecystectomy
Pre-Existing Disease is subject to the same being declared at ¥ Cholecystitis ¥ Surgery of hernia
the time of application and accepted by the Company.
¥ Pancreatitis
4.1.2. SPECIFIC WAITING PERIOD (CODE- EXCL 02) ¥ Fissure/
i. Expenses related to the treatment of the following listed fistula in anus,

conditions, surgeries/treatments shall be excluded until the haemorrhoids,
expiry of 24 months of continuous coverage, as may be the pilonidal sinus
case after the date of inception of the first Policy with the ¥ Gastro
Company. This exclusion shall not be applicable for claims Esophageal Reflux
arising due to an Accident. Disorder (GERD),
ulcer and erosion
ii. In case of enhancement of Base Sum Insured the exclusion of stomach and
shall apply afresh to the extent of Base Sum Insured increase. duodenum
iii. If any of the specified disease/procedure falls under the waiting ¥ Cirrhosis
period specified for Pre-Existing Diseases, then the longer of (however alcoholic

cirrhosis is ii. Any services for people who are terminally ill to address
permanently physical, social, emotional and spiritual needs.
excluded) 4.1.6. OBESITY/ WEIGHT CONTROL (CODE: EXCL06):
¥ Perineal and
Expenses related to the surgical treatment of obesity that does not
perianal abscess
fulfil all the below conditions:
¥ Rectal prolapse
i. Surgery to be conducted is upon the advice of the Doctor
Urogenital ¥ Calculus diseases ¥ Surgery on prostate
of urogenital unless necessitated by ii. The surgery/Procedure conducted should be supported by
system including malignancy clinical protocols
kidney, ureter, ¥ Surgery for hydrocele/
iii. The member has to be 18 years of age or older and
bladder stones rectocele
¥ Benign iv. Body Mass Index (BMI);
hyperplasia of
• Greater than or equal to 40 or
prostate
¥ Varicocele • Greater than or equal to 35 in conjunction with any of the
following severe co-morbidities following failure of less
Eye ¥ Cataract ¥ Surgery for correction of
invasive methods of weight loss:
¥ Retinal eye sight due to refractive
detachment error above dioptre 7.5 o Obesity-related cardiomyopathy
(-6/+6 dioptre if Optional
¥ Glaucoma o Coronary heart disease
Benefit-3.7.10 Smart
Covers has been opted o Severe Sleep Apnea
under the Policy)
o Uncontrolled Type 2 Diabetes
Others ¥ Congenital ¥Surgery of varicose veins
internal disease and varicose ulcers 4.1.7. CHANGE-OF-GENDER TREATMENTS (CODE: EXCL 07):
General ¥ Benign tumors ¥ Nil Expenses related to any treatment, including surgical management,
(Applicable of non-infectious to change characteristics of the body to those of the opposite sex.
to all organ etiology Such as
4.1.8. COSMETIC OR PLASTIC SURGERY (CODE: EXCL 08):
systems cysts, nodules,
/ organs polyps, lumps or Expenses for cosmetic or plastic surgery or any treatment to change
whether or growth. appearance unless for reconstruction following an Accident, Burn(s)
not described or Cancer or as part of Medically Necessary Treatment to remove
above) a direct and immediate health risk to the insured. For this to be
considered a medical necessity, it must be certified by the attending
4.1.3. FIRST THIRTY DAYS WAITING PERIOD (CODE- EXCL03)
i. Expenses related to the treatment of any illness within 30 days
4.1.9. HAZARDOUS OR ADVENTURE SPORTS (CODE: EXCL 09):
from the first policy commencement date shall be excluded
except claims arising due to an Accident, provided the same Expenses related to any treatment necessitated due to participation
are covered. as a professional in hazardous or adventure sports, including but
not limited to, para-jumping, rock climbing, mountaineering, rafting,
ii. This exclusion shall not, however, apply if the Insured Person
motor racing, horse racing or scuba diving, hand gliding, sky diving,
has Continuous Coverage for more than twelve months.
deep-sea diving.
iii. The within referred waiting period is made applicable to the
4.1.10. BREACH OF LAW (CODE: EXCL 10):
enhanced Base Sum Insured in the event of granting higher
Base Sum Insured subsequently Expenses for treatment directly arising from or consequent upon any
Insured Person committing or attempting to commit a breach of law
4.1.4. INVESTIGATION & EVALUATION (CODE: EXCL04)
with criminal intent.
i. Expenses related to any admission primarily for diagnostics
4.1.11. EXCLUDED PROVIDERS (CODE: EXCL 11):
and evaluation purposes only are excluded.
Expenses incurred towards treatment in any Hospital or by any
ii. Any diagnostic expenses which are not related or not incidental
Medical Practitioner or any other provider specifically excluded by
to the current diagnosis and treatment are excluded except
the Insurer and disclosed in its website / notified to the policyholders
under the Benefit 3.7.1.4 Health Check Up.
are not admissible. However, in case of life threatening situations or
4.1.5. REST CURE, REHABILITATION AND RESPITE CARE (CODE: EXCL05) following an accident, expenses up to the stage of stabilization are
payable but not the complete claim. (For updated and detailed list of
Expenses related to any admission primarily for enforced bed rest Excluded Providers refer website- www.reliancegeneral.co.in )
and not for receiving treatment. This also includes:
4.1.12. SUBSTANCE ABUSE AND ALCOHOL (CODE: EXCL12):
i. Custodial care either at home or in a nursing facility for
personal care such as help with activities of daily living such Treatment for, Alcoholism, drug or substance abuse or any addictive
as bathing, dressing, moving around either by skilled nurses condition and consequences thereof
or assistant or non-skilled persons.

4.1.13. WELLNESS AND REJUVENATION (CODE: EXCL13): Base Sum Insured subsequently.
Treatments received in heath hydros, nature cure clinics, spas or 4.2.3. Treatment outside Discipline: Treatment taken from
similar establishments or private beds registered as a nursing home anyone not falling within the scope of definition of Medical
attached to such establishments or where admission is arranged Practitioner or from a Medical Practitioner who is
wholly or partly for domestic reasons. practicing outside the discipline for which he is licensed or
any kind of self-medication
4.1.14. DIETARY SUPPLEMENTS & SUBSTANCES (CODE: EXCL14):
4.2.4. Hearing Aids and spectacles: Any charges incurred on
Dietary supplements and substances that can be purchased without
hearing aids, cost of spectacles, contact lenses, routine eye
prescription, including but not limited to Vitamins, minerals and
and ear examinations.
organic substances unless prescribed by a Medical Practitioner as
part of hospitalization claim or day care procedure. 4.2.5. External durable medical equipment: Any expenses
incurred on, corrective devices, external durable medical
4.1.15. REFRACTIVE ERROR (CODE: EXCL 15):
equipment of any kind, like wheelchairs, walkers, belts,
Expenses related to the treatment for correction of eyesight due to collars, caps, splints, braces, stockings of any kind, diabetic
refractive error less than 7.5 dioptres. footwear, glucometer/thermometer, crutches, ambulatory
devices, instruments used in treatment of sleep apnea
4.1.16. UNPROVEN TREATMENTS-CODE (CODE: EXCL 16) syndrome (C.P.A.P) or continuous ambulatory peritoneal
Expenses related to any unproven treatment, services and supplies dialysis (C.A.P.D.) and oxygen concentrator for asthmatic
for or in connection with any treatment. Unproven treatments are condition.
treatments, procedures or supplies that lack significant medical 4.2.6. Sleep Apnea: Any treatment related to sleep apnea,
documentation to support their effectiveness. general debility and convalescence.
4.1.17. STERILITY AND INFERTILITY (CODE: EXCL17) 4.2.7. External Congenital Anomaly: Treatment of External
Expenses related to sterility and infertility. This includes: Congenital Anomaly.
i. Any type of contraception, sterilization 4.2.8. Artificial Life support equipment’s: Artificial life maintenance,
including life support machine use, where such treatment will
ii. Assisted Reproduction services including artificial insemination not result in recovery or restoration of the previous state of
and advanced reproductive technologies such as IVF, ZIFT, health.
GIFT, ICSI
4.2.9. Non-payable items: Expenses against items mentioned
iii. Gestational Surrogacy in “Annexure A- List I” shall not be payable. This exclusion
iv. Reversal of sterilization shall be waived off, if Optional Benefit - 3.7.1.3“Consumable
Cover” has been opted under the Policy.
4.1.18. MATERNITY EXPENSES (CODE - EXCL 18)
4.2.10. Outpatient Treatment: Treatment which has been done on
i. Medical treatment expenses traceable to childbirth (including an outpatient basis without any associated Hospitalization.
complicated deliveries and caesarean sections incurred
during hospitalization) except ectopic pregnancy; 4.2.11. Overseas Treatment: Treatment received outside India.
ii. Expenses towards miscarriage (unless due to an accident) 4.2.12. Self-injury: Any intentional self-inflicted Injury, suicide or
and lawful medical termination of pregnancy during the attempted suicide.
Policy Period. 4.2.13. Documentation charges: Any charges incurred to procure
4.2. SPECIFIC EXCLUSIONS any medical certificate, treatment/Illness related documents
pertaining to any period of Hospitalization/Illness.
4.2.1. 15 DAYS WAITING PERIOD FOR COVID-19:
4.2.14. Charges other than Reasonable & Customary Charges:
i. Any Expenses related to the treatment of Covid-19 within Any Medical Expenses which are not Reasonable and
15 days from the first Policy commencement date shall be Customary Charges
excluded.
4.2.15. RMO charges and Service charge: Expenses related to
ii. This exclusion shall not apply if the Insured Person has any kind of RMO charges, service charge where nursing
continuous coverage for more than twelve months. charges are also charged, night charges levied by the
Hospital under whatever head.
iii. The within referred Waiting Period is made applicable to the
enhanced Base Sum Insured in the event of granting higher 4.2.16. Nuclear Attack: Nuclear, Chemical or Biological attack/
Base Sum Insured subsequently. weapons, contributed to, caused by, resulting from or from
any other cause or event contributing concurrently or in
4.2.2. 24 MONTHS WAITING PERIOD FOR VISION CORRECTION
any other sequence to the loss, claim or expense. For the
i. Any Expenses related to the treatment of Vision Correction purpose of this Clause:
within 24 months from the first Policy commencement date
a. Nuclear attack/ weapons means the use of any nuclear
shall be excluded.
weapon or device or waste or combustion of nuclear fuel
ii. This exclusion shall not apply if the Insured Person has or the emission, discharge, dispersal, release or escape
continuous coverage for more than twelve months. of fissile/ fusion material emitting a level of radioactivity
capable of causing any Illness, incapacitating disablement
iii. The within referred Waiting Period is made applicable to the
or death.
enhanced Base Sum Insured in the event of granting higher

b. Chemical attack/ weapons means the emission, discharge, shall be liable to pay interest to the policyholder at a rate
dispersal, release or escape of any solid, liquid or gaseous 2% above the bank rate from the date of receipt of last
chemical compound which, when suitably distributed, is necessary document to the date of payment of claim.
capable of causing any Illness, incapacitating disablement
(Explanation: “Bank rate” shall mean the rate fixed by the Reserve
or death.
Bank of India (RBI) at the beginning of the financial year in which
c. Biological attack/ weapons means the emission, discharge, claim has fallen due)
dispersal, release or escape of any pathogenic (disease
5.1.4. COMPLETE DISCHARGE
producing) micro-organism(s) and/or biologically produced
toxin(s) (including genetically modified organisms and Any payment to the Policyholder, Insured Person or his/her
chemically synthesized toxins) which are capable of causing nominees or his/her legal representative or assignee or
any Illness, incapacitating disablement or death. to the Hospital, as the case maybe, for any benefit under
the Policy shall be a valid discharge towards payment of
4.2.17. War (whether declared or not) and war like occurrence
claim by the Company to the extent of that amount for the
or invasion, acts of foreign enemies, hostilities, civil war,
particular claim.
rebellion, revolutions, insurrections, mutiny, military or
usurped power, seizure, capture, arrest, restraints and 5.1.5. MULTIPLE POLICIES
detainment of all kinds.
i. In case of multiple policies taken by an Insured Person
4.3. PERMANENT EXCLUSIONS during a period from one or more insurers to indemnify
treatment costs, the Insured Person shall have the right
A permanent exclusion will be applied on Pre-Existing medical or
to require a settlement of his/her claim in terms of any of
physical condition or treatment of an Insured Person, if such exclusion
his/her policies. In all such cases the insurer chosen by the
is accepted by the Proposer and specifically mentioned in the Policy
Insured Person shall be obliged to settle the claim as long
Schedule. This option, as per Company’s underwriting policy, will be
as the claim is within the limits of and according to the terms
used for such condition(s) or treatment(s) that otherwise would have
of the chosen Policy.
resulted in rejection of insurance coverage under this Policy to such
Insured Person. The list of such diseases/ conditions or treatments ii. Insured Person having multiple policies shall also have
are enclosed as an Annexure-F the right to prefer claims under this Policy for the amounts
disallowed under any other Policy / Policies even if the
SECTION-5 GENERAL TERMS AND CLAUSES
Sum Insured is not exhausted. Then the Insurer shall
5.1. STANDARD GENERAL TERMS AND CLAUSES independently settle the claim subject to the terms and
conditions of this Policy.
5.1.1. DISCLOSURE OF INFORMATION
iii. If the amount to be claimed exceeds the sum insured under
The Policy shall be void and all premium paid thereon shall be
a single Policy, the Insured Person shall have the right to
forfeited to the Company in the event of misrepresentation, mis
choose insurer from whom he/she wants to claim the
description or non-disclosure of any material fact by the Policyholder.
balance amount.
(Explanation: “Material facts” for the purpose of this policy shall mean
iv. Where an Insured Person has policies from more than
all relevant information sought by the company in the proposal
one insurer to cover the same risk on indemnity basis, the
form and other connected documents to enable it to take informed
Insured Person shall only be indemnified the treatment
decision in the context of underwriting the risk).
costs in accordance with the terms and conditions of the
5.1.2. CONDITION PRECEDENT TO ADMISSION OF LIABILITY chosen Policy.
The terms and conditions of the Policy must be fulfilled by the Insured 5.1.6. FRAUD
Person for the Company to make any payment for claim(s) arising
If any claim made by the Insured Person, is in any respect fraudulent,
under the Policy.
or if any false statement, or declaration is made or used in support
5.1.3. CLAIM SETTLEMENT (PROVISION FOR PENAL INTEREST) 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
i. The Company shall settle or reject a claim, as the case may under this Policy, all benefits under this Policy and the premium paid
be, within 30 days from the date of receipt of last necessary shall be forfeited.
document.
Any amount already paid against claims made under this Policy but
ii. In the case of delay in the payment of a claim, the Company which are found fraudulent later shall be repaid by all recipient(s)/
shall be liable to pay interest to the policyholder from the Policyholder(s), who has made that particular claim, who shall be
date of receipt of last necessary document to the date of jointly and severally liable for such repayment to the insurer.
payment of claim at a rate 2% above the bank rate.
For the purpose of this clause, the expression "fraud"means any of
iii. However, where the circumstances of a claim warrant an the following acts committed by the insured person or by his agent or
investigation in the opinion of the Company, it shall initiate the Hospital/doctor/any other party acting on behalf of the Insured
and complete such investigation at the earliest, in any Person, with intent to deceive the insurer or to induce the insurer to
case not later than 30 days from the date of receipt of last issue an Insurance Policy:
necessary document. In such cases, the Company shall
settle or reject the claim within 45 days from the date of i. The suggestion, as a fact of that which is not true and which
receipt of last necessary document. the Insured Person does not believe to be true;
iv. In case of delay beyond stipulated 45 days, the Company ii. The active concealment of a fact by the Insured Person
having knowledge or belief of the fact;

iii. Any other act fitted to deceive; and Waiting Periods as per lRDAl guidelines on portability.
iv. Any such act or omission as the law specially declares to be For Detailed Guidelines on portability, kindly refer the www.irdai.gov.
fraudulent. in(Circular- IRDA/HLT/REG/CIR/003/012020, dated 01012020).
The Company shall not repudiate the claim and/or forfeit the policy 5.1.10. RENEWAL OF POLICY
benefits on the ground of Fraud, if the Insured Person/beneficiary can
i. The Policy shall ordinarily be renewable except on grounds
prove that the misstatement was true to the best of his knowledge
of fraud, misrepresentation by the Insured Person.
and there was no deliberate intention to suppress the fact or that
such misstatement of or suppression of material fact are within the ii. The Company shall endeavor to give notice for renewal.
knowledge of the insurer. However, the Company is not under obligation to give any
notice for renewal.
5.1.7. CANCELLATION
iii. Renewal shall not be denied on the ground that the insured
i. The Policyholder may cancel this policy by giving 7 days’
person had made a claim or claims in the preceding policy
written notice and in such an event, the Company shall
years.
refund premium for the unexpired Policy Periodas detailed
below: iv. Request for renewal along with the requisite premium shall
• In case of no claim in the policy be received by the Company before the end of the Policy
In the event of cancellation by the insured the refund amount Period
shall be on pro-rata basis and shall be calculated as per the v. At the end of the Policy Period, the policy shall terminate
terms laid out below: and can be renewed within the Grace Period of 30 days to
Calculation of Pro-Rata refund: maintain continuity of benefits without break in policy.
Return Premium=Total Policy Premium*(1-((Number of Policy
vi. The grace period for payment of the premium for all types
days expired)/(Total Policy Days) )) of insurance policies shall be: fifteen days where premium
For e.g. If Policy Premium for 1 year (365 days) policy is Rs. payment mode is monthly and thirty days in all other cases.
10000, and if cancellation is effected on expiry of 243 days
from policy inception, then The Return Premium = 10000 * vii. Coverage is not available during the grace period, except in
(1- (243 / 365)) = Rs. 3342.47. case where the premium is paid in instalment
• In case of claim in the policy viii. No loading shall apply on renewals based on individual
Where any claim has been admitted or has been lodged claims experience.
by the person under the Policy, there shall be no refund of
premium for the Policy Year in which the claim occurs. 5.1.11. WITHDRAWAL OF POLICY
For e.g. If Policy Premium for 1 year (365 days) policy is Rs. i. In the likelihood of this product being withdrawn in future,
10000. Considering the claim year is 1st Year (200 days), then the Company will intimate the Insured Person about the
no refund shall be made for the Policy Year. same 90 days prior to expiry of the Policy.
The Company may cancel the Policy at any time on grounds of ii. Insured Person will have the option to migrate to similar
misrepresentation, non-disclosure of material facts, fraud by the health insurance product available with the Company at
Insured Person by giving 7 days’ written notice. There would be no the time of renewal with all the accrued continuity benefits
refund of premium on cancellation on grounds of misrepresentation, such as cumulative bonus, waiver of waiting period. as per
non-disclosure of material facts or fraud. lRDAl guidelines, provided the policy has been maintained
5.1.8. MIGRATION without a break
The Insured Person will have the option to migrate the Policy to 5.1.12. MORATORIUM PERIOD
other health insurance products/plans offered by the Company by After completion of sixty continuous months of coverage (including
applying for migration of the Policy atleast 30 days before the Policy portability and migration) in health insurance policy, no policy
renewal date as per lRDAl guidelines on Migration. If such person and claim shall be contestable by the insurer on grounds of non-
is presently covered and has been continuously covered without disclosure, misrepresentation, except on grounds of established
any lapses under any health insurance product/plan offered by the fraud. This period of sixty continuous months is called as moratorium
Company, the Insured Person will get the accrued continuity benefits period. The moratorium would be applicable for the sums insured of
in waiting periods as per lRDAl guidelines on migration the first policy. Wherever the sum insured is enhanced, completion
For Detailed Guidelines on migration, kindly refer the www.irdai.gov. of sixty continuous months would be applicable from the date of
in(Circular-IRDA/HLT/REG/CIR/003/012020, Dated-01012020) enhancement of sums insured only on the enhanced limits.
5.1.9. PORTABILITY 5.1.13. PREMIUM PAYMENT IN INSTALMENTS (WHEREVER APPLICABLE)
The Insured Person will have the option to port the Policy to other If the Insured Person has opted for Payment of Premium on an
insurers by applying to such insurer to port the entire Policy along instalment basis i.e. Lumpsum, Half Yearly, Quarterly or Monthly,
with all the members of the family, if any, at least 45 days before, but as mentioned in the Policy Schedule/Certificate of Insurance, the
not earlier than 60 days from the Policy renewal date as per lRDAl following Conditions shall apply (notwithstanding any terms contrary
guidelines related to portability. If such person is presently covered elsewhere in the policy)
and has been continuously covered without any lapses under any i. The grace period of fifteen days (where premium is paid on a
health insurance policy with an Indian General/Health insurer, the monthly instalments) and thirty days (where premium is paid
proposed Insured Person will get the accrued continuity benefits in in quarterly / half-yearly / annual instalments) is available on

the premium due date, to pay the premium. In case of any grievance the Insured Person may contact the
Company through
ii. If the policy is renewed during grace period, all the credits
(sum insured, No Claim Bonus, Specific Waiting periods, Website: www. Relianceada.com
waiting periods for pre-existing diseases, Moratorium period
Toll free: 1800-3009
etc.) accrued under the policy shall be protected
Dedicated Senior Citizen helpline: 022-33834185 (paid line)
iii. The Insured Person will get the accrued continuity benefit in
respect of the ‘Waiting Periods’ ‘ Specific Waiting Periods’ in E-mail: [email protected]
the event of payment of premium within the stipulated grace
Period Fax: +91 22 3303 4662 Courier: Any branch office, the correspondence
address, during normal business hours.
iv. No interest will be charged If the instalment premium is not
paid on due date. Write to us at: Reliance General Insurance, (Correspondence Only)
Correspondence Unit, Winway Building 2nd &3rd Floor,11/12 Block
v. In case of instalment premium due not received within the No-4,Old no-67,South Takoganj,Indore(M.P)-452001.Insured Person
grace period, the policy will get cancelled. may also approach the grievance cell at any of the Company’s
branches with the details of grievance.
vi. In the event of a claim, all subsequent premium instalments
shall immediately become due and payable. If Insured Person is not satisfied with the redressal of grievance
through one of the above methods, Insured Person may contact the
vii. The Company has the right to recover and deduct all the
grievance officer at:
pending installments from the claim amount due under the
Policy. Grievance Redressal Officer
5.1.14. Possibility of Revision of Terms of the Policy Including the The Grievance Cell,
Premium Rates
Reliance General Insurance Co. Limited
The Company, with prior approval of lRDAl, may revise or modify the
terms of the policy including the premium rates. The Insured Person No. 1-89/3/B/40 to 42/ks/301, 3rd floor,
shall be notified three months before the changes are effected. Krishe Block, Krishe Sapphire, Madhapur
5.1.15. FREE LOOK PERIOD Hyderabad – 500 081
The Free Look Period shall be applicable on new individual health Grievance Redressal officer
insurance policies and not on renewals or at the time of porting/ email ID: rgicl.headgrievances@relian ceada.com
migrating the policy.
(For updated details of grievance officer, kindly refer the link.
The Insured Person shall be allowed free look period of thirty days
from date of receipt of the policy document to review the terms and https: / / reliance general.co.in/ Insurance/About -Us/Grievance-
conditions of the Policy, and to return the same if not acceptable. Redressal.aspx
If the Insured has not made any claim during the Free Look Period, If Insured Person is not satisfied with the redressal of grievance
the Insured shall be entitled to through above methods, the Insured Person may also approach
the office of Insurance Ombudsman of the respective area/region
i. A refund of the premium paid less any expenses incurred by for redressal of grievance as per Insurance Ombudsman Rules 2017.
the Company on medical examination of the insured person
and the stamp duty charges or The contact details of the Insurance Ombudsman offices have been
provided as Annexure-B
ii. Where the risk has already commenced and the option
of return of the policy is exercised by the insured person, Grievance may also be lodged at lRDAl Integrated Grievance
a deduction towards the proportionate risk premium for Management System https://igms. irda.qov. in/
period of cover or 5.2. SPECIFIC TERMS AND CLAUSES
iii. Where only a part of the insurance coverage has 5.2.1. MATERIAL CHANGE
commenced, such proportionate premium commensurate
with the insurance coverage during such period; The Policyholder/Insured Person shall immediately notify the
Company in writing of any material change in the risk at his own
5.1.16. NOMINATION expense and the Company may adjust the scope of cover and/or
The Policyholder is required at the inception of the Policy to make a premium, if necessary, accordingly.
nomination for the purpose of payment of claims under the Policy in 5.2.2. RECORDS TO BE MAINTAINED
the event of death of the Policyholder. Any change of nomination shall
be communicated to the Company in writing and such change shall The Policyholder/ Insured Person shall keep an accurate record
be effective only when an endorsement on the Policy is made. In the containing all relevant medical records until final adjustment (if
event of death of the Policyholder. the Company will pay the nominee any) and resolution of all Claims under this Policy and shall allow
(as named in the Policy Schedule/Policy Certificate/Endorsement(if the Company or its representative(s) to inspect such records. The
any)) and in case there is no subsisting nominee, to the legal heirs Policyholder/ Insured Person shall furnish such information as the
or legal representatives of the policyholder whose discharge shall Company may require under this Policy .
be treated as full and final discharge of its liability under the Policy.
5.2.3. NO CONSTRUCTIVE NOTICE
5.1.17. REDRESSAL OF GRIEVANCE
Any knowledge or information of any circumstance or condition in

relation to the Policyholder/ Insured Person which is in possession or e-mail.
of the Company and not specifically informed by the Policyholder
5.2.10. OVERRIDING EFFECT OF POLICY SCHEDULE
/ Insured Person shall not be held to bind or prejudicially affect the
Company notwithstanding subsequent acceptance of any premium. In case of any inconsistency in the terms and conditions in this
Policy vis-a-vis the information contained in the Policy Schedule, the
5.2.4. POLICY DISPUTES
information contained in the Policy Schedule shall prevail
Any and all disputes or differences under or in relation to validity,
SECTION-6 OTHER TERMS AND CONDITION
construction, interpretation and effect to this Policy shall be
determined by the Indian Courts and subject to Indian law. 6.1. CLAIMS INTIMATION, ASSESSMENT AND MANAGEMENT
5.2.5. LIMITATION PERIOD The fulfillment of the terms and conditions of this Policy (including the
realization of premium by their respective due dates) in so far as they
In no case whatsoever the Company shall be liable for any Claim
relate to anything to be done or complied with by the Policyholder
under this Policy, if the requirement of Clause 6.1 above are not
or any Insured Person, including complying with the following steps,
complied with, unless the Claim is the subject of pending action;
shall be the condition precedent to the admissibility of the Claim.
it being expressly agreed and declared that if the Company shall
disclaim liability for any Claim hereunder and such Claim shall not Upon the discovery or happening of any Illness / Injury that may give
within 12 calendar months from the date of the disclaimer have been rise to a Claim under this Policy, then as a condition precedent to
made the subject matter of a suit in court of law then the Claim shall the admissibility of the Claim, the Policyholder/ Insured Person shall
for all purposes be deemed to have been abandoned and shall not undertake the following:
thereafter be recoverable.
6.1.1. CLAIMS INTIMATION
5.2.6. ALTERATIONS IN THE POLICY
In the event of any Disease or Illness/ Injury or occurrence of any
This Policy constitutes the complete contract of insurance. No change other contingency which has resulted in a Claim or may result in a
or alteration shall be valid or effective unless approved in writing Claim covered under the Policy, the Policyholder/ Insured Person,
by the Company, which approval shall be evidenced by a written must notify the TPA/Company either at the call center or in writing
endorsement signed and stamped by the Company. However, immediately, in the event of :
change or alteration with respect to increase/ decrease of the Base
Sum Insured shall be permissible only at the time of renewal of the i. Planned Hospitalization, the Policyholder /Insured Person
Policy subject to underwriting decision of the Company will intimate such admission at least 48 hours prior to the
planned date of admission.
5.2.7. ENDORSEMENTS (MID TERM ADDITION/DELETION OF
INSURED PERSONS) ii. Emergency Hospitalization, the Policyholder /Insured
Person will intimate such admission within 24 hours of such
i. Mid-Term Addition of Family: Mid-term addition of Family admission.
members shall be allowed in the event of following:
The following details are to be provided to the TPA/Company at the
a) Newborn baby covered from 90 days time of intimation of Claim:
b) Spouse in the event of marriage. a. Policy Number
ii. Mid Term Deletion of Policyholder/Family: Midterm b. Name of the Policyholder
deletion of Policyholder or his/her Family members shall
be allowed on pro-rata basis only in the event of Death of c. Name of the Insured Person in whose relation the Claim is
the Insured Person or his/her Family members subject to being lodged.
no claim has been made against the deleted person. d. Nature of Illness / Injury
iii. The Company may at any time terminate coverage to the e. Name and address of the attending Medical Practitioner
Policyholder or his/her Family members on grounds as and Hospital
specified in Clause 5.1.1 Disclosure to information norm,
by giving 15 days’ notice and by sending an endorsement f. Date of Admission to Hospital or proposed date of
to Policyholder’s address shown in the Policy Schedule admission to Hospital for Planned Hospitalization
without refund of premium. g. Any other information as requested by the Company.
5.2.9. COMMUNICATION 6.1.2. CLAIMS PROCEDURE
Any communication meant for the Company must be in writing(by i. CASHLESS:
physical or digital mode) and be delivered to its address shown in the
Policy Schedule. Any communication meant for the Policyholder will Cashless facility is available only at a Network Hospital and shall
be sent by the Company to his last known address or the address as be available for Benefits-3.1.1 (Hospitalization Expenses) and 3.1.4
shown in the Policy Schedule. (Modern Treatment), unless specified otherwise. The Insured Person
can avail Cashless facility at the time of admission into any Network
All notifications and declarations for the Company must be in writing Hospital, by presenting the health card as provided by the TPA/
and sent to the address specified in the Policy Schedule. Agents are Company with this Policy, along with a valid photo identification
not authorized to receive notices and declarations on the Company’s proof (Voter ID card / Driving License / Passport / PAN Card / any
behalf. other identity proof as approved by the Company).
Notice and instructions will be deemed served 10 days after posting To avail Cashless facility, the following procedure must be followed
or immediately upon receipt in the case of hand delivery, facsimile

by the Policyholder/ Insured Person: Insured Person is required to check the applicable list of Network
Hospital on the Company’s website.
a. Pre-authorization: Prior to Hospitalization, the Policyholder/
Insured Person must call the call center of the TPA/Company ii. RE-IMBURSEMENT:
and request authorization by way of submission of a
In case of any Claim under the Benefits, where Cashless facility
completed Pre-authorization form at least 48 hours before
is not availed, the list of documents as mentioned in Clause 6.1.4:
a planned Hospitalization and in case of an Emergency
Claim Documents shall be provided by the Policyholder/Insured
situation, within 24 hours of Hospitalization.
Person, immediately but not later than 15 days of discharge from the
b. The TPA/Company will process the Policyholder’s/ Insured Hospital, at the Policyholder’s/ Insured Person’s expense to avail
Person’s request for authorization after having obtained the Claim.
accurate and complete information for the Illness/ Injury
Note- For reimbursement claim under Benefit-3.1.4 Domiciliary
for which Cashless facility for Hospitalization is sought by
Hospitalization, Benefit-3.1.6 Post Hospitalization and Benefit-3.7.11.1
the Policyholder/ Insured Person and the Company will
Home Care Treatment the above mentioned condition of“ not later
confirm such Cashless authorization / rejection in writing or
than 15 days of discharge from the Hospital” shall stands modified
by other means.
as under:
c. If the procedure above is followed and the Policyholder’s/
a. Benefit-3.1.4 Domiciliary Hospitalization “not later than 15
Insured Person’s request for Cashless facility is authorized,
days of completion of Domiciliary Hospitalization “
the Policyholder/ Insured Person will not be required to pay
for the Hospitalization Expenses which are covered under b. Benefit-3.1.6 Post Hospitalization “not later than 15 days of
this Policy and fall within the Company’s liability (within the completion of Post hospitalization period “
authorized limit).Original bills and evidence of treatment in
respect of the same shall be left with the Network Hospital. c. Benefit-3.7.11.1 Home Care Treatment ““not later than 15
days of completion of Home Care Treatment.
d. The Company/TPA (On behalf of Company) reserves the
right to review each Claim for Hospitalization Expenses and 6.1.3. RESPONSIBILITY OF POLICYHOLDER/ INSURED PERSON
coverage will be determined according to the terms and i. Forthwith intimate / file / submit a Claim in accordance with
conditions of this Policy. The Policyholder/ Insured Person Clause 6.1 of this Policy.
shall, in any event, be required to settle all other expenses,
co-payment and / or deductibles (if applicable), directly with ii. If so requested by the TPA/Company, the Insured Person
the Hospital. will have to submit himself for a medical examination by
the Company's nominated Medical Practitioner as often
e. Cashless facility for Hospitalization Expenses shall be as it considers reasonable and necessary. The cost of such
limited exclusively to Medical Expenses incurred for examination will be borne by the Company.
treatment undertaken in a Network Hospital for Illness or
Injury which are covered under the Policy. iii. The Policyholder/ Insured Person is required to check
the applicable list of Network Hospitalization the TPA/
f. There can be instances where the TPA/Company may deny Company’s website or call center before availing the
Cashless facility for Hospitalization due to insufficient Sum Cashless services.
Insured or insufficient information to determine admissibility
in which case the Policyholder/ Insured Person may be iv. On occurrence of an event which will lead to a Claim under
required to pay for the treatment and submit the Claim this Policy, the Policyholder/ Insured Person shall:
for reimbursement to the TPA/Company which will be a. Allow the Medical Practitioner or any of the Company’s
considered subject to the Policy Terms &Conditions. representatives to inspect the medical and Hospitalization
g. The Policyholder/ Insured Person shall be required to records, investigate the facts and examine the Insured
submit the documents as mentioned in Clause 6.1.4: Claim Person.
Documents, with the Network Hospital. b. Assist and not hinder or prevent the Company’s
Note: Under Cashless facility, the TPA/Company may authorize upon representatives in pursuance of their duties for ascertaining
the Policyholder‘s / Insured Person’s request for direct settlement the admissibility of the Claim under the Policy.
of admissible Claim as per agreed charges & terms and conditions c. If the Policyholder / Insured Person does not comply with
between Network Hospital and the TPA/Company. In such cases, the provisions of these conditions all benefits under this
the TPA/Company will directly settle all eligible amounts as per the Policy shall be forfeited at the Company’s option.
Policy Terms &Conditions with the Network Hospital to the extent the
Claim is covered under the Policy. 6.1.4. CLAIM DOCUMENTS
The Company, at its sole discretion, reserves the right to modify, add The Policyholder / Insured Person shall submit to the TPA/Company/
or restrict any Network Hospital for Cashless services available under Network Hospital (as applicable) the following documents for or in
the Policy. Before availing the Cashless service, the Policyholder / support of the Claim:

Benefit Covers List of Claim Documents vii. Any other document as required by
No. the Company to assess the Claim
Benefit- Hospitalization Benefit- Critical Illness i. Same Documents as mentioned for
3.1 Cover: 3.4 Cover: Benefit -3.1 - Hospitalization Cover
Hospitalization Waiver of are required
Expenses, Premium
Domestic Road Benefit- Renewal i. Same Documents as mentioned for
Ambulance, 3.5 Benefits: Benefit- 3.1 - Hospitalization Cover
Domiciliary are required
Cumulative
Hospitalization,
Bonus, Call ii. Documents as mentioned for
Modern
Option for Benefit: 3.3 (Personal Accident
Treatment,
Enhancement Cover)
Pre and Post
of Base Sum iii. Proof of employment
Hospitalization,
Insured and
Organ Donor E
Loyalty Cover
Hospitalization i. Duly completed and signed Claim
Benefit- Value Added As per case, if required
Cover: Form, in original
3.6 Covers:
Hospitalization ii. Medical Practitioner’s referral letter
Wellness
Expenses, advising Hospitalization
Services,
Domestic Road iii. Medical Practitioner’s prescription Claim Service
Ambulance, advising drugs / diagnostic tests / Guarantee,
Domiciliary consultation Policy Service
Hospitalization,
iv. Original bills, receipts and Guarantee
Modern
Treatment, discharge card from the Hospital / Benefit-3.7-Optional Covers
Pre and Post Medical Practitioner
Benefit- Enhanced i. Same Documents as mentioned for
Hospitalization, v. Original bills from pharmacy / 3.7.1 covers: Benefit - 3.1 - Hospitalization Cover
Organ Donor chemists are required
Guaranteed
Expenses vi. Original pathological / diagnostic Cumulative
test reports and payment receipts Bonus,
vii. Indoor case papers Unlimited
viii. Ambulance receipt and bill Reinstatement
of Base Sum
ix. First Information Report/ Final
Insured,
Police Report, if applicable
Consumable
x. Post mortem report, if available Cover
Benefit- Extra Cover: i. Same Documents as mentioned for Benefit- Double Cover i. Same Documents as mentioned for
3.2 Reinstatement Benefit - 3.1 - Hospitalization Cover 3.7.2 Benefit- 3.1 - Hospitalization Cover
of Base Sum are required are required
Insured and
Extra Sum Benefit- Change in i. Same Documents as mentioned for
Insured 3.7.3 Room Rent Benefit -3.1 - Hospitalization Cover
limits are required
Benefit- Personal i. Duly completed and signed Claim
3.3 Accident Form, in original Benefit- Reduction in i. Same Documents as mentioned for
Cover: 3.7.4 Pre-Existing Benefit -3.1 - Hospitalization Cover
ii. Death certificate(In case of Death Waiting Period are required
Accidental Claim)
Death Cover Benefit- Voluntary i. Same Documents as mentioned for
iii. Disability Certificate(In case of 3.7.5 Aggregate Benefit -3.1 - Hospitalization Cover
Disability Claim) Deductible are required
iv. Post mortem report if available and
Benefit- Removal of Co- i. Same Documents as mentioned for
applicable
3.7.6 Payment Benefit -3.1 - Hospitalization Cover
v. First Information Report/ Final Police are required
Report, if applicable
Benefit- Hospital Cash i. Same Documents as mentioned for
vi. Identity proof of Nominee or 3.7.7 Benefit - 3.1 - Hospitalization Cover
Original Succession Certificate/ are required
Original Legal Heir Certificate or any
other proof to the satisfaction of the
Company for the purpose of a valid
discharge in case nomination is not
filed by deceased.

Benefit- Convenience i. Same Documents as mentioned for Expenses as mentioned in Benefit-3.1.1 Hospitalization Expenses
3.7.8 Cover: Benefit - 3.1 - Hospitalization Cover barring the below mentioned expense break ups:
Change in are required. a. Cost of Pharmacy and Consumables
Pre-Post ii. Radio Taxi bill and receipt
b. Cost of Implants and Medical Devices
Hospitalization,
Air Ambulance, c. Cost of Diagnostics
Radio Taxi,
Convalescence The proportional reduction will be done in a manner consistent with
Cover the below table:
Benefit- Preventive i. Duly completed and signed Claim Sr. Header Explanation
3.7.9 Cover: Form, in original No.
Health ii. Health Check up bills and Receipts I Actual Room Room Rent (Including items to be
Checkup and iii. Vaccination bills and Receipts Rent subsumed under Room Rent as
Vaccination
defined under Annexure A)
Benefit- Smart Cover: i. Same Documents as mentioned for
II Eligible Room Room Rent allowed as per policy
3.7.10 Change in Benefit - 3.1 - Hospitalization Cover
Rent Limit is Single Private A.C Room (upto
Modern are required
Deluxe Room)
Treatment,
Vision A Actual Medical As per submitted documents
Correction, Bills Incurred
Second (-) Any expense
Opinion not covered
Benefit- Family Care i. Same Documents as mentioned for under Policy
3.7.11 Cover: Home Benefit-3.1-Hospitalization Cover Benefits
Care Treatment, are required B = Covered Medi-
Companion ii. Companion’s accommodation bills cal Expenses
and Child and receipts (-) cost of Phar-
Cover macy and
Note - The Company may call for any other documents as consumables,
required by the Company to assess the Claim. implants
and medical
When original bills, receipts, prescriptions, reports and other
devices and
documents are given to any other insurer or to the reimbursement
diagnostics
provider, verified photocopies attested by such other insurer/
reimbursement provider along with an original certificate of the D = Covered Med-
extent of payment received from them needs to be submitted. ical Expenses
which shall
NOTE : be subject to
i. Claim once paid under one Benefit cannot be paid again Proportionate
under any other Benefit. Deduction
(*) (Eligible Room
ii. All invoices / bills should be in Insured Person’s name.
Rent Limit)/
6.1.5. PROPORTIONATE DEDUCTIONS (Actual Room
Rent)
Subject to the other Terms and Conditions of this Policy, the Associate
Medical Expenses (and the Room Rent) incurred by the Insured E = Claim after If Actual Room Rent is within
Person pertaining to a Hospitalization shall be proportionately Proportionate eligibility, then no deduction to be
reduced in deriving at the payable amount of the corresponding Deduction applied [E=D]
Claim, in the event of (as the case maybe): (+) Cost of
i. The Insured Person chooses a higher room category than the Pharmacy and
category that is eligible as per the terms and conditions of consumables,
the Policy. In this case, higher room category means a room implants
category in which the room rent expenses charged by the and medical
Hospital is more expensive than the eligible room category as devices and
per the terms and conditions of the Policy. diagnostics
F = Assessed
ii. The Insured Person chooses a room category in which the
Claim amount
room rent charges are more than the applicable Base Sum
Insured sub-limit (in percentage or Rupee terms) on the room (-) Deduction for
rent as per the Policy terms and conditions. Copay
In the above, Associate Medical Expense, means all admissible G = Ground up

invoice break ups (or bill heads) of the Hospitalization Medical claim amount

(-) Deductions vii. For the Reimbursement Claims, the Company will pay the
for Policy De- Policyholder/Insured Person. In the event of death of the
ductibles and Policyholder, the Company will pay the nominee (as named
Limits* in the Policy Schedule) and in case of no nominee at its
discretion to any adult Insured Person in the Policy whose
H = Payable claim discharge shall be treated as full and final discharge of its
amount liability under the Policy.
*The Final Claim amount would be deducted, in the following viii. The Company will only be liable to pay for such Benefits for
progressive order, from: which the Policyholder/ Insured Person has specifically
a. Base Sum Insured claimed in the Claim Form.
b. Benefit- 3.2.2- Extra Sum Insured or Benefit-3.7.2-Double 6.2. Co-Payment

Cover (whichever is applicable) The Policyholder/Insured Person shall bear a Co-Payment
c. Benefit-3.5.1-Cumulative bonus of 20% on the Assessed Claim Amount, if at the time of
inception of the first Policy with the Company, the age of the
d. Benefit-3.6.3-Policy Service Guaranteed Sum Insured (if Insured Person (or eldest Insured Person in case of Family
applicable) Floater Policy) is 61 years and above.
e. Benefit-3.2.1 Reinstated Sum Insured or Benefit-3.7.1.2 In case of an Individual Policy, the above-mentioned Co-
Unlimited Reinstatement of Base Sum (whichever is Payment shall be applicable on each and every claim
applicable) incurred by that particular Insured Person whose age at the
time of inception of the first Policy is >=61 years.
Proportionate Deduction is subject to the following:
For Floater Policy, the Co-Payment shall be applicable on
i. Apart from the Associate Medical Expenses, no other
each and every claim incurred under the Policy during the
expenses will be proportionately reduced
Policy Year.
ii. If the given Hospital do not follow differential billing or
If the Parents are covered in a floater policy and the age
if there are items in the claim for which the Hospital do
of Parents at the time of entering into the Policy is >=61
not follow differential billing, the Insurer shall not be
years then the Co-Payment shall be applicable on both the
proportionately reducing the Claims. This shall be applied
Parents’ claim and not on other Insured Persons.
in case of admissions in Government Hospitals and the
Network Hospitals of the Insurer. If the Proposer (who is also an Insured Person) or his or her
spouse at the time of entering into the Policy is >=61 years
iii. ICU charges shall not be proportionately reduced in all
then Co-Payment shall be applicable on each and every
cases.
claim of all Insured Persons under the Policy.
6.1.6. Payment Terms
The Co-Payment shall not be applicable on Benefit 3.1.1.3
i. This Policy covers medical treatment taken within India, and - Accomodation Bonus, Benefit - 3.3.1 Accidental Death
payments under this Policy shall be made in Indian Rupees Cover, Benefit - 3.4.1 - Waiver of Premium, Benefit 3.5.3
within India. Loyalty Cover, Benefit - 3.6 .1 Wellness Services, Benefit 3.7.7
Hospital Cash (if opted), Benefit - 3.7.8.4 Convalescence
ii. Claims shall not be admissible under this Policy unless
Cover, Benefit-3.7.9.1 Health Check Up, Benefit - 3.7.9.2
the TPA/Company has been provided with the complete
Vaccination Cover, Benefit - 3.7.11.2 Companion Cover,
documentation / information which the Company
Benefit - 3.7.11.3 Child Care Cover.
has requested to establish its liability for the Claim, its
circumstances and its quantum unless the Policyholder / ii. Zone Wise Co-Payment
Insured Person have complied with the obligations under
Zone A:
this Policy.
Delhi, New Delhi & NCR including Faridabad, Noida,
iii. The Company shall not indemnify the Policyholder / Ghaziabad, Gurugram, Noida, Gautam Buddha Nagar,
Insured Person for any period of Hospitalization of less than Mumbai & Suburbs, MMR (Mumbai Metropolitan Region),
24 hours except for the Day Care Treatment Navi Mumbai & Suburbs, Thane City & Suburbs, Mira Road,
Bhayandar, Panvel, Kalyan & Dombivali, State of Gujarat,
iv. The claims payable under all benefits are limited to Total Kolkata & Suburbs.
Liability, defined under this Policy.
Zone B: Rest of India
v. The Sum Insured of the Insured Person shall be reduced
by the amount payable / paid under the Benefit(s) and If the Insured Person has paid the premium for Zone A then
the balance shall be available as the Sum Insured for the Insured can avail treatment anywhere in India without any
unexpired Policy Year. This clause shall not be applicable to Co-Payment.
the Benefit 3.7.1.2 Unlimited Reinstated Sum Insured in case If the Insured Person has paid the premium for Zone B and
Benefit 3.7.1 Enhanced Covers is opted. avails the treatment in Zone B then no Co-Payment shall be
vi. For Cashless Claims, the payment shall be made to the applicable but if the Insured Persons avails the treatment in
Network Hospital whose discharge would be complete Zone A then Co-Payment of 20% shall be applicable.
and final. Below is the illustration on the Zone-Wise Co-Payment
Applicability:

Pricing/ Premium Claims Zone Co -pay (Yes/No)
Paying Zone
Zone A Zone A No Co-pay
Zone B Zone B No Co-pay
Zone A Zone B No Co-pay
Zone B Zone A Co -pay of 20%
The basis of Co-payment would primarily prevent any claims leakage prevalent due to treatment in a zone different than the pricing
zone.
Please Note-In addition to above, on each and every claim made under this Policy, Co-Payment mentioned in above Clause-6.2 (i)
(if applicable) ,shall apply over and above the Zone wise Co-Payment.
Annexure-I Coverage Summary
Policy Period 1, 2 years and 3 years

Plan Type There are 3 plans
Plus, Power and Prime
New Business Base Sum Insured Plus: 3,5
(in lakhs) Power: 10,15,20
Prime: 25,30,50,100
Renewal Business/ Call Option Plus: 3,5, 6,9
Base Sum Insured (in lakhs) Power: 10,12,15,18,20,24,
Prime: 25,30,36, 40,48,50,60,72,80,100
Room Category For Plus and Power: Single Private Air-Conditioned Room
For Prime : Actuals
Benefit No. Covers Limits for Plus Limits for Power Limits for Prime Basis of Payment Pre-Requisite for
Claim
Benefit 3.1 :- Hospitalization Cover:
3.1.1 Hospitalization Upto the Sum Upto the Sum Upto the Sum Indemnity Not applicable
Expenses: Insured Insured Insured 3.1.1.1 - In Patient
Accommodation
3.1.1.1 - In Patient Accommodation Accommodation Treatment
Treatment Bonus: Additional Bonus: Additional Bonus: Additional (applicable for
3.1.1.2 - Day Care fixed daily fixed daily fixed daily Accommodation
Treatment amount of Rs amount of Rs amount of Rs Bonus)
1000(Payable, 1000(Payable, 1000(Payable,
3.1.1.3 -
only if applicable) only if applicable) only if applicable)
Accomodation
Bonus
3.1.2 Domestic Road upto 1500 per upto 3000 per Actuals Indemnity 3.1.1.1 - In Patient
Ambulance hospitalization hospitalization (including Intercity Treatment
Intercity Intercity ambulance cost:
Ambulance Ambulance beyond 100km)
cost (beyond cost (beyond
100km): upto 100km): upto
Rs 20000 per Rs 20000 per
hospitalization hospitalization
3.1.3 Domiciliary Within the Sum Insured Indemnity Not applicable
Hospitalization
3.1.4 Modern upto 50% of Base Sum Insured upto 100% of Indemnity 3.1.1 -
Treatment Base Sum Insured Hospitalization
Expenses or
3.1.3 - Domiciliary
Hospitalization

3.1.5 Pre upto 60 days, within the Sum Insured Indemnity 3.1.1 -
Hospitalization Hospitalization
Expenses, 3.1.3
- Domiciliary
Hospitalization
or 3.1.4 - Modern
Treatment
3.1.6 Post upto 60 days, within the Sum Insured upto 90 days, Indemnity 3.1.1 -
Hospitalization within the Sum Hospitalization
Insured Expenses, 3.1.3
- Domiciliary
Hospitalization
or 3.1.4 - Modern
Treatment
3.1.7 Organ Donor Upto 50% of Base Sum Insured, Upto 50% of Base Indemnity 3.1.1.1 - In Patient
Expenses subject to maximum of Rs 5 lakhs Sum Insured, Treatment
subject to
maximum of Rs
10 lakhs
Benefit -3.2: Extra Cover
3.2.1 Reinstatement On subsequent claim, one reinstatement up to 100% of Indemnity 3.1 -
of Base Sum Base Sum Insured for unrelated illness/injury, sub-limit of Hospitalization
Insured 20% of Base Sum Insured for related illness/injury Cover
3.2.2 Extra Sum Additional,20% of Base Sum Insured on same claim, in Indemnity 3.1 -
Insured single Hospitalization Hospitalization
Cover
Benefit-3.3-Personal Accident Cover
3.3.1 Accidental Death Not Applicable 5% of Base Sum Insured subject to Benefit Not applicable
Cover minimum of Rs 1lakh
Benefit-3.4-Critical Illness Cover
3.4.1 Waiver of Not Applicable Waives off renewal Policy Premium on Not Applicable Not applicable
Premium diagnosis of listed Critical Illness
Benefit-3.5-Renewal Benefits
3.5.1 Cumulative 33.33% increase in Base Sum Insured for every claim Indemnity 3.1 -
Bonus free Policy Year, max upto 100% of Base Sum Insured and Hospitalization
33.33% decrease for every claim year Cover
3.5.2 Call Option for After 4 continuous and consecutive claim free Policy Years, Indemnity 3.1 -
Enhancement if Policyholder avails this benefit then enhanced Sum Hospitalization
of Base Sum Insured is sum of expiring Policy's Base Sum Insured and Cover
Insured accumulated Cumulative Bonus
3.5.3 Loyalty Cover Refer Benefit-3.5.3 Loyalty Cover Benefit and 3.1.1.1 - In Patient
Indemnity Treatment(
applicable for
Hospital Cash
and Leave
Compensation
benefit)
Benefit -3.6-Value Added Covers
3.6.1 Wellness Services This is Service in which Insured Person can seek Medical Not Applicable Not applicable
advice through telephonic or online mode
3.6.2 Claim Service Cashless Claim - 1% of Delayed Claim Amount( for delay Indemnity 3.1.1
Guarantee beyond 6 hours to 12 hours ),additional 1% for every Hospitalization
additional delay of 6 business hours Expenses
Reimbursement Claim-1% of Delayed Claim Amount (for
delay beyond 21 days to upto 42 days),additional 1% for
every additional delay of 6 business hours
Maximum limit - 6% of Delayed Claim Amount

3.6.3 Policy Service 10000 20000 20000 Indemnity Not applicable
Guarantee
Benefit - 3.7 - Optional Covers*
Benefit - 3.7.1 - Enhanced covers
3.7.1.1 Guaranteed This benefit waives off the condition of decrease in Indemnity 3.1 -
Cumulative Cumulative Bonus in case of a claim in immediate Hospitalization
Bonus previous Policy Year Cover
3.7.1.2 Unlimited On subsequent claim, Unlimited reinstatement of Base Indemnity 3.1 -
Reinstatement Sum Insured on unrelated illness or injury, sub-limit of Hospitalization
of Base Sum 100% of Base Sum Insured for related illness/injury. Cover
Insured This benefit supersedes Benefit no-3.2.1-Reinstatement of
Base Sum Insured
3.7.1.3 Consumable Within Sum Insured Indemnity 3.1 -
Cover Hospitalization
Cover,
3.2- Extra Cover,
3.5 - Renewal
Benefits,
3.7.1 - Enhanced
Covers (if
applicable),
3.7.2 - Double
Cover,
3.7.10-Smart
Covers
3.7.2 Double Cover Additional,100% of Base Sum Insured for Same claim. This Indemnity 3.1 -
benefit supersedes-Benefit no-3.2.2 Extra Sum Insured Hospitalization
Cover
3.7.3 Change in Room Category of Room Category of Room Category of Room Indemnity 3.1.1
Rent limits capped to: Twin upgrade to : capped to: Single Hospitalization
sharing Actuals OR Private A.C room Expenses
Category of Room
capped to: Twin
sharing
3.7.4 Reduction in Pre- This benefit reduces the Pre-Existing Waiting Period to 24 Not Applicable 3.1 -
Existing Waiting months or 12 months Hospitalization
Period Cover
3.7.5 Voluntary Options are:10000,25000,50000,100000 Indemnity 3.1 -
Aggregate Hospitalization
Deductible Cover
3.7.6 Removal of Co- This benefit waives off the Co-Payment condition of 20% Indemnity 3.1 -
Payment on the Assessed Claim Amount, applicable on Policies Hospitalization
where the Insured age, first time entering into the Policy is Cover
>=61 years
3.7.7 Hospital Cash Daily Cash options:1000,1500,2000,2500 max up to 30 Benefit 3.1.1.1 - In Patient
days for In Patient Hospitalization and 15 days for ICU Treatment
Hospitalization
Minimum Hospitalization of 72 hours
Benefit 3.7.8 - Convenience Cover
3.7.8.1 Change in Pre-Hospitalization-90 days Indemnity 3.1.1 -
Pre-Post Post Hospitalization-180 days Hospitalization
Hospitalization Expenses,
limit 3.1.3 - Domiciliary
Hospitalization or
3.1.4 - Modern
Treatment

3.7.8.2 Air Ambulance 7.5% of Base Sum Insured or Rs 5 Lakhs whichever is Indemnity 3.1.1.1 - In Patient
higher Treatment
3.7.8.3 Radio Taxi 1000 per Hospitalization Indemnity 3.1.1.1 - In Patient
Treatment
3.7.8.4 Convalescence 10000 25000 Benefit 3.1.1.1 - In Patient
Cover Treatment
Benefit 3.7.9 - Preventive Care Cover
3.7.9.1 Health Checkup 3000 (Annual) Indemnity Not applicable
3.7.9.2 Vaccination 2000 (Annual) 3500 (Annual) Indemnity Not applicable
Cover
Benefit - 3.7.10 - Smart Cover
3.7.10.1 Change in 100% of Base Sum Insured Not Applicable Indemnity 3.1.1 -
Modern Hospitalization
Treatment limits Expenses or
3.1.3 - Domiciliary
Hospitalization
3.7.10.2 Vision Correction 50000 100000 Indemnity 3.1.1 -
Hospitalization
Expenses
3.7.10.3 Second Opinion 3000 5000 Indemnity Not applicable
Benefit - 3.7.11 - Family Care Cover
3.7.11.1 Home Care Within Sum Insured Indemnity Not applicable
Treatment
3.7.11.2 Companion Per day Daily Cash:1000, max up to 30 days Benefit 3.1.1.1 - In Patient
Cover Minimum Hospitalization of 72 hours Treatment
3.7.11.3 Child Care Cover Per day Daily Cash:1000, max up to 30 days Benefit 3.1.1.1 - In Patient
Minimum Hospitalization of 72 hours Treatment
*Optional Covers are available for Sum Insured Rs 5 lakhs and above except for Benefit no.3.7.3 Change in Room Rent Limits and Benefit
no-3.7.5 Voluntary Aggregate Deductible.
Note - The maximum liability of the Company to pay the claims under this Policy is limited to Total Liability defined under the Policy.
Illustration for Benefit- Reinstatement/Unlimited Reinstatement of Base Sum Insured

Illustration 1 - Reinstatement of Base Sum Insured - Inbuilt Cover
Double Cover: Not Opted (Applicable: In-built Extra Sum Insured (20% of Base Sum Insured)
Enhanced cover: Not Opted (Unlimited Reinstatement of Base Sum Insured not applicable)
Sum Insured Available Claim details Sum Insured Utilization
Treatment
Base Extra Accumulated Policy Reinstatement Assessed Base Extra Accumulated Reinstatement Claim
taken for Service
Claim Sum Sum Cumulative Service of Base Sum Hospitalization Sum Sum Cumulative of Base Sum Amount
Disease / Guarantee
Insured Insured Bonus Guarantee Insured amount Insured Insured Bonus Insured Payable
Injury / Illness
Claim 6,00,000 1,20,000 2,00,000 - - CABG 5,00,000 5,00,000 - - - - 5,00,000
1
Claim 1,00,000 1,20,000 2,00,000 - - Stroke 4,50,000 1,00,000 1,20,000 2,00,000 - - 4,20,000
2
Claim - - - - 6,00,000 Accident 8,00,000 - - - - 6,00,000 6,00,000
3
Claim - - - - - Accident 4,50,000 - - - - - -
4 (related injury)
- - - - - Hospitalization 2,00,000 - - - - - -
Claim
due to
5
Pneoumonia
In the above scenario, Total Hospitalization Amount is Rs 24,00,000 and the claim out go us Rs 15,20,000. Policyholder has to pay Rs 8,80,000 from his pocket and for future claims in the same Policy Year,
Policyholder has zero Sum Insured balance

Illustration 2 - Reinstatement of Base Sum Insured - inbuilt Cover
Double Cover: Opted (100% on same claim)

Enhanced Covers: Not Opted (Unlimited Reinstatement of Base Sum Insured not applicable)
Treatment
Base Accumulated Reinstatement Assessed Base Accumulated Reinstatement Claim
Double Policy Service taken for Double Service
Claim Sum Cumulative of Base Sum Hospitalization Sum Cumulative of Base Sum Amount
Cover Guarantee Disease / Cover Guarantee
Insured Bonus Insured amount Insured Bonus Insured Payable
Injury / Illness
Claim 1 6,00,000 6,00,000 2,00,000 - - CABG 5,00,000 5,00,000 - - - - 5,00,000
Claim 2 1,00,000 6,00,000 2,00,000 - - Stroke 4,50,000 1,00,000 3,50,000 - - - 4,50,000
Claim 3 - - 2,00,000 - 6,00,000 Accident 8,00,000 - - 2,00,000 - 6,00,000 8,00,000
- - - - - Accident 4,50,000 - - - - 1,20,000 1,20,000
Claim 4
(related Injury)
- - - - - Hospitalization 2,00,000 - - - - - -
Claim 5 due to
Pneoumonia
In the above scenario, Total Hospitalization Amount is 2,40,000 and the claim outgo is Rs 17,50,000. Policyholder has paid 6,50,000 from his pocket and for future claims in the same Policy Year,
Policyholder has zero Sum Insured balance.
Illustration for Guaranteed Cumulative Bonus
Illustration on application of Cumulative Bonus (Base policy) and Guaranteed Cumulative Bonus (Optional cover)
Particulars Limits Case 1- Claim of 2 lakhs incurred during Case 2- Claim of 6 lakhs incurred during
the year year
Guaranteed Cumu- Not Opted Opted Not Opted Opted
lative Bonus (Opted /
Not Opted)
Base Sum Insured 500000 Utilised by 2 lakhs Utilised by 2 lakhs Fully utilised Fully utilised
Cumulative Bonus 500000 333,333 500,000 233,333 400,000
In Case 1 (Claim amount less than Base Sum Insured): The customer gets reduced CB of 3.33 lakhs if Guaranteed Cumulative Bonus has
not been opted and gets Rs 5 lakhs as CB if Guaranteed Cumulative Bonus has been opted
In Case 2(Claim amount more than Base Sum Insured): The customer gets reduced CB of 2.33 lakhs if Guaranteed Cumulative Bonus
has not been opted and gets Rs 4 lakhs as CB if Guaranteed Cumulative Bonus has been opted(as CB reduced to the extent of utilization
of CB amount for the payment of claim above Base Sum Insured)
Illustration for Voluntary Aggregate Deductible
Below is the illustration on application of Voluntary Aggregate Deductible.
A policy with Sum Insured 5 lakhs has made following three claims in the policy year. Assuming the available SI is 5 lakhs with no other
benefits enhancing the SI, the table below illustrates the claim payable by RGI under each deductible option:
Aggregate Voluntary Deductible Illustration

Claim Treatment taken Assessed Claim payable under each deductible option
for disease/ illness Hospitalisation amount 10000 25000 50000 100000
1 Pneumonia 50000 40000 25000 0 0
2 Accident 100000 100000 100000 100000 50000
3 CABG 400000 360000 375000 400000 400000
Total 550000 500000 500000 500000 450000
Out of pocket expenses for policyholder under each 50000 50000 50000 100000
deductible option
Illustration for Accommodation Bonus
The illustration below explains the working of Accommodation Bonus
Customer has opted Plan” Power” for Sum Insured Rs 5 lakhs, as per the Plan, the customer is eligible to avail the treatment in a room
category up to Single private A.C Room.

Case Room Category No. of hospital days Inpatient Claim Payable* Accommodation Bonus Payable
1 Single Pvt. A.C room 5 As per Inpatient Claim Assessment Zero
2 Twin Sharing A.C Room 5 As per Inpatient Claim Assessment 1000*5=5000
3 General Ward 5 As per Inpatient Claim Assessment 1000*5=5000
*This would not have impact on Accommodation Bonus payable amount.
In the above example, the Accommodation Bonus gets triggered only on the basis of opting Room Category lower than single Private A.C
Room.
Illustration 3 - Unlimited Reinstatement of Base Sum Insured
Double Cover: Not Opted (Applicable: inbuilt Extra Sum Insured (20% of Base Sum Insured))
Enhanced Covers: Opted (Unlimited Reinstatement of Base Sum Insured is applicable)
Base Extra Accumulated Policy Unlimited Treatment Assessed Base Extra Accumulated Service Reinstatement Claim
Sum Cover Cumulative Service Reinstatement taken for Hospitalization Sum Cover Cumulative Guarantee Amount
Claim Insured Bonus Guarantee Disease / amount Insured Bonus Payable
Injury / Illness
Claim 6,00,000 1,20,000 2,00,000 - - CABG 5,00,000 5,00,000 - - - - 5,00,000

1
Claim 1,00,000 1,20,000 2,00,000 - 5,00,000 Stroke 4,50,000 1,00,000 1,20,000 2,00,000 - 30,000 4,50,000
2
Claim - - - - 6,00,000 Accident 8,00,000 - - - - 6,00,000 6,00,000
3
Claim - - - - 6,00,000 Accident 4,50,000 - - - - 4,50,000 4,50,000
4 (related injury))
Hospitalization 2,00,000
Claim
- - - - 6,00,000 due to 2,00,000 - - - - 2,00,000
5
Pneoumonia
In the above scenario, Total Hospitalization Amount is 24,00,000 and the claim out go is Rs 22,00,000. Policyholder has to pay 2,00,000 from his pocket and for future claims in the same Policy Year,
Policyholder has Sum Insured balance of Rs 1,50,000 on related illness or injury(since 4,50,000 has be paid) and unlimited Sum Insured for unrelated illness or injury.
Illustration 4 - Unlimited Reinstatement of Base Sum Insured
Double Cover: Opted (100% on same claim)

Enhanced Covers: Opted (Unlimited Reinstatement of Base Sum Insured is applicable)
Base Double Accumulated Policy Unlimited Treatment Assessed Base Double Accumulated Service Reinstatement Claim
Sum Cover Cumulative Service Reinstatement taken for Hospitalization Sum Cover Cumulative Guarantee Amount
Claim
Insured Bonus Guarantee Disease /Injury amount Insured Bonus Payable
/ Illness
Claim 6,00,000 6,00,000 2,00,000 - - CABG 5,00,000 5,00,000 - - - - 5,00,000
1
Claim 4,50,000
1,00,000 6,00,000 2,00,000 - 5,00,000 Stroke 4,50,000 1,00,000 3,50,000 - - -
2
Claim 8,00,000
- - 2,00,000 - 6,00,000 Accident 8,00,000 - - 2,00,000 - 6,00,000
3
Claim Accident 4,50,000
- - - - 6,00,000 4,50,000 - - - - 4,50,000
4 (related injury))
Hospitalization 2,00,000
Claim
- - - - 6,00,000 due to 2,00,000 - - - - 2,00,000
5
Pneoumonia
In the above scenario, Total Hospitalization Amount is 24,00,000 and the claim out go is Rs 24,00,000. Policyholder has to pay nothing from his pocket and for future claims in the same Policy Year, Policyholder
has Sum Insured balance of Rs 1,50,000 on related inlless or injury(since 4,50,000 has been paid) and unlimited Sum Insured for unrelated illness or injury
ANNEXURE-A- ATTACHED TO POLICY WORDINGS 4 BELTS/ BRACES

1. List I - Items for which coverage is not available in the policy 5 BUDS
SI No Item 6 COLD PACK/HOT PACK
1 BABY FOOD 7 CARRY BAGS
2 BABY UTILITIES CHARGES 8 EMAIL / INTERNET CHARGES
3 BEAUTY SERVICES 9 FOOD CHARGES (OTHER THAN PATIENT's DIET PROVIDED

BY HOSPITAL)

10 LEGGING S 54 CREAMS POWDERS LOTIONS (Toiletries are not payable,
11 LAUNDRY CHARGES only prescribed medical pharmaceuticals payable)
12 MINERAL WATER 55 ECG ELECTRODES
13 SANITARY PAD 56 GLOVES
14 TELEPHONE CHARGES 57 NEBULISATION KIT
15 GUEST SERVICES 58 ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT,

ORTHOKIT,RECOVERY KIT, ETC]
16 CREPE BANDAGE
59 KIDNEY TRAY
17 DIAPER OF ANY TYPE
60 MASK
18 EYELET COLLAR
61 OUNCE GLASS
19 SLINGS
62 OXYGEN MASK
20 BLOOD GROUPING AND CROSS MATCHING OF DONORS
SAMPLES 63 PELVIC TRACTION BELT
21 SERVICE CHARGES WHERE NURSING CHARGE ALSO 64 PAN CAN

CHARGED 65 TROLLY COVER
22 Television Charges 66 UROMETER, URINE JUG
23 SURCHARGES 67 AMBULANCE
24 ATTENDANT CHARGES 68 VASOFIX SAFETY
25 EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH FORMS 2. List II — Items that are to be subsumed into Room Charges
PART OF BED CHARGE)
26 BIRTH CERTIFICATE SI No Item
27 CERTIFICATE CHARGES 1 BABY CHARGES (UNLESS SPECIFIED/INDICATED)
28 COURIER CHARGES 2 HAND WASH
29 CONVEYANCE CHARGES 3 SHOE COVER
30 MEDICAL CERTIFICATE 4 CAPS
31 MEDICAL RECORDS 5 CRADLE CHARGES
32 PHOTOCOPY ES CHARGES 6 COMB
33 MORTUARY CHARGES 7 EAU-DE-COLOGNE / ROOM FRESHNERS
34 WALKING AIDS CHARGES 8 FOOT COVER
35 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE HOSPITAL) 9 GOWN
36 SPACER 10 SLIPPERS
37 SPIROMETRE 11 TISSUE PAPER
38 NEBULIZE R KIT 12 TOOTH PASTE
39 STEAM INHALER 13 TOOTH BRUSH
40 ARMSLING 14 BED PAN
41 THERMOMETER 15 FACE MASK
42 CERVICAL COLLAR 16 FLEXI MASK
43 SPLINT 17 HAND HOLDER
44 DIABETIC FOOT WEAR 18 SPUTUM CUP
45 KNEE BRACES (LONG/ SHORT/ HINGED) 19 DISINFECTANT LOTIONS
46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER 20 LUXURY TAX
47 LUMBO SACRAL BELT 21 HVAC
48 NIMBUS BED OR WATER OR AIR BED CHARGES 22 HOUSE KEEPING CHARGES
49 AMBULANCE COLLAR 23 AIR CONDITIONER CHARGES
50 AMBULANCE EQUIPMENT 24 IM IV INJECTION CHARGES
51 ABDOMINAL BINDER 25 CLEAN SHEET
52 PRIVATE NURSES CHARGES- SPE CIAL NURSING CHARGES 26 BLANKET/WARMER BLANKET
53 SUGAR FREE Tablets 27 ADMISSION KIT

28 DIABETIC CHART CHARGES 18 COTTON
29 DOCUMENTATION CHARGES / ADMINISTRATIVE EXPENSES 19 COTTON BANDAGE
30 DISCHARGE PROCEDURE CHARGES 20 SURGICAL TAPE
31 DAILY CHART CHARGES 21 APRON
32 ENTRANCE PASS / VISITORS PASS CHARGES 22 TORNIQUET
33 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE 23 ORTHOBUNDLE, GYNAEC BUNDLE
34 FILE OPENING CHARGES 4. List IV — Items that are to be subsumed into costs of treatment
35 INCIDENTAL EXPENSES / MISC. CHARGES (NOT EXPLAINED)
SI No Item
36 PATIENT IDENTIFICATION BAND / NAME TAG
1 ADMISSION/REGISTRATION CHARGES
37 PULSEOXYMETER CHARGES
2 HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC PUR-
3. List III — Items that are to be subsumed into Procedure Charges POSE
SI No Item 3 URINE CONTAINER
1 HAIR REMOVAL CREAM 4 BLOOD RESERVATION CHARGES AND ANTE NATAL BOOK-
ING CHARGES
2 DISPOSABLES RAZORS CHARGES (for site preparations)
5 BIPAP MACHINE
3 EYE PAD
6 CPAP/ CAPD EQUIPMENTS
4 EYE SHEILD
7 INFUSION PUMP— COST
5 CAMERA COVER
8 HYDROGEN PEROXIDE\SPIRIT\ DISINFECTANTS ETC
6 DVD, CD CHARGES
9 NUTRITION PLANNING CHARGES - DIETICIAN CHARGES-
7 GAUSE SOFT DIET CHARGES
8 GAUZE 10 HIV KIT
9 WARD AND THEATRE BOOKING CHARGES 11 ANTISEPTIC MOUTHWASH
10 ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS 12 LOZENGES
11 MICROSCOPE COVER 13 MOUTH PAINT
12 SURGICAL BLADES, HARMONICSCALPEL,SHAVER 14 VACCINATION CHARGES
13 SURGICAL DRILL 15 ALCOHOL SWABES
14 EYE KIT 16 SCRUB SOLUTION/STERILLIUM
15 EYE DRAPE 17 Glucometer & Strips
16 X-RAY FILM 18 URINE BAG
17 BOYLES APPARATUS CHARGES
Annexure-B
OMBUDSMAN OFFICE
Office of the Address Contact Details Areas of Jurisdiction
Ombudsman
AHMEDABAD Office of the Insurance Ombudsman, Tel.: 079 - 27546150/27546139 Gujarat, UT of Dadra & Nagar
2nd Floor, Ambica House, Near C.U. Shah Fax: 079 - 27546142 Haveli, Daman and Diu
College, 5, Navyug Colony, Ashram Road, Email:
Ahmedabad – 380 001. [email protected]
BENGALURU Office of Insurance Ombudsman, Tel.: 080 - 26652048 / 26652049 Karnataka
Jeevan Soudha Building, PID No. 57-27-N- Email:
19, Ground Floor, 19/19, 24th Main Road, [email protected]
JP Nagar, 1st Phase, Bengaluru – 560078.
BHOPAL Office of the Insurance Ombudsman, Tel.: 0755 - 2769201, 2769202 Madhya Pradesh &
Janak Vihar Complex, 2nd Floor, 6, Malviya Fax: 0755 - 2769203 Chhattisgarh
Nagar, Opp. Airtel Office, Near New Market, Email:
Bhopal – 462 003. [email protected]

BHUBANESHWAR Office of the Insurance Ombudsman, Tel.: 0674 - 2596461 /2596455 Orissa
62, Forest park, Bhubaneshwar – 751 009. Fax: 0674 - 2596429
Email:
[email protected]
CHANDIGARH Office of the Insurance Ombudsman, Tel.: 0172 - 2706196 / 2706468 Punjab, Haryana, Himachal
S.C.O. No. 101, 102 & 103, 2nd Floor, Batra Fax: 0172 - 2708274 Pradesh, Jammu & Kashmir,
Building, Sector 17 – D, Chandigarh – 160 017. UT of Chandigarh
Email:
[email protected]
CHENNAI Office of the Insurance Ombudsman, Tel.: 044 - 24333668 / 24335284 Tamil Nadu, UT - Pondicherry
Fatima Akhtar Court, 4th Floor, 453, Anna Fax: 044 – 24333664 Town and Karaikal (which are
Salai, Teynampet, Chennai – 600 018. part of UT of Pondicherry)
Email:
[email protected]
DELHI Office of the Insurance Ombudsman, Tel.: 011 - 23239633 / 23237532 Delhi
2/2 A, Universal Insurance Building, Asaf Fax: 011 - 23230858
Ali Road, New Delhi – 110 002. Email: [email protected]
GUWAHATI Office of the Insurance Ombudsman, Tel.: 0361 - 2132204 / 2132205 Assam, Meghalaya, Manipur,
Jeevan Nivesh, 5th Floor, Nr. Panbazar Fax: 0361 - 2732937 Mizoram, Arunachal Pradesh,
Over Bridge, S.S. Road, Guwahati – 781001 Nagaland and Tripura
Email:
(ASSAM). [email protected]
HYDERABAD Office of the Insurance Ombudsman, Tel.: 040 - 65504123 / 23312122 Andhra Pradesh, Telangana
6-2-46, 1st floor, "Moin Court", Lane Opp. Fax: 040 - 23376599 and UT of Yanam - a part of
Saleem Function Palace, A. C. Guards, UT of Pondicherry.
Email:
Lakdi-Ka-Pool, Hyderabad - 500 004. [email protected]
JAIPUR Office of the Insurance Ombudsman, Tel.: 0141 - 2740363 Rajasthan
Jeevan Nidhi – II Bldg., Gr. Floor, Bhawani Email:
Singh Marg, Jaipur - 302 005. [email protected]
ERNAKULAM Office of the Insurance Ombudsman, Tel.: 0484 - 2358759 / 2359338 Kerala, UT of
LIC OF INDIA, 10th Floor, ‘Jeevan Prakash’, Fax: 0484 - 2359336 (a) Lakshadweep, (b) Mahe-a
Divisional Office, M. G. Road, Ernakulam, part of UT of Pondicherry.
Email:
Kochi – 682011. [email protected]
KOLKATA Office of the Insurance Ombudsman, Tel.: 033 - 22124339 / 22124340 West Bengal, UT of
Hindustan Bldg. Annexe, 4th Floor, 4, C.R. Fax: 033 - 22124341 Andaman & Nicobar Islands,
Avenue, Kolkata - 700 072. Sikkim
Email:
[email protected]
LUCKNOW Office of the Insurance Ombudsman, Tel.: 0522 - 2231330 / 2231331 Districts of Uttar Pradesh:
6th Floor, Jeevan Bhawan, Phase-II, Fax: 0522 - 2231310 Laitpur, Jhansi, Mahoba,
Nawal Kishore Road, Hazratganj, Hamirpur, Banda, Chitrakoot,
Email:
Lucknow - 226 001. Allahabad, Mirzapur,
[email protected]
Sonbhabdra, Fatehpur,
Pratapgarh, Jaunpur,
Varanasi, Gazipur, Jalaun,
Kanpur, Lucknow, Unnao,
Sitapur, Lakhimpur, Bahraich,
Barabanki, Raebareli, Sravasti,
Gonda, Faizabad, Amethi,
Kaushambi, Balrampur, Basti,
Ambedkar Nagar, Sultanpur,
Maharajgang, Sant Kabir
Nagar, Azamgarh, Kushinagar,
Gorkhpur, Deoria, Mau,
Ghazipur, Chandauli, Ballia,
Sidharath Nagar.

MUMBAI Office of the Insurance Ombudsman, Tel.: 022 - 26106552 / 26106960 Goa, Mumbai Metropolitan
3rd Floor, Jeevan Seva Annexe, S. V. Road, Fax: 022 - 26106052 Region excluding Navi
Santacruz (W), Mumbai - 400 054. Mumbai & Thane.
Email:
[email protected]
NOIDA Office of the Insurance Ombudsman, Tel.: 0120 - 2514252 / 2514253 State of Uttaranchal and the
Bhagwan Sahai Palace, 4th Floor, Main Email: following Districts of Uttar
Road, Naya Bans, Sector 15, Dist: Gautam [email protected] Pradesh: Agra, Aligarh,
Buddh Nagar, U.P. - 201301. Bagpat, Bareilly, Bijnor,
Budaun, Bulandshehar, Etah,
Kanooj, Mainpuri, Mathura,
Meerut, Moradabad,
Muzaffarnagar, Oraiyya,
Pilibhit, Etawah, Farrukhabad,
Firozbad, Gautam Budha
Nagar, Ghaziabad, Hardoi,
Shahjahanpur, Hapur, Shamli,
Rampur, Kashganj, Sambhal,
Amroha, Hathras, Kanshiram
Nagar, Saharanpur.
PATNA Office of the Insurance Ombudsman, Tel.: 0612 - 2680952 Bihar, Jharkhand.
1st Floor, Kalpana Arcade Building, Bazar Email:
Samiti Road, Bahadurpur, Patna - 800 006. [email protected]
PUNE Office of the Insurance Ombudsman, Tel.: 020 - 41312555 Maharashtra, Area of Navi
Jeevan Darshan Bldg., 3rd Floor, C.T.S. No.s. Email: Mumbai and Thane excluding
195 to 198, N.C. Kelkar Road, Narayan Peth, [email protected] Mumbai Metropolitan Region.
Pune – 411 030.
The updated details of Insurance Ombudsman are available on IRDAI website: www.irdai.gov.in, on the website of General Insurance Council:
www.gicouncil.in, our website www.reliancegeneral.co.in
Annexure-F
Below mentioned Diseases maybe permanently excluded under the Policyin the case where suchDiseases are Pre-Existing at the time of
first proposal of this Product with the Company
Sr. Disease ICD Code

No.
1 Sarcoidosis D86.0-D86.9
2 Malignant C00-C14 Malignant neoplasms of lip, oral cavity and pharynx, • C15-C26 Malignant neoplasms of digestive organs,
Neoplasms • C30-C39 Malignant neoplasms of respiratory and intrathoracic organs • C40-C41 Malignant neoplasms of
bone and articular cartilage • C43-C44 Melanoma and other malignant neoplasms of skin • C45-C49 Malignant
neoplasms of mesothelial and soft tissue • C50-C50 Malignant neoplasms of breast • C51-C58 Malignant
neoplasms of female genital organs • C60-C63 Malignant neoplasms of male genital organs • C64-C68 Malignant
neoplasms of urinary tract • C69-C72 Malignant neoplasms of eye, brain and other parts of central nervous
system • C73-C75 Malignant neoplasms of thyroid and other endocrine glands • C76-C80 Malignant neoplasms
of ill-defined, other secondary and unspecified sites • C7A-C7A Malignant neuroendocrine tumours • C7B-C7B
Secondary neuroendocrine tumours • C81-C96 Malignant neoplasms of lymphoid, hematopoietic and related tissue
• D00-D09 In situ neoplasms • D10-D36 Benign neoplasms, except benign neuroendocrine tumours • D37-D48 Neoplasms
of uncertain behaviour, polycythaemia vera and myelodysplastic syndromes • D3A-D3A Benign neuroendocrine tumours
• D49-D49 Neoplasms of unspecified behaviour
3 Epilepsy G40 Epilepsy
4 Heart Ailment I49 Other cardiac arrhythmias, (I20-I25)Ischemic heart diseases, I50 Heart failure, I42Cardiomyopathy; I05-I09 - Chronic
Congenital heart rheumaticheart diseases. • Q20 Congenital malformations of cardiac chambers and connections • Q21 Congenital
disease and malformations of cardiac septa • Q22 Congenital malformations of pulmonary and tricuspid valves • Q23 Congenital
valvular heart malformations of aortic and mitral valves • Q24 Other congenital malformations of heart • Q25 Congenital malformations
disease of great arteries • Q26 Congenital malformations of great veins • Q27 Other congenital malformations of peripheral
vascular system• Q28 Other congenital malformations of circulatory system • I00-I02 Acute rheumatic fever • I05-I09
• Chronic rheumatic heart diseases Nonrheumatic mitral valve disorders mitral (valve): • disease (I05.9) • failure (I05.8)
• stenosis (I05.0). When of unspecified cause but with mention of: • diseases of aortic valve (I08.0), • mitral stenosis or
obstruction (I05.0) when specified as congenital (Q23.2, Q23.3) when specified as rheumatic (I05), I34.0Mitral (valve)
insufficiency • Mitral (valve): incompetence / regurgitation - • NOS or of specified cause, except rheumatic, I 34.1to
I34.9 - Valvular heart disease.

5 Cerebrovascular I67 Other cerebrovascular diseases, (I60-I69) Cerebrovascular diseases
disease (Stroke)
6 Inflammatory K 50.0 to K 50.9 (including Crohn's and Ulcerative colitis)
Bowel Diseases K50.0 - Crohn's disease of small intestine; K50.1 -Crohn's disease of large intestine; K50.8 - Other Crohn's disease;
K50.9 - Crohn's disease,
7 Chronic Liver K70.0 To K74.6 Fibrosis and cirrhosis of liver; K71.7 - Toxic liver disease with fibrosis and
diseases cirrhosis of liver; K70.3 - Alcoholic cirrhosis of liver; I98.2 - K70.-Alcoholic liver disease; Oesophageal varices in
diseases classified elsewhere. K 70 to K 74.6 (Fibrosis, cirrhosis, alcoholic liver disease, CLD)
8 Pancreatic K85-Acute pancreatitis; (Q 45.0 to Q 45.1) Congenital conditions of pancreas, K 86.1 to K 86.8 - Chronic pancreatitis
diseases
9 Chronic Kidney N17-N19) Renal failure; I12.0 - Hypertensive renal disease with renal failure; I12.9 Hypertensive renal disease without
disease renal failure; I13.1 - Hypertensive heart and renal disease with renal failure; I13.2 - Hypertensive heart and renal
disease with both (congestive) heart failure and renal failure; N99.0 - Post procedural renal failure; O08.4 - Renal failure
following abortion and ectopic and molar pregnancy; O90.4 - Postpartum acute renal failure; P96.0 - Congenital renal
failure. Congenital malformations of the urinary system (Q 60 to Q64), diabetic nephropathy E14.2, N.083
10 Hepatitis B B16.0 - Acute hepatitis B with delta-agent
(super)infection of hepatitis B carrier; B18.0 -Chronic viral hepatitis B with delta-agent; B18.1 -Chronic viral hepatitis B
without delta-agent;
11 Alzheimer's G30.9 - Alzheimer's disease, unspecified; F00.9 -
Disease, G30.9Dementia in Alzheimer's disease,
Parkinson's unspecified, G20 - Parkinson's disease.
Disease -
12 Demyelinating G.35 to G 37
disease
13 Loss of Hearing H90.0 - Conductive hearing loss, bilateral; H90.1 - Conductive hearing loss, unilateral with unrestricted hearing on the
contralateral side; H90.2 - Conductive hearing loss, unspecified; H90.3 - Sensorineural hearing loss, bilateral; H90.4
- Sensorineural hearing loss, unilateral with unrestricted hearing on the contralateral side; H90.6 - Mixed conductive
and sensorineural hearing loss, bilateral; H90.7 - Mixed conductive and sensorineural hearing loss, unilateral with
unrestricted hearing on the contralateral side; H90.8 - Mixed conductive and sensorineural hearing loss, unspecified;
H91.0 - Ototoxic hearing loss; H91.9 - Hearing loss, unspecified
14. Papulosquamous L40 - L45 Papulosquamous disorder of the skin including psoriasis lichen planus
disorder of the skin
15. Avascular necrosis M 87 to M 87.9
(osteonecrosis)


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RELIANCE HEALTH GAIN - POLICY WORDINGS

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ii. Balloon Sinuplasty 3.2 EXTRA COVER

iii. Deep Brain Stimulation 3.2.1 REINSTATEMENT OF BASE SUM INSURED

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OR iii. Time Deductible: If the Hospitalization is for less than a

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3.7.10.1 CHANGE IN MODERN TREATMENT LIMITS I. CANCER OF SPECIFIED SEVERITY

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4.1.1. PRE-EXISTING DISEASES (CODE- EXCL 01) ¥ Adenomyosis

i. Expenses related to the treatment of the following listed fistula in anus,

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5.1.9. PORTABILITY 5.1.13. PREMIUM PAYMENT IN INSTALMENTS (WHEREVER APPLICABLE)

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In the above, Associate Medical Expense, means all admissible G = Ground up

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b. Benefit- 3.2.2- Extra Sum Insured or Benefit-3.7.2-Double 6.2. Co-Payment

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Annexure-I Coverage Summary

Policy Period 1, 2 years and 3 years

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Illustration for Benefit- Reinstatement/Unlimited Reinstatement of Base Sum Insured

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Double Cover: Opted (100% on same claim)

Illustration for Guaranteed Cumulative Bonus

Aggregate Voluntary Deductible Illustration

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Claim 6,00,000 1,20,000 2,00,000 - - CABG 5,00,000 5,00,000 - - - - 5,00,000

Illustration 4 - Unlimited Reinstatement of Base Sum Insured

Double Cover: Opted (100% on same claim)

ANNEXURE-A- ATTACHED TO POLICY WORDINGS 4 BELTS/ BRACES

SI No Item 6 COLD PACK/HOT PACK

1 BABY FOOD 7 CARRY BAGS

2 BABY UTILITIES CHARGES 8 EMAIL / INTERNET CHARGES

3 BEAUTY SERVICES 9 FOOD CHARGES (OTHER THAN PATIENT's DIET PROVIDED

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