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Date: 18/10/2019

Policy Number: 31036801201900


Customer ID: 1000048361

MR. A MOHAN
DOOR NO29 BAR 1 FIRST CROSS SECOND MAIN RAM CHANDRAPURAM,,
BENGALURU,
KARNATAKA - 560021
Mobile: 09972966323

Subject : Max Bupa Health Insurance Policy No. 31036801201900

Dear MR. A MOHAN,

Thank you for choosing Max Bupa as your preferred health insurance partner. At Max Bupa, we put your health first and are committed to provide
you access to the very best of healthcare, backed by the highest standards of service.
Please find enclosed your Max Bupa Policy Kit which will help you understand your policy in detail and give you more information on
how to access our services easily. Your Policy kit includes the following:
• Insurance Certificate: Confirming your specific policy details like date of commencement, persons covered and specific conditions related to
your plan.
• Premium Receipt: Receipt issued for the premium paid by you.
• Policy Terms and Conditions: For a clear understanding of policy coverages and exclusions.
• Proposal form: This is a copy of the proposal form as per the information provided by you. Do inform us immediately in case there is any
change in the details mentioned therein.
• Annexure of Policyholder Servicing Turnaround Times as prescribed by Insurance Regulatory and Development Authority of India (IRDAI)

Do visit us online at www.maxbupa.com to view and download our updated list of network hospitals in your city, download claim forms and for other
useful information. You can register with us online using your policy number, date of birth & email id and access your policy details. In case of any
further assistance, call us at 1860-3010-3333 (customer helpline number) or email us at customercare@maxbupa.com.

I request you to read your policy terms and conditions highlighted in the Customer Information Sheet of this document so that you are fully aware of
your policy benefits.

Assuring you of our best services and wishing you and your loved ones good health always.

Yours Sincerely,

Ashish Mehrotra
Managing Director and Chief Executive Officer

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

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


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

POLICY SERVICING Turnaround time*


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

CLAIM SERVICING Turnaround time


(Calendar Days)
From the date of receipt of last necessary document (no investigation) 30 Days

From the date of receipt of last necessary document (with investigation) 45 Days

GRIEVANCE HANDLING Turnaround time


(Calendar Days)

Acknowledge a grievance - from the date of receipt of grievance 3 days

Resolve a grievance - from the date of receipt of grievance 14 days

*All turnaround time’s will start from the date of receipt of complete documents at Max Bupa Health Insurance Company Ltd.

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


Insurance Certificate

Policy Holder's Name MR. A MOHAN Policy Number 31036801201900

Policy Holder's Address DOOR NO29 BAR 1 FIRST CROSS Date of Commencement From 18/10/2019 00:00 a.m.
SECOND MAIN RAM CHANDRAPURAM,
BENGALURU, Date of Expiry To 17/10/2020 23:59 p.m.
KARNATAKA - 560021
Individual/Family Plan Individual
Details of Electronic Insurance Account (eIA) Policy Period 1 year
eIA Number None
Renewal premium due date 17/10/2020
Insurance Repository Name None

Benefits

1. Health Assurance - Accident Care

Relationship Sum Assured Renewal Benefit (% of Sum Insured) Total Sum Insured
(Including Renewal Benefit)
Applicant Level 1 | 500000 0 Level 1 | 500000

Optional Benefit/Feature Details

Particulars Effective[Y\N] Sum Insured

Temporary Total Disability N 0

Accident Hospitalization N 0

Emergency Ambulance as a part of overall Accident Hospitalization N NA


Sum Insured

Physiotherapy as a part of overall Accident Hospitalization Sum N NA


Insured
1.1 Accident Death Sum Insured: 100% of applicable Sum Insured.
1.2 Accident Permanent Total Disability (PTD) Sum Insured: 125 % of applicable Sum Insured.
1.3 Accident Permanent Partial Disability Sum Insured: % of applicable Sum assured as per grid shown in Terms and Conditions.
1.4 Children Education Benefit Sum Insured: Rs. 0
1.5 Funeral Expenses Sum Insured: Rs. 5000

2. Health Assurance - CritiCare Benefit *

Relationship Sum Insured

Applicant 0

Health Assurance-CritiCare Benefit Option NA


*only one of the two Insured Persons can claim under this benefit in a Policy Year if the cover is issued on a Family Floater basis.

3. Health Assurance - Hospi Cash Benefit Daily Limit

Relationship Daily Hospital Cash Limit

Applicant 0
3.1 Health Assurance- ICU Cash Benefit daily limit -2 time's of daily hospital cash limit.

Signature Not Verified


VIKAS GUJRAL
2019.10.19 06:37
Encryption

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


Intermediary Details

Intermediary Name Intermediary Code Intermediary Contact No.


NA NA NA
Insured Persons' Details
Name of the Insured Person (s) Age Insured DOB Gender Relationship with the policy Pre - Existing Diseases
holder

Mr. A Mohan 36 23/04/1983 Male Applicant None

Nominee Details

Nominee name Relationship with the policy holder

Nagaveni Bai Spouse

Premium Details

Premium (Rs.) - CritiCare 0.00

Premium (Rs.) - Hospi Cash 0.00

Premium (Rs.) - Accident Care 576.00

Loading Premium (Rs.) - Accident Care 0.00

Net Premium/Taxable Value (Rs.) 576.00

Integrated Goods and Service Tax (18.00 %) 103.68

Central Goods and Service Tax (0.00 %) 0.00

State/UT Goods and Service Tax (0.00 %) 0.00

Gross premium (Rs.) 680.00

Gross premium (Rs.) (In words) Six Hundred Eighty Only

Income tax benefit is available as per the existing Income Tax Laws and are subject to changes. Please consult your tax advisor for more details.
For policy term 2 years, premium discount equal to 12.5% on the 2nd year premium and for policy term 3 years, premium discount equal to
12.5% on the 2nd year premium. and 15% on the 3rd year premium would get applied.

Servicing Branch Details

Max Bupa Health Insurance Company Ltd,B-1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi-110044

Policy issuing office : Delhi , Consolidated Stamp Duty deposited as per the order of Government of National Capital Territory of Delhi.

GSTI No.: 07AAFCM7916H1ZA SAC Code / Type of Service : 997133 / General Insurance Services

Max Bupa State Code: 7 Customer State Code / Customer GSTI No.: 29 / NA

Location: New Delhi Chief Operating Officer


Date: 18/10/2019 For and on behalf of Max Bupa Health Insurance Company Limited

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


Company Contact Details

Address: Max Bupa Health Insurance Company Limited. Block B-1/1-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi-110044

Customer Helpline Number: 1860-3010-3333

Email Id: customercare@maxbupa.com

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


Premium Receipt
Dear MR. A MOHAN
DOOR NO29 BAR 1 FIRST CROSS SECOND MAIN RAM
CHANDRAPURAM
BENGALURU
KARNATAKA - 560021

We acknowledge the receipt of payment towards the premium of the following health insurance policy:

Policy Holder's Name Mr. A Mohan Policy Number 31036801201900

Plan Opted for Health Assurance PA5L 1A

Commencement Date# 18/10/2019 Expiry Date 17/10/2020

Premium Calculation:

(A) Premium (Rs.) - Criti Care 0.00

(B) Premium (Rs) - Hospi Cash 0.00

(C) Premium (Rs) - Accident Care 576.00

Net Premium/Taxable Value (Rs.) 576.00

Integrated Goods and Service Tax (18.00 %) 103.68

Central Goods and Service Tax (0.00 %) 0.00

State/Union Territory Goods and Service Tax (0.00 %) 0.00

Gross Premium (Rs.) 680.00

Amount Eligible for Income Tax Benefit (A+B+Total GST Tax @18% in Rs.) 0.00
#
Issuance of policy is subject to clearance of premium paid

Details of persons Insured:


Name of Person Insured Age Gender Relationship to policy holder Individual cover(Rs.)
(only in case of Family First)
Mr. A Mohan 36 Male Applicant NA

Upon issuance of this receipt, all previously issued temporary receipts, if any, related to this policy are considered null and void. For the
purpose of deduction under section 80D, the benefit shall be as per the provisions of the Income Tax Act, 1961 and any amendments made
thereafter.

In the event of non-realization of premium, Tax benefits cannot be obtained against this premium receipt

For your eligibility and deductions please refer to provisions of Income Tax Act 1961 as modified and consult your tax consultant.

GSTI No.: 07AAFCM7916H1ZA SAC Code / Type of Service : 997133 / General Insurance Services

Max Bupa State Code: 7 Customer State Code / Customer GSTI No.: 29 /NA

Location: New Delhi Chief Operating Officer


Date: 18/10/2019 For and on behalf of Max Bupa Health Insurance Company Limited

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


List of Unrecognized Hospital
S.No. City Hospital Name S.No. City Hospital Name
1 Surat Aakansha Hospital 34 Surat Shubham General Hospital
2 Surat Abhinav Hospital 35 Surat Siddhi Clinic & Nursing Home
3 Surat Adhar Ortho Hospital 36 Surat Sparsh MultySpecality Hospital & Trauma Care Center
4 Surat Aris Care Hospital 37 Surat Sree Uday Narayan General Hospital
5 Surat Arzoo Hospital 38 Surat TripathiChartiable Hospital
6 Surat Auc Hospital 39 Ahmedabad Umiya Medical & Surgical Hospital
7 Surat Dharamjivan General Hospital & Trauma Centre 40 Surat Varachha General Hospital
8 Surat Dr. Santosh Basotia Hospital 41 Kushi Nagar Aastha Multispecialty Hospital
9 Surat Ghevariya Dental Clinic 42 Thane Ashwini Nursing Home
10 Surat God Father Hospital 43 Thane Asmita Nursing Home
11 Surat Govind-PrabhaArogyaSankool 44 Thane Balaji Nursing Home
12 Surat Hari Milan Hospital 45 Rohtak Channan Devi Memorial Hospital
13 Surat JaldhiAno-Rectal Hospital 46 Hyderabad Goodlife Hospitals
14 Surat Jeevan Path Gen. Hospital 47 Dhenkanal Jagannath Clinic & Nursing Home
15 Surat Kalrav Children Hospital 48 Allahabad Jeevan Jyoti Hospital
16 Surat Kanchan General Surgical Hospital 49 Mayiladuthurai Krishna Hospital
17 Surat Krishnavati General Hospital 50 Mumbai Mumtaz Nursing Home
18 Surat Mantra Orthopaedic Hospital Gandhidham (Kutch) 51 Kesava Nagar Colony Padmaja Hospital
19 Surat Metas Adventist Hospital 52 Harnaut Pragya Nurshing Home
20 Surat NiramayamHosptial&Prasutigruah 53 Jeedimetla Ram Hospitals
21 Surat Patna Hospital 54 Gurgaon Ramanarayan Hospital
22 Surat Poshia Children Hospital 55 Mumbai Royal Nursing Home
23 Surat Prayosha Hospital 56 Cuttak Sabarmati General Hospital
24 Surat R.D Janseva Hospital 57 Meerut Sahara Hospital
25 Surat Radha Hospital & Maternity Home 58 Mumbai Sb Nursing Home
26 Surat Santosh Hospital 59 Meerut Shagun Hospital
27 Surat Shaurya Hospital 60 Gurgaon Shri Balaji Hospital & Trauma Center
28 Surat Shikha General Hospital Changed Name To Sai Hospital 61 Hyderabad Sri Sai Thirumala Hospitals
29 Surat Shishumangal Children Hospital 62 Bhopal Venus Hospital And Medical Research Centre
30 Surat Shree Ramdev General & Surgical Hospital 63 Vanasthali Puram Vijaya Nursing Home
31 Surat Shree Sai Hospital & PrasutiGruh 64 Allahabad Virendra Hospital
32 Surat ShreyansAnorectal & Daycare Hospital 65 Meerut Yog Nursing Home
33 Surat Shri Panchratna Hospital & Prasutugruah

ANNEXURE – A (Part of Policy Pack)


Format to be filled up by the proposer for change in occupation of the Insured

Policy Name of Date of Relationship City of Previous Occupation New Occupation


with Primary
Number the Insured birth/Age residence or Nature of Work or Nature of Work
Insured

Place: _________ Proposer’s Signature__________ Date: _________(DD/MM/YYYY) Name:__________ Designation__________

ANNEXURE – B
(To be filled by proposer for enhancement of sum insured or scope of cover of the Insured)

Policy Number Previous sum insured / Plan New proposed sum insured / Plan

Place: _________ Proposer’s Signature__________ Date: _________(DD/MM/YYYY) Name:__________ Designation__________

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


Health Assurance –Customer Information Sheet What am I covered for

TITLE DESCRIPTION REFER


TO
POLICY
SECTION
NUMBER

Coverage extended to individual and families. Under family option, AccidentCare coverage is defined as: 2.1
AccidentCare For self is 100% of Sum Insured,
For spouse is 50% of Sum Insured or Rs 10 lacs (whichever is lower) and
For each child is 20% of Sum Insured or Rs 5 lacs (whichever is lower) upto maximum of 2 dependent children.
a. Accident Death: 100% of applicable Sum Insured would be paid if during the Policy Period Insured Person meets with an Accidental bodily injury that
causes death within 365 days from the date of occurrence of such accidental injury and results in direct cause of the death. 2.1.1
b. Accident Permanent Total Disability (PTD): Insured Person would be paid this benefit upon the establishment of Permanent Total Disability caused 2.1.3
due to an Accident (in Policy Period) within 365 days from the occurrence of such accident subject to conditions for Permanent Total Disability being
met and acceptance of claims by the company
Accident Permanent Total Disability: 125% of Sum Insured
We will not make payment under Permanent Total Disability in respect of an Insured Person and for any or all Policy Period more than once in the
Insured Person’s lifetime.
c. Accident Permanent Partial Disability (PPD): If an Insured Person suffers an Accident during policy period and within 365days from the date of
2.1.5
occurrence of such accident and is the sole and direct cause of loss, Insured Person will be paid the percentage of applicabl e Sum Insured (as opted
by Insured Person) as mentioned in the Policy Document
Additional Benefits
a. Child Education Benefit (available only in family option): In case of proposer’s Accident Death or Permanent Total Disability, We will make a onetime
payment as specified in the schedule of insurance certificate, per child towards the cost of education of up to 2 dependent children. This benefit would 2.1.4
be payable to only the dependent children insured under the policy.
b. Funeral Expenses: In case of death of an Insured Person an amount as specified in the schedule of insurance certificate would be paid towards the 2.1.2

funeral expenses of the deceased.


Optional Benefits
a. Temporary Total Disability (TTD): If the Policyholder (Proposer) suffers an Injury solely and directly due to an Accident occurring during the policy
2.1.6
period which solely and directly results in the Policyholder’s Temporary Total Disability within 365 days from the date of accident, We will pay an
amount equal to 1% of TTD sum insured per week for each week that the Temporary Total Disability continues subject always to the availability of the
TTD sum insured.
b. Accident Hospitalization: If the Insured Person is hospitalised during the Policy Period solely and directly due to an Injury sustained arising from an 2.1.7
Accident occurring during the Policy Period, We will reimburse the hospitalization expenses up to the maximum limit of 2% of AccidentCare sum
insured.

a. Insured Person would be paid as per the benefit option chosen on the first diagnosis of any of the below mentioned 20 Critical Illnesses provided the 2.2
CritiCare insured person survives for a minimum of 30 days from the date of diagnosis of such Critical Illness.
b. Under family option, coverage:
For self is 100% of Sum Insured and
For spouse is 100% of Sum Insured
c. Critical illnesses covered as mentioned in the Policy Document

a. If the Insured Person is Hospitalised resulting from an Accident or Illness, We will pay the Daily Hospital Cash amount speci fied in Product Benefit
HospiCash Table for each continuous and completed period of 24 hours of Hospitalisation provided that: 2.3

i. The Illness has occurred after 30 days from date of commencement of the Policy
ii. The Insured Person should have been Hospitalised for a minimum period of atleast 48 hours with continuous and completed peri ods of 24 hours
iii. We will not make any payment in respect of an Insured Person for more than 45 days of Hospitalisation in total under any Poli cy Year (including
7 days of ICU hospitalization)
b. ICU (intensive Care Unit) cash benefit which is equivalent to double the Daily Cash benefit will be payable towards Hospitalisation in ICU up to
maximum of 7 days

Under family option, coverage for adults is 100% of Sum Insured and coverage for each child is 50% of Sum Insured

Permanent
A. Permanent Exclusions for AccidentCare Cover
Exclusions
1. Suicide or self inflicted Injury, whether the Insured Person is medically sane or insane.
2. Treatment for any injury or illness resulting directly or indirectly from nuclear, radiological emissions, war or war like situations (whether war is
declared or not), rebellion (act of armed resistance to an established government or leader), acts of terrorism.
3. Service in the armed forces, or any police organization, of any country at war or at peace or service in any fo rce of an international body or
3(d)(1)
participation in any of the naval, military or air force operation during peace time.
4. Any change of profession after inception of the Policy which results in the enhancement of Our risk, if not accepted and endo rsed by Us on the
Schedule of Insurance Certificate.
5. Committing an assault, a criminal offence or any breach of law with criminal intent.
6. Taking or absorbing, accidentally or otherwise, any intoxicating liquor, drug, narcotic, medicine, sedative or poison, except as prescribed by a

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


Medicial Practitioner other than the Policyholder or an Insured Person.
7. Participation in aviation/marine including crew other than as a passenger in an aircraft/water craft that is authorized by th e relevant regulations to
carry such passengers between established airports or ports.
8. Including but not limited to engaging in or taking part in professional/adventure sports or any hazardous pursuits, such as speed contest or racing
of any kind (other than on foot), bungee jumping, parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding, mountain or rock
climbing necessitating the use of guides or ropes, potholing, abseiling, deep sea diving using hard helmet and breathing apparatus, polo, snow
and ice sports, hunting etc;
9. Body or mental infirmity or any disease except where such condition arises directly as a correspondence of an Accident during the policy period.
However this exclusion is not applicable to claims made under the PPD benefit.
10. Any costs or expenses specified in the List of Expenses Generally Excluded at Annexure II of policy document. This is applicable only for
Accident Hospitalization benefit.

B. Permanent Exclusions for CritiCare

3(d)(2)
1. Acquired Immune Deficiency Syndrome (AIDS), AIDS-related complex or infection by Human Immunodeficiency Virus (HIV); or
2. The Insured Person’s attempted suicide or self-inflicted injuries while sane or insane; or
3. Narcotics used by the Insured Person unless taken as prescribed by a Medical Practitioner, or the Insured Person’s abuse of drugs and/or
consumption of alcohol; or
4. The directions, advice and guidance of the treating Medical Practitioner shall be strictly followed. We shall not be obliged to make any payment
that arises out of willful failure to comply with such directions, advice or guidance
5. Treatment for any injury or illness resulting directly or indirectly from nuclear, radiological emissions, war or war like si tuations (whether war is
declared or not), rebellion (act of armed resistance to an established government or leader), acts of terrorism.
6. Taking part in any naval, military or air force operation during peace time; or
7. Participation in aviation/marine including crew other than as a passenger in an aircraft/water craft that is authorized by the relevant regulations to
carry such passengers between established airport or ports
.
8. Including but not limited to engaging in or taking part in professional/adventure sports or any hazardous pursuits, such as speed contest or racing
of any kind (other than on foot), bungee jumping, parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding, mountain or rock
climbing necessitating the use of guides or ropes, potholing, abseiling, deep sea diving using hard helmet and breathing apparatus, polo, snow
and ice sports, hunting etc; or
9. Participation by the Insured Person in a criminal or a breach of law with criminal intent; or
3(d)(3)
C. Permanent Exclusions for HospiCash Benefit
1. Hospitalisation not in accordance with the diagnosis and treatment of the condition for which the Hospital confinement was required;
2. Hospitalization solely for diagnostic or observation purpose;
3. Treatment for weight reduction or weight improvement regardless of whether the same is caused (directly or indirectly) by a medical condition;
4. Any dental care or Surgery of cosmetic nature, extraction of impacted tooth/teeth, orthodontics or orthognathic Surgery, or tempero-mandibular
joint disorder except as necessitated by an Accidental Injury;
5. Treatment for infertility or impotency, sex change or any treatment related to it, abortion, sterilization and contraception including any
complications relating thereto;
6. Treatment arising from pregnancy and it’s complications which shall include childbirth or abortion or threatened abortion excluding ectopic
pregnancy;
7. Hereditary and Genetic Disorders: Screening, counseling or treatment related to Hereditary and Genetic Disorders;
8. Hospitalisation primarily for diagnosis, X-ray examinations, general physical or medical check-up not followed by active treatment during the
Hospitalisation period or Hospitalisation where no active treatment is given by the Medical Practitioner;
9. Unproven/Experimental treatments/off-label treatment;
10. Alternative treatment;
11. Treatment of any mental or psychiatric condition including but not limited to insanity, mental or nervous breakdown / disorder, depression,
dementia, Alzheimer’s disease or rest cures;
12. Admission to a nursing home or home for the care of the aged for rehabilitation, or convalescence;
13. Treatment directly or indirectly arising from alcohol, drug or substance abuse and any Illness or Accidental Injury which may be suffered after
consumption of intoxicating substances, liquors or drugs;
14. Treatment directly or indirectly arising from or consequent upon war (whether war be declared or not), invasion, acts of forei gn enemies,
hostilities, civil war, rebellion, active participation in strikes, riots or civil commotion, revolution, insurrection or military or usurped power, and full-
time service in any of the armed forces;
15. Acquired Immune Deficiency Syndrome (AIDS) and all Illnesses or diseases caused by or related to the Human Immuno-deficiency Virus;
16. Sexually transmitted diseases;
17. Cosmetic or plastic Surgery except to the extent that such Surgery is necessary for the repair of damage caused solely by Accidental Inju ries;
treatment of xanthelesema, syringoma, and ance alopecia
18. Nuclear disaster, radioactive contamination and/or release of nuclear or atomic energy;
19. Treatment for Accidental Injury or Illness caused by intentionally self-inflicted Injuries; or any attempts of suicide while sane or insane;
20. Treatment for Accidental Injury or Illness caused by violation or attempted violation of the law, or resistance to arrest;
21. Including but not limited to engaging in or taking part in professional/adventure sports or any hazardous pursuits, such as speed contest or racing
of any kind (other than on foot), bungee jumping, parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding, mountain or rock

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


climbing necessitating the use of guides or ropes, potholing, abseiling, deep sea diving using hard helmet and breathing apparatus, polo, snow
and ice sports, hunting etc;
22. Circumcision unless necessary for treatment of a disease or necessitated due to an Accident;
23. Hospitalisation where the Insured Person is a donor for any organ transplant;
24. Any treatment outside of Republic of India;
25. Treatment to assist reproduction, including IVF treatment;
26. Hormone Replacement Therapy;
27. Puberty and Menopause related Disorders: Treatment for any symptoms, Illness, complications arising due to physiological conditions associated
with Puberty, Menopause such as menopausal bleeding or flushing;
28. Artificial Life Maintenance: Artificial life maintenance, including life support machine used to sustain a person, who has been declared brain dead,
as demonstrated by:
(a) Deep coma and unresponsiveness to all forms of stimulation;
(b) Absent pupillary light reaction;
(c) Absent oculovestibular and corneal reflexes; or
(d) Complete apnea
29. Sleep disorders: Treatment for sleep apnea, snoring or any other sleep-related breathing problem;
30. Treatment for developmental problems: Treatment for, or related to developmental problems, including – learning difficulties (such as dyslexia),
behavioral problems, including attention deficit hyperactivity disorder (ADHD);

Waiting Period a. Initial Waiting Period


3(a)
Criticare: Benefits will not become payable if the signs or symptoms of any of the listed critical illnesses commence within 90 days from the date of
commencement of CritiCare coverage of the first policy.
HospiCash: Benefits will not become payable if the signs or symptoms and/or Treatment fall within 30 days from the date of commencement of
HospiCash coverage except accidents.
b. Pre-Existing Diseases (Applicable for CritiCare and HospiCash)
Benefits will not be available for Pre-existing Diseases until 48 months of continuous coverage have elapsed since the inception of the first Policy with 3(b)
Us or other insurer in case of portability, for the respective benefit.
c. Specific Waiting Period for the HospiCash Benefit
For the payment of the HospiCash Benefit, the disease conditions / treatments listed below will be subject to a waiting period of 24 months and will be 3(c)
covered from the commencement of the third Policy Year as long as the Insured Person has been insured continuously under the Policy without any
break
1. Stones in biliary and urinary systems
2. Lumps/ cysts/ nodules/ polyps/ internal tumours excluding malignancies
3. Gastric and duodenal ulcers
4. Surgery on tonsils / adenoids
5. Osteoarthrosis / arthritis / gout / rheumatism / spondylosis / spondylitis / intervertebral disc prolapse
6. Cataract and its complications
7. Fissure / Fistula / Haemorrhoids of anal and rectal region
8. Hernia / hydrocele / varicocoele / spermatocoele
9. Chronic renal failure or end stage renal failure
10. Sinusitis / deviated nasal septum / tympanoplasty / chronic suppurative otitis media
11. Benign prostatic hypertrophy
12. Joint replacements surgery except in case of accidents
13. Dilatation and curettage except in case of surgical abortion
14. Varicose veins of legs
15. Dysfunctional uterine bleeding / fibroids / prolapse uterus / endometriosis
16. Diabetes and related complications including but not limited to:
a) Hyperglycaemia with or without coma
b) Hypoglycaemia with or without coma
c) Diabetic Ketoacidosis
d) Diabetic Nephropathy
e) Diabetic Retinopathy
f) Diabetic Neuropathy
17. Hysterectomy for any benign disorder
18. Thyroid and parathyroid gland disorders excluding malignancy
19. Any Congenital Anomaly or inherited disorder or developmental conditions

Lump sum payout for all the three benefits – CritiCare, AccidentCare and HospiCash;
Payout basis
AccidentCare cover also has an optional Accident Hospitalization benefit which is payable only as reimbursement and optional Temporary Total Disability
benefit.

Renewal  The Waiting Periods mentioned in the Policy wording will get reduced by 1 year with every continuous renewal for the respective benefit under Health
Conditions Assurance Policy.

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


 All the three benefits under Health Assurance can be renewed for lifetime unless the Insured Person or any one acting on beha lf of an Insured Person
has acted in a dishonest or fraudulent manner or any misrepresentation under or in relation to this Policy.

 Renewal premium is subject to change with prior approval from IRDA.

 There will be no underwriting on Policy renewal. The first year underwriting results will continue.

 We will allow a grace period of 30 days from the due date of the renewal premium for payment to Us

Renewal
Benefits If the AccidentCare cover is renewed, the Sum Insured will be increased by 5% of the Sum Insured (shown in the Schedule of Insurance Certificate during
the first Policy Year) for every claim free Policy Period up to a cumulative maximum of 25% of the Sum Insured for all the applicable benefits other than 4(j)
Accident Temporary Total Disability (TTD) and Accident Hospitalization mentioned under the AccidentCare cover only.
At the time of renewal in case of an insured person attaining 70 years of age, for Policyholder’s Sum Insured of more than 100 lacs, the Renewal Benefit will
also be reduced in the same proportion of reduction in Sum Insured.

You may terminate this Policy by giving 30 days’ prior written notice to Us. We shall cancel the Policy and refund the premium for the period as mentioned
herein below, provided that no claim has been made under the Policy by or on behalf of any Insured Person:
Cancellation

2 years 3 years
1 year

Policy in-force up
Policy in-force up to Refund % Refund % Policy in-force up to Refund %
to

Up to 30 days Up to 30 days 87.5% Up to 30 days 90%


75%

31 to 90 days 31 to 90 days 75% 31 to 90 days 87.5%


50%

91 to 180 days 91 to 180 days 62.5% 91 to 180 days 75%


25% 4(g)

181 to 365 days 181 to 365 days 60%


50%

366 to 455days 366 to 455days 50%


25%

exceeding 180 days 0% 456 to 545 days 456 to 545 days 25%
12%

545 to 720 days


Exceeding 545 12%
0%
days
Exceeding 720 days
0%

However, policy would be cancelled, and no claim or refund would be due if Insured Person has not correctly disclosed details about current and past health
status or has otherwise encouraged or participated in any fraudulent claims under the Policy or has made any mis-representation in the documents submitted
in support of income.

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


Policy Document

1. Terms & Conditions 2.1.5 Accident Permanent Partial Disability (PPD)


The insurance cover provided under this Policy to the Insured Person/s up If an Insured Person suffers Permanent Partial Disability solely and directly
to the Sum Insured is and shall be subject to (a) the terms, conditions and due to an Accident and within 365 days from occurrence of such Accident,
exclusions to this Policy and (b) the receipt of premium, and (c) Disclosure We will pay the amount specified in the grid below which is a percentage
to information norm (including by way of the Proposal form or of the Sum Insured, provided that:
Information Summary Sheet) for Yourself and on behalf of each of the
2.1.5.1 The Permanent Partial Disability is proved to Our satisfaction; and
Insured Persons
a disability certificate is presented to Us, and such disability certificate
2. Benefit shall be issued by a Medical Board duly constituted by the Central and/or
the State Government: and
This Policy provides benefits as specified in the Schedule of Insurance
Certificate for the specified events occurring during the Policy Period and 2.1.5.2 We will admit a claim under 2.1.5 only if the Permanent Partial
while the policy is in force for an illness and/or, Accident and/or Disability continues for a period of at least 6 continuous calendar months
Hospitalisation or the conditions described below subject to any specific from the commencement of the Permanent Partial Disability, unless it is
limits specified in the Product Benefits Table, the terms, conditions, irreversible; and
limitations and specific and general exclusions mentioned in the Policy
2.1.5.3 If the Insured Person dies before a claim has been admitted under
and as shown in the Schedule of Insurance Certificate and eligibility for the
2.1.5, no amount will be payable under 2.1.5, however We will consider
insurance plan opted for as specified in the Product Benefits Table.
the claim under 2.1.1.
2.1. AccidentCare (Individual or Family option)
2.1.5.4 If a claim has been admitted under 2.1.3, then no further claim in
If any of the Insured Persons dies or sustains any Injury resulting solely and respect of the same condition will be admitted under 2.1.5.
directly from an Accident occurring during the Policy Period at any
2.1.5.5 If this benefit is triggered and the entire Sum Insured does not get
location worldwide, and while the Policy is in force, We will provide the
utilized, then the balance Sum Insured shall be available for other
benefits described below.
Permanent Partial Disability until the entire Sum Insured is consumed. This
If a claim gets triggered under Accident Death or Accident Permanent Sum Insured limit shall be a lifetime limit and once this limit is exhausted
Total Disability for any Insured Person, the coverage shall terminate for the whether due to any or more than one of the Permanent Partial Disabilities,
respective Insured Person post payment of the benefit but for the other the Policy and all benefits there under shall cease thereafter.
Insured Person, the coverage shall continue till the end of the policy
The table below shows the amount payable basis the nature of disability.
period and shall be renewable.
2.1.1 Accident Death Permanent Partial Disability Grid

If an Insured Person dies solely and directly due to an Accidental Injury Sno Nature of Disability % of Sum
within 365 days from occurrence of the Accident we will pay the Sum Insured
Insured. 1. Loss or total and permanent loss of use of both the hands
from the wrist joint 100%
2.1.2 Funeral Expenses 2. Loss or total and permanent loss of use of both feet from
If We have accepted a claim for the Accidental death of an Insured Person the ankle joint 100%
under 2.1.1 above, then in addition to any amount payable under 2.1.1, 3. Loss or total and permanent loss of use of one hand
We will make an one time payment as specified in the Schedule of from the wrist joint and of one foot from the ankle joint 100%
Insurance Certificate towards the funeral expenses of that Insured Person. 4. Loss or total and permanent loss of use of one hand from
the wrist joint and total and permanent loss of sight in one eye 100%
2.1.3 Accident Permanent Total Disability (PTD) 5. Loss or total and permanent loss of use of one foot from
If an Insured Person suffers Permanent Total Disability solely and directly the ankle joint and total and permanent loss of sight in one eye 100%
due to an Accident and within 365 days from occurrence of such accident, 6. Total and permanent loss of speech and hearing in both ears 100%
We will pay the sum insured provided that: 7. Total and permanent loss of hearing in both ears 50%
8. Loss or total and permanent loss of use of one hand from
2.1.3.1 the Permanent Total Disability is proved to Our satisfaction; and a wrist joint 50%
disability certificate is presented to Us, and such disability certificate shall 9. Loss or total and permanent loss of use of one foot from
be issued by a Medical Board duly constituted by the Central and/or the ankle joint 50%
State Government; and 10. Total and permanent loss of sight in one eye 50%
2.1.3.2 We will admit a claim under 2.1.3 only if the Permanent Total 11. Total and permanent loss of speech 50%
Disability continues for a period of at least 6 continuous calendar months 12. Permanent total loss of use of four fingers and thumb of
from the commencement of the Permanent Total Disability unless there either hand 40%
are no chances of variation over time, in the degree of disability as in 13. Permanent total loss of use of four fingers of either hand 35%
amputation/Loss of limbs etc; and 14. Uniplegia 25%
15. Permanent total loss of use of one thumb of either hand
2.1.3.3 If the Insured Person dies before a claim has been admitted under a. Both joints 25%
2.1.3, no amount will be payable under 2.1.3, however We will consider b. One joint 10%
the claim under 2.1.1; and 16 Permanent total loss of use of fingers of either hand
2.1.3.4 We will not make payment under 2.1.3 in respect of an insured a. Three joints 10%
person and for any and all policy periods more than once in the insured b. Two joints 8%
person’s lifetime. c. One joint 5%
17 Permanent total loss of use of toes of either foot
2.1.4 Child Education Benefit (available only in Family option with a. All toes- one foot 20%
children) b. Great toe- both joints 5%
If We have accepted a claim for the Accidental Death or Permanent Total c. Great toe- one joint 2%
Disability of the Policyholder under 2.1.1 or 2.1.3 respectively, then in d. Other than great toe, one toe 1%
addition to any amount payable under 2.1.1 or 2.1.3, We will make a one
time payment as specified in the Schedule of Insurance Certificate as an 2.1.6 Temporary Total Disability (TTD) (Op onal Benefit)
education benefit for each of the Policyholder’s dependent children,
provided that the child is an insured person under the Policy. Such benefit If the Policyholder suffers an Injury solely and directly due to an Accident
shall be payable for a maximum of up to 2 Dependent Children. occurring during the Policy Period which solely and directly results in the

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


Policyholder’s Temporary Total Disability within 365 days from date of - Op on 1, Rs.50,00,000 shall be paid as lump sum
occurrence of such Accident, We will pay an amount equal to 1% of the - Op on 2, Rs.50,00,000 is paid as lump sum on 1st June 2016. In
TTD Sum Insured per week for each week that the Temporary Total addi on, from next year onwards at the beginning of each year for
Disability con nues subject always to the availability of the TTD Sum subsequent 5 years i.e on 1st June of every year from 2017 to 2021,
Insured. payout equal to Rs.5,00,000 shall be made to the beneficiary.

It is agreed and understood that for the purpose of 2.1.6, For the purpose of this Cri Care Cover, ‘Cri cal Illness’ means the
following illnesses:
2.1.6.1 We shall not be liable to make any payment under 2.1.6 in respect
of more than 100 weeks in a life me (life me limit) and once this life me 1. Cancer of Specified Severity
limit is a ained, the TTD benefit cannot be renewed any further. However,
the Policy can be renewed with all other benefits including the op onal A malignant tumor characterized by the uncontrolled growth and spread
Accident Hospitaliza on Benefit. The Policyholder shall have an op on to of malignant cells with invasion and destruc on of normal ssues. This
renew the benefit un l the life me limit is exhausted. diagnosis must be supported by histological evidence of malignancy and
confirmed by a pathologist. The term cancer includes leukemia,
2.1.6.2 The amount payable under 2.1.6 is calculated on a per day basis lymphoma and sarcoma.
and shall be payable from the first day of onset of the Temporary Total
Disability provided that the Temporary Total Disability con nues for at The following are excluded:
least 3 con nuous days.
• Tumours showing the malignant changes of carcinoma in situ and
2.1.7 Accident Hospitaliza on (Op onal Benefit) tumours which are histologically described as premalignant or non
invasive, including but not limited to: Carcinoma in situ of breasts,
The Accident Hospitaliza on benefit shall be available only for Cervical dysplasia CIN-1, CIN-2 & CIN-3.
hospitaliza on in India following an Accident. If the Insured Person is • Any skin cancer other than invasive malignant melanoma.
hospitalised during the Policy Period solely and directly due to an Injury
• All tumours of the prostate unless histologically classified as having a
sustained arising from an Accident occurring during the Policy Period, We
Gleason score greater than 6 or having progressed to at least clinical
will pay the Medical Expenses incurred subject to the maximum amount
TNM classifica on T2N0M0.
specified in the Schedule of Insurance Cer ficate.
• Papillary micro - carcinoma of the thyroid less than 1 cm in diameter.
2.2. Cri Care Cover (Individual or Family Floater op on) • Chronic lymphocyc c leukaemia less than RAI stage 3.

If an Insured Person suffers a Cri cal Illness during the Policy Period and • Microcarcinoma of the bladder.
while the Policy is in force, We will pay the Sum Insured provided that: • All tumours in the presence of HIV infec on.

2.2.1 Such Cri cal Illness first occurs or manifests itself during the Policy What does it mean?
Period; and
Cancer (also known as a malignant tumour) is a disease where cells
2.2.2 The signs and symptoms of such Cri cal Illness commence a er 90 change and grow in an abnormal way. If le untreated, they can destroy
days from the date of commencement of the Policy i.e. the benefit would surrounding healthy cells and eventually destroy healthy cells in other
not be payable if the signs or symptoms occurred during the first 90 days parts of the body. There are about 200 different types of cancer, varying
or earlier from the date of commencement of coverage, as specified in the widely in outlook and treatment.
Schedule of Insurance Cer ficate; and
2. Myocardial Infarc on
2.2.3 The Insured Person survives for a minimum period of at least 30 days
from the date of diagnosis of such Cri cal Illness for the claim to be (First Heart A ack of specific severity)
admissible under 2.2. I. The first occurrence of heart a ack or myocardial infarc on, which
means the death of a por on of the heart muscle as a result of
2.2.4 If this Cri cal Illness cover is in force on a Family Floater basis, then: inadequate blood supply to the relevant area. The diagnosis for
Myocardial Infarc on should be evidenced by all of the following
2.2.4.1 We will not be liable to make payment under this cover in respect criteria:
of any and all Insured Persons more than once in a Policy Year;
i. A history of typical clinical symptoms consistent with the
2.2.4.2 If We have admi ed a claim under this cover for an Insured Person diagnosis of acute myocardial infarc on (For e.g. typical chest
in any Policy Year, this cover shall not be renewed in respect of that pain)
Insured Person for any subsequent Policy Year, but the cover will be ii. New characteris c electrocardiogram changes
renewable for the other Insured Persons.
iii. Eleva on of infarc on specific enzymes, Troponins or other
2.2.5 The benefit shall be paid as per the benefit op on chosen at specific biochemical markers.
incep on: II. The following are excluded:
2.2.5.1 Benefit Op on 1: Sum Insured as lump sum
i. Other acute Coronary Syndromes
2.2.5.2 Benefit Op on 2: Sum Insured as lump sum along with 10% of the ii. Any type of angina pectoris
Sum Insured payable annually at the beginning of each year from the date
iii. A rise in cardiac biomarkers or Troponin T or I in absence of overt
of payment of lump sum benefit, for subsequent 5 years. The coverage
ischemic heart disease OR following an intra-arterial cardiac
under the Policy shall cease for that Insured Person. This cover shall not be
procedure.
renewed in respect of that Insured Person for any subsequent policy year,
but the cover will be renewed for the other Insured Persons. Once the What Does It Mean?
benefit gets triggered, the annual benefits shall be paid at respec ve
intervals irrespec ve of the survival status of the insured. A heart a ack, also known as a myocardial infarc on, happens when part
of the heart muscle dies because it has been starved of oxygen. This causes
For Ex: If the Sum Insured chosen at incep on is Rs.50,00,000 then as per severe pain and an increase in cardiac enzymes and troponins, which are
chosen op on: released into the blood stream from the damaged heart muscle.

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


3. Open Chest CABG What Does It Mean?

I. The actual undergoing of heart surgery to correct blockage or narrowing in A coma is a state of unconsciousness from which the pa ent cannot be
one or more coronary artery(s), by coronary artery bypass gra ing done aroused and has no control over bodily func ons. It may be caused by
via a sternotomy (cu ng through the breast bone) or minimally invasive illness, stroke, infec on, very low blood sugar or serious accident.
keyhole coronary artery bypass procedures. The diagnosis must be Recovery rates vary, depending upon the depth and dura on of the coma.
supported by a coronary angiography and the realiza on of surgery has to
be confirmed by a cardiologist. 6. Kidney Failure Requiring Regular Dialysis

II. The following are excluded: End stage renal disease presen ng as chronic irreversible failure of both
kidneys to func on, as a result of which either regular renal dialysis
i. Angioplasty and/or any other intra-arterial procedures (hemodialysis or peritoneal dialysis) is ins tuted or renal transplanta on
is carried out. Diagnosis has to be confirmed by a specialist medical
What does it mean? prac oner.

Coronary arteries can become narrowed or blocked by the build-up of What Does It Mean?
fa y deposits caused by poor lifestyle such as high fat diet, smoking and
high blood pressure. This may cause symptoms including chest pain and The kidneys perform an important role filtering the body’s waste to pass
can some mes cause a heart a ack. Coronary artery by-pass surgery is as urine. If the kidneys fail, there is a harmful build up of the body’s waste
used to treat blocked arteries in the heart by diver ng the blood supply products. In severe cases it may be necessary for the filtering to be done by
around the blocked artery using a vein, usually taken from the leg, arm or a dialysis machine or, in some cases, a transplant may be needed.
chest. This defini on covers surgery if it requires the heart to be reached
by a surgical incision through the chest wall or sternum (breastbone), to 7. Stroke Resul ng in Permanent Symptoms
replace the blocked arteries with a vein.
Any cerebrovascular incident producing permanent neurological
4. Open Heart Replacement or Repair of Heart Valves sequelae. This includes infarc on of brain ssue, thrombosis in an
intracranial vessel, haemorrhage and embolisa on from an extracranial
The actual undergoing of open-heart valve surgery is to replace or repair source.
one or more heart valves, as a consequence of defects in, abnormali es of,
or disease-affected cardiac valve(s). The diagnosis of the valve Diagnosis has to be confirmed by a specialist medical prac oner and
abnormality must be supported by an echocardiography and the evidenced by typical clinical symptoms as well as typical findings in CT Scan
realiza on of Surgery has to be confirmed by a specialist medical or MRI of the brain.
prac oner.
Evidence of permanent neurological deficit las ng for atleast 3 months
Catheter based techniques including but not limited to, balloon has to be produced.
valvotomy/valvuloplasty are excluded.
The following are excluded:
What does it mean? i. Transient ischemic a acks (TIA)
ii. Trauma c Injury of the brain
Heart valve repair or replacement surgery is done when valves are
damaged or diseased and do not work the way they should. When one (or iii. Vascular disease affec ng only the eye or op c nerve or ves bular
more) valve(s) becomes steno c (s ff), narrowed or diseased due to any func ons
reasons, the heart must work harder to pump the blood through the valve.
If your heart valve(s) becomes damaged, you may have the following What Does It Mean?
symptoms:
Strokes are caused by a sudden loss of blood supply or haemorrhage to a
• Dizziness par cular part of the brain. The symptoms and how well a person recovers
will depend on which part of the brain is affected and the extent of the
• Chest pain
damage. A transient ischaemic a ack, some mes referred to as a ‘mini-
• Breathing difficul es stroke’, does not result in any permanent neurological deficit. These are
• Palpita ons not covered by this defini on, because symptoms aren’t permanent and
• Edema (swelling) of the feet, ankles, or abdomen (belly) will disappear within 24 hours.

• Rapid weight gain due to fluid reten on 8. Major Organ/Bone Marrow Transplant

This defini on implies a large surgical incision made in the chest and the The actual undergoing of a transplant of:
heart stopped for a me so that the surgeon can repair or replace the
valve(s). • One of the following human organs: heart, lung, liver, kidney,
pancreas, that resulted from irreversible end-stage failure of the
5. Coma of Specified Severity relevant organ, or
• Human bone marrow using haematopoie c stem cells.
A state of unconsciousness with no reac on or response to external
s muli or internal needs. The undergoing of a transplant has to be confirmed by a specialist medical
This diagnosis must be supported by evidence of all of the following:
prac oner.
a) no response to external s muli con nuously for at least 96 hours;
The following are excluded:
b) life support measures are necessary to sustain life; and
• Other stem-cell transplants
c) permanent neurological deficit which must be assessed at least 30 • Where only islets of langerhans are transplanted
days a er the onset of the coma.
What Does It Mean?
The condi on has to be confirmed by a specialist medical prac oner. An organ may become so diseased that it needs to be replaced.
Coma resul ng directly from alcohol or drug abuse is excluded.

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


9. Permanent Paralysis of Limbs shortness of breath, excessive bleeding and an increased chance of
catching infec ons.
Total and irreversible loss of use of two or more limbs as a result of Injury
or disease of the brain or spinal cord. A specialist medical prac oner 13. Bacterial Meningi s
must be of the opinion that the paralysis will be permanent with no hope Bacterial meningi s is a bacterial infec on of the meninges of the brain
of recovery and must be present for more than 3 months. causing brain dysfunc on. There must be an unequivocal diagnosis by a
consultant physician of bacterial meningi s that must be proven on
What Does It Mean? analysis and culture of the cerebrospinal fluid. There must also be
permanent objec ve neurological deficit that is present on physical
Paralysis is the complete loss of use. It may be caused by injury or illness. A examina on at least 3 months a er the diagnosis of the meningi s
limb is an arm or leg. infec on.

10. Motor Neurone Disease with Permanent Symptoms What Does It Mean?

Motor neurone disease diagnosed by a specialist medical prac oner as Bacterial meningi s causes inflamma on to the meninges, which is the
spinal muscular atrophy, progressive bulbar palsy, amyotrophic lateral protec ve layer around the brain and spinal cord. It’s caused by a bacterial
sclerosis or primary lateral sclerosis. There must be progressive infec on and needs prompt medical treatment. Ini al symptoms include
degenera on of cor cospinal tracts and anterior horn cells or bulbar headache, fever and vomi ng.
efferent neurons. There must be current significant and permanent
func onal neurological impairment with objec ve evidence of motor 14. Loss of Speech
dysfunc on that has persisted for a con nuous period of at least 3
months. I. Total and irrecoverable loss of the ability to speak as a result of injury or
disease to the vocal cords. The inability to speak must be established for a
What Does It Mean? con nuous period of 12 months. This diagnosis must be supported by
medical evidence furnished by an Ear, Nose, Throat (ENT) specialist.
Motor neurone disease (MND) is a gradual weakening and was ng of the
muscles, usually beginning in the arms and legs. This may cause difficulty II. All psychiatric related causes are excluded
walking or holding objects. As the disease develops, other muscle groups
may be affected, such as those involving speech, swallowing and What Does It Mean?
breathing. Eventually, 24 hour care may be needed.
The total loss of the ability to speak. It’s o en caused when the vocal cords
11. Mul ple Sclerosis with Persis ng Symptoms need to be removed because of a tumour or a serious injury.

I. The unequivocal diagnosis of Definite Mul ple Sclerosis confirmed and 15. End Stage Liver Disease
evidenced by all of the following:
Permanent and irreversible failure of liver func on that has resulted in all
i. inves ga ons including typical MRI findings which unequivocally three of the following:
confirm the diagnosis to be mul ple sclerosis and
ii. there must be current clinical impairment of motor or sensory a) Permanent jaundice; and
b) Ascites; and
func on, which must have persisted for a con nuous period of at
c) Hepa c Encephalopathy.
least 6 months.
II. Other causes of neurological damage such as SLE and HIV are excluded. Liver failure secondary to drug or alcohol abuse is excluded.

What Does It Mean? What Does It Mean?

Mul ple sclerosis (MS) is the most common disabling neurological disease The liver is an important organ, which carries out several of the body’s vital
among young adults and is usually diagnosed between the ages of 20 and func ons such as helping with diges on and clearing toxins. This defini on
40. covers liver failure at an advanced stage. This type of liverfailure leads to
permanent jaundice (yellow discoloura on of the skin), ascites (build up of
12. Aplas c Anaemia fluid in the abdomen), and encephalopathy (brain disease or damage).

Aplas c Anemia is chronic persistent bone marrow failure. A cer fied 16. Deafness
hematologist must make the diagnosis of severe irreversible aplas c
anemia. There must be permanent bone marrow failure resul ng in bone Total and irreversible loss of hearing in both ears as a result of illness or
marrow cellularity of less than 25% and there must be two of the accident. This diagnosis must be supported by pure tone audiogram test
following: and cer fied by an Ear, Nose and Throat (ENT) specialist. Total means “the
loss of hearing to the extent that the loss is greater than 90decibels across
a) Absolute neutrophil count of less than 500/mm³ all frequencies of hearing” in both ears.
b) Platelets count less than 20,000/mm³
What Does It Mean?
c) Re culocyte count of less than 20,000/mm³
The Insured Person must be receiving treatment for more than 3 This means permanent loss of hearing in both ears, measured by using an
consecu ve months with frequent blood product transfusions, bone audiogram across different frequencies, which vary from low to high pitch.
marrow s mula ng agents, or immunosuppressive agents or the Insured
Person has received a bone marrow or cord blood stem cell transplant. 17. End-stage Lung Disease
Temporary or reversible Aplas c Anemia is excluded and not covered
End stage lung disease, causing chronic respiratory failure, as evidenced
under this Policy.
by all of the following:
What Does It Mean?
a) FEV1 test results consistently less than 1 litre measured on 3
Aplas c anaemia is a serious condi on where bone marrow fails to occasions 3 months apart; and
b) Requiring con nuous permanent supplementary oxygen therapy for
produce sufficient blood cells or clo ng agents. Symptoms include
hypoxemia; and

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


c) Arterial blood gas analyses with par al oxygen pressures of 55mmHg 2.3 HospiCash Benefit
or less (PaO2< 55mmHg); and
d) Dyspnea at rest. 2.3.1. If an Insured Person is Hospitalized solely and directly due to an
injury arising from an Accident or due to an Illness for a minimum
This diagnosis must be confirmed by a respiratory physician. period of 48 hours, then We will pay the daily allowance as
specified in the Cer ficate of Insurance for each con nuous and
What Does It Mean? completed period of 24 hours of Hospitalisa on from the first day
of Hospitaliza on provided that:
The lungs allow us to breathe in oxygen and get rid of harmful carbon 2.3.2. We shall not be liable to make any payment for Hospitalisa on
dioxide. The defini on of End Stage Lung Disease covers advanced lung and/or treatment and/or treatment following diagnosis which
failure when breathing is severely affected and regular oxygen therapy is occurs within 30 days from the date of commencement of the
required. Policy specified in the Schedule of Insurance Cer ficate, unless
such Hospitalisa on is required solely and directly due to an
18. Fulminant Viral Hepa s
Accident;
A sub-massive to massive necrosis of the liver by any virus, leading 2.3.3. We shall not be liable to make payment of the Daily Allowance
precipitously to liver failure. under this benefit for more than 45 days for an Insured Person in a
Policy Year, including all days of admission to the Intensive Care
This diagnosis must be supported by all of the following: Unit. This is applicable for both individual and family op on.

a) rapid decreasing of liver size; and 2.3.4. If an Insured Person is required to be admi ed to the Intensive
b) necrosis involving en re lobules, leaving only a collapsed re cular Care Unit of a Hospital solely and directly due to an injury arising
framework; and from an Accident or due to an Illness, then We will pay twice the
c) rapid deteriora on of liver func on tests; and Daily Allowance specified in the Cer ficate of Insurance for each
d) deepening jaundice; and con nuous and completed period of 24 hours of admission in the
e) hepa c encephalopathy. Intensive Care Unit for a maximum of 7 days for an Insured Person
in a policy year.
Acute Hepa s infec on or carrier status alone does not meet the
diagnos c criteria. 3. Exclusions

What does it mean? In addi on to exclusions/wai ng periods specified elsewhere in the Policy
Document, We shall not be liable under this Policy for any claim in
Appearance of severe systemic complica ons like sepsis, gastro-intes nal connec on with or in respect of the following:
bleeding, cerebral oedema, renal and cardiac failure, rapidly a er the first
signs of liver disease (such as jaundice), and indicates that the liver has a. Ini al Wai ng Period
sustained severe damage.
Cri care: Benefits will not become payable if the signs or symptoms of any
19. Third Degree Burns of the listed cri cal illnesses commence within 90 days from the date of
commencement of Cri Care coverage of the first policy.
There must be third-degree burns with scarring that cover at least 20% of
the body’s surface area. The diagnosis must confirm the total area HospiCash: Benefits will not become payable if the signs or symptoms
involved using standardized, clinically accepted, body surface area charts and/or Treatment fall within 30 days from the date of commencement of
covering 20% of the body surface area. HospiCash coverage except accidents.

20. Muscular Dystrophy b. Pre-Exis ng Diseases

Muscular Dystrophy is a disease of the muscle causing progressive and For Cri Care and HospiCash, Benefits will not be available for Pre-exis ng
permanent weakening of certain muscle groups. The diagnosis of Diseases un l 48 months of con nuous coverage have elapsed since the
Muscular Dystrophy must be made by a consultant neurologist, and incep on of the first Policy with Us or other insurer in case of portability,
confirmed with the appropriate laboratory, biochemical, histological, and for the respec ve benefit.
electromyographic evidence. The disease must result in the permanent
inability of the Insured Person to perform (whether aided or unaided) at c. Specific Wai ng Period for the HospiCash Benefit under 2.3
least three (3) of the six (6)“Ac vi es of Daily Living”.
For the payment of the HospiCash Benefit, the disease condi ons /
Ac vi es of Daily Living are defined as: treatments listed below will be subject to a wai ng period of 24 months
and will be covered from the commencement of the third Policy Year as
i. Washing : the ability to maintain an adequate level of cleanliness long as the Insured Person has been insured con nuously under the Policy
and personal hygiene without any break
ii. Dressing : the ability to put on and take off all necessary garments,
ar ficial limbs or other surgical appliances that are Medically 1. Stones in biliary and urinary systems
Necessary 2. Lumps/ cysts/ nodules/ polyps/ internal tumours excluding
iii. Feeding : the ability to transfer food from a plate or bowl to the
malignancies
mouth once food has been prepared and made available
iv. Toile ng : the ability to manage bowel and bladder func on, 3. Gastric and duodenal ulcers
maintaining an adequate and socially acceptable level of hygiene 4. Surgery on tonsils / adenoids
v. Mobility : the ability to move indoors from room to room on level
5. Osteoarthrosis / arthri s / gout / rheuma sm / spondylosis /
surfaces at the normal place of residence
spondyli s /intervertebral disc prolapse
vi. Transferring: the ability to move from a lying posi on in a bed to a 6. Cataract and its complica ons
si ng posi on in an upright chair or wheel chair and vice versa. 7. Fissure / Fistula / Haemorrhoids of anal and rectal region
8. Hernia / hydrocele / varicocoele / spermatocoele
9. Chronic renal failure or end stage renal failure

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


10. Sinusi s / deviated nasal septum / tympanoplasty / chronic x. Any costs or expenses specified in the List of Expenses Generally
suppura ve o s media Excluded at Annexure II. This is applicable only for Accident
11. Benign prosta c hypertrophy Hospitaliza on benefit.

12. Joint replacements surgery except in case of accidents 2. Specific Exclusions for Cri Care under 2.2
13. Dilata on and cure age except in case of surgical abor on
In addi on to any condi ons and exclusions listed under each Cri cal
14. Varicose veins of legs
Illness, We shall not be liable to make any payment of the Cri Care Benefit
15. Dysfunc onal uterine bleeding / fibroids / prolapse uterus / under 2.2 if the claim is a ributable to, or based on, or arise out of, or are
endometriosis directly or indirectly connected to any of the following:
16. Diabetes and related complica ons including but not limited to:
a. Acquired Immune Deficiency Syndrome (AIDS), AIDS-related
a) Hyperglycaemia with or without coma
complex or infec on by Human Immunodeficiency Virus (HIV); or
b) Hypoglycaemia with or without coma
b. the Insured Person’s a empted suicide or self-inflicted injuries while
c) Diabe c Ketoacidosis sane or insane; or
d) Diabe c Nephropathy c. narco cs used by the Insured Person unless taken as prescribed by a
e) Diabe c Re nopathy Medical Prac oner, or the Insured Person’s abuse of drugs and/or
f) Diabe c Neuropathy consump on of alcohol; or

17. Hysterectomy for any benign disorder d. The direc ons, advice and guidance of the trea ng Medical
Prac oner shall be strictly followed. We shall not be obliged to
18. Thyroid and parathyroid gland disorders excluding malignancy
make any payment that arises out of willful failure to comply with
19. Any Congenital Anomaly or inherited disorder or developmental such direc ons, advice or guidance.
condi ons
e. Treatment for any injury or illness resul ng directly or indirectly from
d. Permanent Exclusions nuclear, radiological emissions, war or war like situa ons (whether
war is declared or not), rebellion (act of armed resistance to an
1. Specific Exclusions for AccidentCare Cover under 2.1 established government or leader), acts of terrorism
We shall not be liable to make any payment under any benefits under the f. taking part in any naval, military or air force opera on during peace
AccidentCare Cover under 2.1 if the claim is a ributable to, or based on, or me; or
arise out of, or are directly or indirectly connected to any of the following:
g. Par cipa on in avia on/marine including crew other than as a
i. Suicide or self inflicted Injury, whether the Insured Person is passenger in an aircra /water cra that is authorized by the relevant
medically sane or insane. regula ons to carry such passengers between established airport or
ports.
ii. Treatment for any injury or illness resul ng directly or indirectly from
nuclear, radiological emissions, war or war like situa ons (whether h. Including but not limited to engaging in or taking part in
war is declared or not), rebellion (act of armed resistance to an professional/adventure sports or any hazardous pursuits, such as
established government or leader), acts of terrorism. speed contest or racing of any kind (other than on foot), bungee
jumping, parasailing, ballooning, parachu ng, skydiving,
iii. Service in the armed forces, or any police organiza on, of any paragliding, hang gliding, mountain or rock climbing necessita ng
country at war or at peace or service in any force of an interna onal the use of guides or ropes, potholing, abseiling, deep sea diving using
body or par cipa on in any of the naval, military or air force hard helmet and breathing apparatus, polo, snow and ice sports,
opera on during peace me. hun ng etc; or
iv. Any change of profession a er incep on of the Policy which results in i. par cipa on by the Insured Person in a criminal or a breach of law
the enhancement of Our risk, if not accepted and endorsed by Us on with criminal intent; or
the Schedule of Insurance Cer ficate.
v. Commi ng an assault, a criminal offence or any breach of law with 3. Specific Exclusions for HospiCash Benefit under 2.3
criminal intent.
We shall not be liable to make any payment if Hospitalisa on or any claim
vi. Taking or absorbing, accidentally or otherwise, any intoxica ng
under this benefit are a ributable to, or based on, or arise out of, or are
liquor, drug, narco c, medicine, seda ve or poison, except as
directly or indirectly connected to any of the following:
prescribed by a Medical Prac oner other than the Policyholder or
an Insured Person. I. Hospitalisa on not in accordance with the diagnosis and treatment
of the condi on for which the Hospital confinement was required;
vii. Par cipa on in avia on/marine including crew other than as a
passenger in an aircra /water cra that is authorized by the ii. Hospitaliza on solely for diagnos c or observa on purpose;
relevant regula ons to carry such passengers between established iii. Treatment for weight reduc on or weight improvement regardless
airports or ports. of whether the same is caused (directly or indirectly) by a medical
condi on;
viii. Including but not limited to engaging in or taking part in
professional/adventure sports or any hazardous pursuits, such as iv. Any dental care or Surgery of cosme c nature, extrac on of
speed contest or racing of any kind (other than on foot), bungee impacted tooth/teeth, orthodon cs or orthognathic Surgery, or
jumping, parasailing, ballooning, parachu ng, skydiving, tempero-mandibular joint disorder except as necessitated by an
paragliding, hang gliding, mountain or rock climbing necessita ng Accidental Injury;
the use of guides or ropes, potholing, abseiling, deep sea diving using v. Treatment for infer lity or impotency, sex change or any treatment
hard helmet and breathing apparatus, polo, snow and ice sports, related to it, abor on, steriliza on and contracep on including any
hun ng etc; complica ons rela ng thereto;
ix. Body or mental infirmity or any disease except where such condi on vi. Treatment arising from pregnancy and it’s complica ons which shall
arises directly as a correspondence of an Accident during the Policy include childbirth or abor on or threatened abor on excluding
Period. However this exclusion is not applicable to claims made ectopic pregnancy;
under the PPD benefit. vii. Hereditary and Gene c Disorders: Screening, counseling or
treatment related to Hereditary and Gene c Disorders;

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


viii. Hospitalisa on primarily for diagnosis, X-ray examina ons, general 4. Standard Terms and Condi ons
physical or medical check-up not followed by ac ve treatment during
the Hospitalisa on period or Hospitalisa on where no ac ve a. Observance of terms and condi ons.
treatment is given by the Medical Prac oner;
The due observance and fulfillment of the terms, condi ons and
ix. Unproven/Experimental treatments/off-label treatment;
endorsements of this Policy in so far as they relate to anything to be done
x. Alterna ve treatment; or complied with by the Insured Person, shall be a condi on precedent to
xi. Treatment of any mental or psychiatric condi on including but not any liability to make payment under this Policy .
limited to insanity, mental or nervous breakdown / disorder,
depression, demen a, Alzheimer’s disease or rest cures; b. Subroga on and Contribu on
xii. Admission to a nursing home or home for the care of the aged for
Subroga on and Contribu on provisions are not applicable to the Policy.
rehabilita on, or convalescence;
xiii. Treatment directly or indirectly arising from alcohol, drug or c. Fraudulent claims
substance abuse and any Illness or Accidental Injury which may be
suffered a er consump on of intoxica ng substances, liquors or If a claim is in any way found to be fraudulent, or if any false statement, or
drugs; declara on is made or used in support of such a claim, or if any fraudulent
xiv. Treatment directly or indirectly arising from or consequent upon war means or devices are used by the Insured Person or any false or incorrect
(whether war be declared or not), invasion, acts of foreign enemies, disclosure to informa on norms or anyone ac ng on behalf of the Insured
hos li es, civil war, rebellion, ac ve par cipa on in strikes, riots or Person to obtain any benefit under this Policy, then this Policy shall be void
civil commo on, revolu on, insurrec on or military or usurped and all claims being processed shall be forfeited for all Insured Persons
power, and full- me service in any of the armed forces; and all sums paid under this Policy shall be repaid to Us by all Insured
xv. Acquired Immune Deficiency Syndrome (AIDS) and all Illnesses or Persons who shall be jointly liable for such repayment.
diseases caused by or related to the Human Immuno-deficiency
d. Free Look Provision
Virus;
xvi. Sexually transmi ed diseases; You have a period of 15 days from the date of receipt of the Policy
xvii. Cosme c or plas c Surgery except to the extent that such Surgery is document to review the terms and condi ons of this Policy. The Free Look
necessary for the repair of damage caused solely by Accidental period will be 30 days if the Policy is purchased through distance
Injuries; treatment of xanthelesema, syringoma, acne and alopecia; marke ng mode and Policy Period is 3 years. If You have any objec ons to
xviii. Nuclear disaster, radioac ve contamina on and/or release of any of the terms and condi ons, You may cancel the Policy sta ng the
nuclear or atomic energy; reasons for cancella on and provided that no claims have been made
under the Policy, We will refund the premium paid by You a er deduc ng
xix. Treatment for Accidental Injury or Illness caused by inten onally self-
the amounts spent on stamp duty charges, pre policy medical checkup
inflicted Injuries; or any a empts of suicide while sane or insane;
and propor onate risk premium for the period on cover. All rights and
xx. Treatment for Accidental Injury or Illness caused by viola on or benefits under this Policy shall immediately stand ex nguished on the
a empted viola on of the law, or resistance to arrest; free look cancella on of the Policy. The free look provision is not
xxi. Including but not limited to engaging in or taking part in applicable and available at the me of Renewal of the Policy.
professional/adventure sports or any hazardous pursuits, such as
speed contest or racing of any kind (other than on foot), bungee e. Portability :
jumping, parasailing, ballooning, parachu ng, skydiving,
paragliding, hang gliding, mountain or rock climbing necessita ng All health insurance policies are portable. You should ini ate ac on to
the use of guides or ropes, potholing, abseiling, deep sea diving using approach another insurer to take advantage of portability well before the
hard helmet and breathing apparatus, polo, snow and ice sports, renewal date to avoid any break in the policy coverage due to delay in
hun ng etc.; acceptance of the proposal by the other insurer.
xxii. Circumcision unless necessary for treatment of a disease or
If You/the Insured Person has exercised the Portability Op on at the me
necessitated due to an Accident;
of Renewal of Your previous health insurance policy by submi ng Your
xxiii. Hospitalisa on where the Insured Person is a donor for any organ applica on and the completed Portability form with complete
transplant; documenta on at least 45 days before, but not earlier than 60 days from
xxiv. Any treatment outside of Republic of India; the expiry of Your previous Policy Period, then the Insured Person will be
xxv. Treatment to assist reproduc on, including IVF treatment; provided with credit gained for Pre-exis ng Diseases in terms of Wai ng
xxvi. Hormone Replacement Therapy; Periods and me bound exclusions up to the exis ng Sum Insured and
cover in accordance with the exis ng guidelines of the IRDAI provided
xxvii.Puberty and Menopause related Disorders: Treatment for any
that:
symptoms, Illness, complica ons arising due to physiological
condi ons associated with Puberty, Menopause such as menopausal a. The ported Insured Person was insured con nuously and without a
bleeding or flushing; break under another Indian retail health insurance policy with any
xxviii. Ar ficial Life Maintenance: Ar ficial life maintenance, including life other Indian general insurance company or stand-alone health
support machine used to sustain a person, who has been declared insurance company or any group/retail indemnity health insurance
brain dead, as demonstrated by: policy from Us.
a. Deep coma and unresponsiveness to all forms of s mula on; b. The Wai ng Period with respect to change in Sum Insured or plan
b. Absent pupillary light reac on; shall be taken into account as follows:
c. Absent oculoves bular and corneal reflexes; or i. If the ported Sum Insured is higher than the Sum Insured under
d. Complete apnea the expiring policy, Wai ng Periods would be applied on the
xxix. Sleep disorders: Treatment for sleep apnea, snoring or any other amount of proposed increase in Sum Insured only, in accordance
sleep-related breathing problem; with the exis ng guidelines of the IRDAI.

xxx. Treatment for developmental problems: Treatment for, or related to ii. If the proposed Plan is to be changed and not the Sum Insured
developmental problems, including – learning difficul es (such as then the applicable Wai ng Periods would be applied as per the
dyslexia), behavioral problems, including a en on deficit proposed plan.
hyperac vity disorder (ADHD);

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


c. In case of different policies and plan in previous years, the Portability 1 year 2 years 3 years
Op on would be provided for the expiring policy or Plan which is to Policy in-force Refund Policy in-force Refund Policy in-force Refund
up to Premium up to Premium up to Premium
be ported to Us. (%) (%) (%)
Up to 30 days 75% Up to 30 days 87.5% Up to 30 days 90%
d. The Portability Op on has been accepted by Us within 15 days of 31 to 90 days 50% 31 to 90 days 75% 31 to 90 days 87.5%
receiving Your Proposal and Portability Form subject to the 91 to 180 days 25% 91 to 180 days 62.5% 91 to 180 days 75%
following: exceeding 180 days 0% 181 to 365 days 50% 181 to 365 days 60%
366 to 455 days 25% 366 to 455 days 50%
i. You shall have paid Us the applicable premium in full; 456 to 545 days 12% 456 to 545 days 25%
Exceeding 545 days 0% 545 to 720 days 12%
ii. We might have, subject to Our medical underwri ng as per Our Exceeding 720 0%
days
Board approved underwri ng policy, restricted the terms upon
which We have offered cover, the decision as to which shall be in
Our sole and absolute discre on; 2. Automa c Cancella on:
iii. There was no obliga on on Us to insure all Insured Persons or to
a. Individual Policy:
insure all Insured Persons on the proposed terms, even if You have
given Us all documenta on; The Policy shall automa cally terminate on death of the Insured
iv. We have received necessary details of medical history and claim Person.
history from the previous insurance company for the Insured
b. For Policy issued to Family:
Person’s previous health insurance policy through the IRDAI’s
web portal. The Policy shall automa cally terminate in the event of the death of
v. No addi onal loading or charges have been applied by Us all the Insured Persons.
exclusively for por ng the Policy.
c. Refund:
e. In case You have opted to switch to any other insurer under
Portability provisions(Por ng Out) and the outcome of acceptance of A refund in accordance with the table in Sec on 4(h)(1) above shall
the Portability request is awaited from the new insurer on the date of be payable if there is an automa c cancella on of the Policy provided
Renewal, that no claim has been filed under the Policy by or on behalf of any
Insured Person.
i. We may upon Your request extend this Policy for a period of not
less than one month at an addi onal premium to be paid on a pro 3. Cancella on by Us:
rata basis.
Without prejudice to the above, We may terminate this Policy during
ii. If during this extension period a claim has been reported, You
the Policy Period by sending 30 days prior wri en no ce to Your
shall be required to first pay the balance of the full annual Policy
address shown in the Schedule of Insurance Cer ficate without
premium. Our liability for the payment of such claim shall
refund of premium (for cases other than non coopera on) if in Our
commence only once such premium is received. Alternately We
opinion:
may deduct the premium for the balance period and pay the
balance claim amount if any and issue the Policy for the remaining i. You or any Insured Person or any person ac ng on behalf of either
period. has acted in a dishonest or fraudulent manner under or in rela on to
iii. We reserve the right to modify or amend the terms and the this Policy; and/or
applicability of the Portability op on in accordance with the
ii. You or any Insured Person has not disclosed the material facts or
provisions of the regula ons and guidance issued by the IRDAI as
misrepresented in rela on to the Policy; and/or
amended from me to me.
iii. You or any Insured Person has not co operated with Us. In such cases,
f. No fica on :
premium will be refunded on pro-rata basis provided that no claim
You will inform Us immediately of any change in the address, nature has been filed under the Policy by or on behalf of any Insured Person.
of job, state of health, or of any other changes affec ng You or any
For avoidance of doubt, it is clarified that no claims shall be admi ed
Insured Person through the format Annexure III.
and/or paid by Us during the no ce period.
We shall allow the enhancement in Sum Insured or scope of cover
The policy shall terminate for AccidentCare cover in case of change in
only at the me of Renewal, provided You in mate Us at the me of
occupa on of the Policyholder resul ng in change in the Risk Class to
Renewal. The decision of acceptance of enhancement of the sum
Category 3. In case of family op on, the cover of all insured persons
insured or the scope of cover will be based on our underwri ng
shall terminate. However, in case of change in occupa on of any
policy and shall be subject to payment of applicable premium for
insured person other than Policyholder resul ng in change in the
such enhanced cover.
Risk Class to Category 3, the cover of that par cular insured person
g. Cancella on/ Termina on (other than free look cancella on) only shall terminate. In all such cases of termina on, pro-rata
premium will be refunded provided that no claim has been filed
1. Cancella on by Insured Person: under the Policy by or on behalf of any Insured Person.

You may terminate this Policy during the Policy Period by giving Us at 4. Withdrawal of Product: This product may be withdrawn at Our
least 30 days prior wri en no ce. We shall cancel the Policy and op on subject to prior approval of the Insurance Regulatory and
refund the premium for the balance of the Policy Period in Development Authority of India (IRDAI) or due to a change in
accordance with the table below provided that no claim has been regula ons. In such a case We shall provide an op on to migrate to
made under the Policy by or on behalf of any Insured Person. our other suitable retail products as available with Us. We shall no fy
You of any such change at least 3 months prior to the date from which
such withdrawal shall come into effect.

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


5. Revision or Modifica on: The product and/or premium rates may be l. No ces
revised or modified subject to prior approval of the Insurance
Regulatory and Development Authority of India(IRDAI). In such case Any no ce, direc on or instruc on given under this Policy shall be in
We shall no fy You of any such change at least 3 months prior to the wri ng and delivered by hand, post, or facsimile to
date from which such revision or modifica on shall come into effect,
provided it is not otherwise provided by the authority. i. The You/Insured Person at the address specified in the Schedule
of Insurance Cer ficate or at the changed address of which We
h. Territorial Jurisdic on must receive wri en no ce.

a) AccidentCare including Temporary Total Disability coverage is ii. Us at the following address.
available worldwide. Customer Services Department
b) Accident Hospitalisa on, Cri Care and HospiCash are available in Max Bupa Health Insurance Company Limited
India only. B-1/I-2, Mohan Coopera ve Industrial Estate
c) All claims shall be payable in India in Indian Rupees only. Mathura Road, New Delhi-110044

i. Policy Disputes In addi on, We may send You/Insured Person other informa on through
electronic and telecommunica ons means with respect to Your Policy
Any dispute concerning the interpreta on of the terms, condi ons, from me to me.
limita ons and/or exclusions contained herein shall be governed by
Indian law and shall be subject to the jurisdic on of the Indian Courts m. Claims Procedure
at New Delhi.
All claims under this Policy will be adjudicated a er the occurrence of the
j. Renewal of Policy event and further submission of Necessary Documents. The benefits will
be paid in line with the coverage in the insurance plan opted by You and
The Renewal premium is payable on or before the due date in the will be irrespec ve of the actual costs incurred by You.
amount shown in the Schedule of Insurance Cer ficate or at such
altered rate as may be reviewed and no fied by Us before i. List of Necessary Documents are as follows:
comple on of the Policy Period. We are under no obliga on to no fy
You of the Renewal date of Your Policy. We will allow a Grace Period 1. For Cri Care:
of 30 days from the due date of the Renewal premium for payment to a. Duly filled and signed claim form and KYC documents.
Us. No benefits or coverage under the Policy will be available for the b. Final Hospital Discharge Summary in original / self a ested copies if
period for which no premium is received. the originals are submi ed with another insurer, if applicable.
If the Policy is not Renewed within the Grace Period then We may c. Final Hospital Bill in original / self a ested copies if the originals are
agree to issue a fresh policy subject to Our underwri ng criteria and submi ed with another insurer, if applicable.
no con nuing benefits shall be available from the expired Policy. d. Consulta on notes and / or inves ga on reports from outside the
If any Dependent Child has completed 21 years at the me of hospital prior to hospitaliza on.
Renewal, then such insured person will have to take a separate e. Copy of First Informa on Report (FIR) (if Cri Care being claimed for is
policy as he/she will no longer be eligible as Dependent Child, admissible in event of an Accident)
however the con nuity benefits will be passed on to the separate f. Copy of Medico Legal Cer ficate duly a ested by the concerned
policy taken by such Insured Person. hospital (if Cri Care being claimed for is admissible in event of an
There will not be any loading at the me of Renewal on individual Accident) if applicable
claims experience of the Insured Person. Renewal of the Policy will 2. For HospiCash:
not ordinarily be denied other than on grounds of moral hazard,
misrepresenta on or fraud or non-coopera on by You. a. Duly filled and signed claim form with KYC documents.
b. Final Hospital Discharge Summary in original / self a ested copies if
Please note: the originals are submi ed with another insurer.
c. Final Hospital Bill in original / self a ested copies if the originals are
1. Under Accident Care, specifically for the Policyholder’s Sum Insured submi ed with another insurer.
of 100 lacs and above, on the insured person a aining age 70 years,
d. Consulta on notes and / or inves ga on reports from outside the
the coverage would get reduced to a flat sum insured of Rs100 lacs
hospital prior to hospitaliza on.
from the date of next renewal of the Policy, irrespec ve of the
original sum insured e. Copy of First Informa on Report (FIR) / Panchnama (In case of
accidental injury) if applicable.
2. Accidental Temporary Total Disability benefit is available provided f. Copy of Medico Legal Cer ficate (In case of accidental injury) if
that life me limit of 100 weeks is not exhausted. applicable.
3. Accident Death
k. Renewal Benefits (For AccidentCare Cover only):
a. Duly filled and signed claim form and KYC documents
If the AccidentCare cover is renewed, the Sum Insured will be b. Copy of Death Cer ficate (issued by the office of Registrar of Births
increased by 5% of the Sum Insured (shown in the Schedule of and Deaths)
Insurance Cer ficate during the first Policy Year) for every claim free
Policy Period up to a cumula ve maximum of 25% of the Sum Insured c. Copy of First Informa on Report (FIR) / Panchnama
for all the applicable benefits other than Accident Temporary Total d. Copy of Medico Legal Cer ficate duly a ested by the concerned
Disability (TTD) and Accident Hospitaliza on men oned under the hospital, if applicable.
AccidentCare cover only. e. Copy of hospital record, if applicable

At the me of renewal in case of an insured person a aining 70 years f. Copy of Post Mortem report wherever applicable
of age, for Policyholder’s Sum Insured of more than 100 lacs, the 4. Accident Permanent Total Disability
Renewal Benefit will also be reduced in the same propor on of
a. Duly filled and signed claim form and KYC documents
reduc on in Sum Insured.

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


b. Hospital Discharge Summary (in original) / self a ested copies if the claims for HospiCash and Accident Hospitaliza on under AccidentCare
originals are submi ed with another insurer. are to be no fied to Us within 48 hours from the date of occurrence of the
c. Final Hospital Bill (in original) / self a ested copies if the originals are accident or hospitaliza on. All necessary documents shall be submi ed
submi ed with another insurer. within 30 days from the date of in ma on of the claim or date of
discharge, whichever is earlier. In case where the delay in in ma on is
d. Medical consulta ons and inves ga ons done from outside the
proved to be genuine and for reasons beyond the control of the Insured
hospital.
Person or Nominee specified in the Schedule of Insurance Cer ficate, We
e. Cer ficate of Disability issued by a Medical Board duly cons tuted by may condone such delay and process the claim, We reserve a right to
the Central and/or the State Government. decline such requests for claim process where there is no merit for a
f. Copy of First Informa on Report (FIR) / Panchnama if applicable delayed claim
g. Copy of Medico Legal Cer ficate duly a ested by the concerned
Upon acceptance of a claim, the payment of the amount due shall be
hospital, if applicable.
made within 30 days from the date of receipt of last necessary document.
5. Accident Permanent Par al Disability In the case of delay in payment, We shall be liable to pay interest at a rate
which is 2% above the bank rate prevalent at the beginning of the financial
a. Duly filled and signed claim form and KYC documents
year in which the claim is reviewed by it.
b. Hospital Discharge Summary (in original) / self a ested copies if the
originals are submi ed with another insurer. If You hold an indemnity policy with Us, a single No fica on for Claim will
c. Final Hospital Bill (in original) / self a ested copies if the originals are apply to both the indemnity plan as well as this Policy, even if the
submi ed with another insurer. No fica on for Claim for this Policy does not explicitly men on this. The
d. Medical consulta ons and inves ga ons done from outside the benefits under the indemnity plan will be paid out in accordance to the
hospital. terms and condi ons of the respec ve plan.
e. Cer ficate of Disability issued by a Medical Board duly cons tuted by
n. Altera on to the Policy
the Central and/or the State Government.
f. Copy of First Informa on Report (FIR) / Panchnama if applicable This Policy cons tutes the complete contract of insurance. Any change in
g. Copy of Medico Legal Cer ficate duly a ested by the concerned the Policy will only be evidenced by a wri en endorsement signed and
hospital, if applicable. stamped by Us. No one except Us can change or vary this Policy.

6. Temporary Total Disability o. Nominee


a. Duly filled and signed claim form and KYC documents
You are mandatorily required at the incep on of the Policy, to make a
b. Hospital Discharge Summary (in original) / self a ested copies if the
nomina on for the purpose of payment of claims, under the Policy in the
originals are submi ed with another insurer.
event of death.
c. Final Hospital bill (in original)/ self a ested copies if the originals are
submi ed with another insurer. i. Any change of nomina on shall be communicated to Us in wri ng
d. Copy of First Informa on Report (FIR) / Panchnama / Inquest report if and such change shall be effec ve only when an endorsement on the
applicable. Policy is made by Us.
e. Copy of Medico Legal Cer ficate duly a ested by the concerned
ii. In case of any Insured Person other than You under the Policy, for the
hospital if applicable.
purpose of payment of claims in the event of death, the default nominee
f. A endance record of employer / Cer ficate of employer confirming would be You.
period of absence if applicable
g. Disability cer ficate from trea ng doctor with seal and stamp. p. Obliga ons in case of a minor
h. Medical cer ficate and Fitness cer ficate with seal and stamp.
If an Insured Person is less than 18 years of age, You/adult Insured Person
7. Accident Hospitaliza on shall be completely responsible for ensuring compliance with all the
1. Duly filled and signed claim form and KYC documents terms and condi ons of this Policy on behalf of that minor Insured Person.

2. Hospital Discharge Summary (in original) / self a ested copies if the q. Customer Service and Grievances Reddressal:
originals are submi ed with another insurer.
3. Copy of First Informa on Report (FIR) / Panchnama / Inquest report i. In case of any query or complaint/grievance, You / Insured Person
if applicable may approach Our office at the following address:
4. Copy of Medico Legal Cer ficate duly a ested by the concerned Customer Services Department
hospital if applicable. Max Bupa Health Insurance Company Limited
5. Final Hospital bill with receipt /copies a ested by other insurer if the B-1/I-2, Mohan Coopera ve Industrial Estate
originals are submi ed with them. Mathura Road, New Delhi-11004
Contact No: 1860-3010-3333
6. Original bills with suppor ng prescrip ons and reports for Fax No.: 1800-3070-3333
inves ga ons done outside the hospital/ copies a ested by other Email ID: customercare@maxbupa.com
insurer if the originals are submi ed with them.
7. Original bills with suppor ng prescrip ons for medicines purchased ii. In case You/Insured Person are not sa sfied with the decision of the
from outside the hospital./ copies a ested by other insurer if the above office, or have not received any response within 10 days,
originals are submi ed with them. You/Insured Person may contact the following official for resolu on:

ii. We reserve the right to call for: Head – Customer Services


Max Bupa Health Insurance Company Limited
1. Any other necessary documenta on or informa on that We believe B-1/I-2, Mohan Coopera ve Industrial Estate
may be required; and Mathura Road, New Delhi-110044
Contact No: 1860-3010-3333
The claims for AccidentCare or Cri Care have to be no fied to Us within 30 Fax No.: 1800-3070-3333
days from the date of death or disability or diagnosis of the illness. The Email ID: customercare@maxbupa.com

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


iii. In case You/Insured Person are not sa sfied with Our (a) Legally married husband and wife as long as they con nue to be
decision/resolu on, You may approach the Insurance Ombudsman married; and
at the addresses given in Annexure I.
(b) Up to two of their Dependent Children as defined under Def 7(i).
iv. The complaint should be made in wri ng duly signed by the
ii) For the Cri Care Cover only means a unit comprising of upto 2
complainant or by his/her legal heirs with full details of the complaint
members who are related to each other in the following manner:
and the contact informa on of the complainant.
(a) Legally married husband and wife as long as they con nue to be
v. As per provision 13(3)of the Redressal of Public Grievances Rules
married.
1998,the complaint to the Ombudsman can be made
iii) For the HospiCash Benefit only means a unit comprising of up to
1. only if the grievance has been rejected by the Grievance Redressal four members who are related to each other in the following
Machinery of the Insurer; manner:

2. within a period of one year from the date of rejec on by the insurer; (a) Legally married husband and wife as long as they con nue to be
married; and
3. if it is not simultaneously under any li ga on.
(b) Up to their two Dependent Children as defined under Def7(ii).
5. Interpreta ons & Defini ons
Def. 10. Disclosure to Informa on Norm: The Policy shall be void and all
In this Policy the following words or phrases shall have the meanings premium paid hereon shall be forfeited to the Company, in the
a ributed to them wherever they appear in this Policy and for this event of mis-representa on, mis-descrip on or non-disclosure of
purpose the singular will be deemed to include the plural, the male any material fact.
gender includes the female where the context permits:
Def. 11. Grace Period means the specified period of me immediately
Def. 1. Accident or Accidental means a sudden, unforeseen and following the premium due date during which a payment can be
involuntary event caused by external visible and violent means. made to renew or con nue a Policy in force without loss of
con nuity benefits such as wai ng periods and coverage of Pre-
Def. 2. Alterna ve treatments: are forms of treatments other than exis ng Diseases. Coverage is not available for the period for
treatment “Allopathy” or “modern medicine” and includes which no premium is received.
Ayurveda, Unani, Sidha and Homeopathy in the Indian context.
Def. 12. Hospital means any ins tu on established for Inpa ent care and
Def. 3. Congenital Anomaly refers to a condi on (s) which is present Day Care Treatment of illness and / or injuries and which has been
since birth, and which is abnormal with reference to form, registered as a hospital with the local authori es under the
structure or posi on. Clinical Establishments (Registra on and Regula on) Act, 2010 or
i) Internal Congenital Anomaly : Congenital Anomaly which is not in under the enactments specified under the Schedule of Sec on
the visible and accessible parts of the body 56(1) of the said Act or complies with all minimum criteria as
under:
ii) External Congenital Anomaly: Congenital Anomaly which is in the
visible and accessible parts of the body. a) has qualified nursing staff under its employment round the clock;

Def. 4. Condi on Precedent shall mean a policy term or condi on upon b) has at least 10 inpa ent beds, in those towns having a popula on
which the Insurer's liability under the policy is condi onal upon. of less than 10,00,000 and atleast15 inpa ent beds in all other
places;
Def. 5. Contribu on is essen ally the right of an insurer to call upon
other insurers liable to the same insured to share the cost of an c) has qualified Medical Prac oner (s) in charge round the clock;
indemnity claim on a rateable propor on of Sum Insured. This d) has a fully equipped opera on theatre of its own where surgical
clause shall not apply to any benefit offered on fixed benefit basis. procedures are carried out
Def. 6. Cri cal Illnesses mean those illnesses or diseases of specified e) maintains daily records of pa ents and makes these accessible to
severity as specified in Subsec on 2.2 the insurance company’s authorized personnel.
Def. 7. Dependent Children Def. 13. Hospitalisa on or Hospitalised means the admission in a
i) For the AccidentCare Cover only means Your unmarried children Hospital for a minimum period of 24 Inpa ent Care consecu ve
aged between 2 years and 21 years at the me of first Policy with hours except for specified procedures/treatments, where such
Us, who are financially dependent on You and do not have their admission could be for a period of less than 24 consecu ve hours.
own independent households. Def. 14. Informa on Summary Sheet means the record and confirma on
ii) For the HospiCash Benefit only means Your unmarried children of informa on provided to Us or Our representa ves over the
aged between 1 day and 21 years at the me of first Policy with telephone for the purposes of applying for this Policy.
Us, who are financially dependent on You and do not have their Def. 15. Injury: Injury means accidental physical bodily harm excluding
own independent households income. illness or disease solely and directly caused by external, violent
Def. 8. Dismemberment means physical loss of a limb (arm, leg, hand) and visible and evident means which is verified and cer fied by a
and/or a significant sense such as sight due to an accident. Medical Prac oner.

Def. 9. Family: Def. 16. Inpa ent Care means treatment for which the insured person has
to stay in a Hospital for more than 24 hours for a covered event.
i) For the AccidentCare Cover only means a unit comprising of up to
four members who are related to each other in the following Def. 17. Intensive Care Unit means an iden fied sec on, ward or wing of a
manner: hospital which is under the constant supervision of a dedicated
Medical Prac oner(s), and which is specially equipped for the

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


con nuous monitoring and treatment of pa ents who are in a No fica on of Claim is the process of no fying a claim to the
cri cal condi on, or require life support facili es and where the insurer or TPA by specifying the melines as well as the address /
level of care and supervision is considerably more sophis cated telephone number to which it should be no fied.
and intensive than in the ordinary and other wards.
Def. 26. Off-label drug or treatment means “use of pharmaceu cal drug
Def. 18. Illness means sickness or a disease or pathological condi on for an unapproved indica on or in an unapproved age group,
leading to the impairment of normal physiological func on which dosage or route of administra on”.
manifests itself during the Policy Period and requires medical
treatment Def. 27. PermanentTotal Disability means disablement of the Insured
Person such that at least one of the following condi ons is
a) Acute Condi on-Acute condi on is a disease, illness or injury that sa sfied
is likely to respond quickly to treatment which aims to return the
person to his or her state of health immediately before suffering (a) Unable to Work
the disease/illness/injury which leads to full recovery. The Insured Person suffers an Injury and due to such Injury the
b) Chronic condi on – A chronic condi on is defined as a disease, Insured Person is unlikely to ever be able to engage in any occupa on
illness, or injury that has one or more of the following or employment or business for remunera on or profit.
characteris cs:- it needs ongoing or long-term monitoring (b) Loss of use of Limbs or Sight
through consulta ons, examina ons, check-ups, and/or tests- it
needs ongoing or long-term control or relief of symptoms –it The Insured Person suffers from total and irrecoverable loss of:
requires your rehabilita on or for you to be specifically trained to
cope with it- it con nues indefinitely – it comes back or is likely to i. The use of two Limbs (including paraplegia and hemiplegia) OR
come back.
ii. The sight of both eyes OR
Def. 19. Insured Person: means a person named as insured in the
iii. The use of one Limb and the sight of one eye
Schedule of Insurance Cer ficate including You.
(c) Loss of independent living
Def. 20. Limb: is/ are jointed appendages i.e an arm or leg with all its parts
i.e lower limb is the limb of the body extending from the gluteal The Insured Person is permanently unable to perform independently
region to the foot and upper limb is the limb of the body three or more of the following six ac vi es of daily living.
extending from the deltoid region to the hand
i. Washing: the ability to maintain an adequate level of cleanliness
Def. 21. Medical Advise means any consulta on or advice from a Medical and personal hygiene
Prac oner including the issue of any prescrip on or repeat
prescrip on. ii. Dressing: the ability to put on and take off all necessary garments,
ar ficial limbs or other surgical appliances that are Medically
Def. 22. Medical Expenses means those expenses that an Insured Person Necessary
has necessarily and actually incurred for medical treatment on
account of Illness or Accident on the advice of a Medical iii. Feeding: the ability to transfer food from a plate or bowl to the
Prac oner, as long as these are no more than would have been mouth once food has been prepared and made available
payable if the Insured Person had not been insured and no more
iv. Toile ng: the ability to manage bowel and bladder func on,
than other hospitals or doctors in the same locality would have
maintaining an adequate and socially acceptable level of hygiene
charged for the same medical treatment.
v. Mobility: the ability to move indoors from room to room on level
Def. 23. Medically Necessary: Medically necessary treatment is defined
surfaces at the normal place of residence
as any treatment, tests, medica on, or stay in Hospital or part of a
stay in Hospital which: vi. Transferring: the ability to move from a lying posi on in a bed to a
si ng posi on in an upright chair or wheel chair and vice versa.
a) is required for the medical management of the Illness or injury
suffered by the insured; Def. 28. Policy means these terms and condi ons, any annexure thereto
and the Schedule of Insurance Cer ficate (as amended from me
b) must not exceed the level of care necessary to provide safe,
to me), Your statements in the proposal form and the
adequate and appropriate medical care in scope, dura on, or
Informa on Summary Sheet and the policy wording (including
intensity;
endorsements, if any).
c) must have been prescribed by a Medical Prac oner;
Def. 29. Policy Period means the period between the date of
d) must conform to the professional standards widely accepted in commencement and the expiry date of the Policy as stated in the
interna onal medical prac ce or by the medical community in Schedule of Insurance Cer ficate.
India.
Def. 30. Policy Year means the period of one year commencing on the
Def. 24. Medical Prac oner: A Medical Prac oner is a person who date of commencement specified in the Schedule of Insurance
holds a valid registra on from the Medical Council of any State or Cer ficate or any anniversary thereof.
Medical Council of India or Council for Indian Medicine or for
Def. 31. "Portability" means the right accorded to an individual health
Homeopathy set up by the Government of India or a State
insurance policyholder (including family cover), to transfer the
Government and is thereby en tled to prac ce medicine within
credit gained for pre-exis ng condi ons and me bound
its jurisdic on; and is ac ng within the scope and jurisdic on of
exclusions, from one insurer to another or from one plan to
licence.
another plan of the same insurer.
Def. 25. Network Provider means hospitals or health care providers
Def. 32. Pre-exis ng Disease: Pre-Exis ng Disease means any condi on,
enlisted by an insurer or by a TPA and insurer together to provide
ailment or injury or related condi on(s) for which there were
medical services to an insured on payment by a cashless facility.
signs or symptoms, and / or were diagnosed, and / or for which

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


medical advice / treatment was received within 48 months prior
to the first policy issued by the insurer and renewed con nuously
therea er.

Def. 33. Product Benefits Table means the Product Benefits Table issued
by Us and accompanying this Policy and annexures thereto.

Def. 34. Qualified Nurse is a person who holds a valid registra on from
the Nursing Council of India or the Nursing Council of any state in
India.

Def. 35. Renewal defines the terms on which the contract of insurance
can be renewed on mutual consent with a provision of grace
period for trea ng the renewal con nuous for the purpose of all
wai ng periods.

Def. 36. Schedule of Insurance Cer ficate means the schedule provided
in the insurance cer ficate issued by Us, and, if more than one,
then the latest in me.

Def. 37. Subroga on shall mean the right of the insurer to assume the
rights of the insured person to recover expenses paid out under
the policy that may be recovered from any other source.

Def. 38. Sum Insured means the sum shown in the Schedule of Insurance
Cer ficate which represents Our maximum, total and cumula ve
liability for any and all claims under the Policy during the Policy
Year.

Def. 39. Surgery or Surgical Procedure means manual and / or opera ve


procedure (s) required for treatment of an illness or injury,
correc on of deformi es and defects, diagnosis and cure of
diseases, relief of suffering or prolonga on of life, performed in a
hospital or day care centre by a medical prac oner

Def. 40. Temporary Total Disability means a disability (other than a


psychological condi on) arising out of an Accident due to which
the Insured Person is unable to a end to his usual occupa on for
a dura on of not less than three (3) con nuous working days.

Def. 41. Unproven/Experimental treatment means treatment, including


drug experimental therapy, which is not based on established
medical prac ce in India, is treatment experimental or unproven.

Def. 42. We/Our/Us means Max Bupa Health Insurance Company


Limited.

Def. 43. You/Your/Policyholder means the person named in the Schedule


of Insurance Cer ficate.

Any reference to any statute shall be deemed to refer to any


replacement or amendment to that statute.

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


Product Benefit Table
Health Assurance - AccidentCare

Baseline Cover Benefits under AccidentCare


(1)
AccidentCare
For adults 18 to 65 years, and For dependent children 2 years to 21 years
Age at Entry (Maximum 2 children covered)

Policy Tenure 1 year, 2 years or 3 years


30/35/40/45/50/60/75/100/125/150/175/200/
Sum Insured (SI) - In Rs 5 to 25 Lacs (In multiples of 5 lacs)
225/250/275/ 300/350/400/450/500 lacs
For Individual: 100% of Sum Insured

For Family Option (individual limits):


Coverage Allocation Coverage for Self (policyholder) - 100% of Sum Insured
Coverage for Spouse - 50% of Sum Insured or Rs 10 lacs (whichever is lower)
Coverage for Children - 20% of Sum Insured or Rs 5 lacs (whichever is lower)

For Individual: 100% of allocated coverage

For Family Option :


Accident Death Self (policyholder) - 100% of allocated coverage
Spouse - 50% of allocated coverage or Rs 10 lacs (whichever is lower)
Children - 20% of allocated coverage or Rs 5 lacs (whichever is lower)
(2)
Accident Permanent Total Disability 125% of allocated coverage

Accident Permanent Partial Disability As per the grid mentioned herewith

(3) Minimum of 5% of Sum Insured or Rs Minimum of 5% of Sum Insured or Rs


Child Education Benefit 50,000 per child 500,000 per child
(4)
Funeral Expenses Rs 5,000 Rs 50,000

Sum Insured Multiple Sum Insured not to exceed 12/15 times of annual income for salaried/self-employed respectively

Notes:
Customers will have the flexibility to choose any/all of the benefits in any combination. Within each cover they will also have the
option of selecting any of the Sum Insured options.
References:
(1) AccidentCare benefit is renewable lifetime; For the Policyholder's Sum Insured of 100 lacs and above, on the insured person
attaining age 70 years, the coverage would get reduced to a flat sum insured of Rs 100 lacs from the date of next renewal of
the Policy, irrespective of the original sum insured
(2) Details shared in Terms and Conditions document
(3) Available (only under Family Option) in case of Death or Permanent Total Disability of Self. Benefit limited to maximum 2
children(insured under the policy)
(4) Available on Death of any of the Insured Person
Renewal Benefit:
If the AccidentCare cover is renewed, the Sum Insured will be increased by 5% of the Sum Insured (shown in the Schedule of Insurance
Certificate during the first Policy Year) for every claim free Policy Period up to a cumulative maximum of 25% of the Sum Insured for
all the applicable benefits other than Accident Temporary Total Disability (TTD) and Accident Hospitalization mentioned under the
AccidentCare cover only. At the time of renewal in case of an insured person attaining 70 years of age, for Policyholder’s Su I sured
of more than 100 lacs, the Renewal Benefit will also be reduced in the same proportion of reduction in Sum Insured.

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


Permanent Partial Disability Grid
S.No. Nature of Disability %ofallocatedcoverage
1 Loss or total and permanent loss of use of both the hands from the wrist joint 100%
2 Loss or total and permanent loss of use of both feet from the ankle joint 100%
Loss or total and permanent loss of use of one hand from the wrist joint and of one foot from the ankle joint
3 100%
Loss or total and permanent loss of use of one hand from the wrist joint and total and permanent loss of sight in one eye
4 100%
Loss or total and permanent loss of use of one foot from the ankle joint and total and permanent loss of sight in one eye
5 100%
6 Total and permanent loss of Speech and hearing in both ears 100%
7 Total and permanent loss of hearing in both ears 50%
8 Loss or total and permanent loss of use of one hand from wrist joint 50%
9 Loss or total and permanent loss of use of one foot from ankle joint 50%
10 Total and permanent loss of sight in one eye 50%
11 Total and permanent loss of speech 50%
12 Permanent total loss of use of four fingers and thumb of either hand 40%
13 Permanent total loss of use of four fingers of either hand 35%

14 Uniplegia 25%
15 Permanent total loss of use of one thumb of either hand
a. Both joints 25%
b. One joint 10%
16 Permanent total loss of use of finger of either hand
a. Three joints 10%
b. Two joints 8%
c. One joint 5%
17 Permanent total loss of use of toes of either foot
a. All Toes - One Foot 20%
b. Great Toe - Both Joints 5%
c. Great Toe - One Joint 2%
d. Other than Great Toe, One Toe 1%

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


Product Benefit Table
Health Assurance - AccidentCare
Optional Benefits
OptionalBenefitsunder AccidentCare

TTD Sum Insured – 1 lac to 20 lacs (in multiple of 50,000)


Temporary Total Disability (TTD)(5) TTD benefit - 1% of TTD Sum Insured payable per week. Such weekly payout shall be made for a
maximum of 100 weeks
(6) TTD Sum Insured not to exceed Lower of (2 times of Annual Income or AccidentCare Sum Insured)
TTD Sum Insured Multiple

Accident Hospitalisation limit


(confined to Indian territory only) Up to 2% of AccidentCare Sum Insured
Surgical Operations

Nursing Care Drugs and


Surgical Dressing
Medical Practitioner's/Surgeon's Fee

Room Rent
Covered up to the Accident Hospitalization limit. Claim settlement on reimbursement basis
Operation Theater Charges only and coverage limited to India only.

Anesthetics Fees (including administration), X-ray


examinations or treatments, including CT

Diagnostic Procedures and Therapies

Prosthetic Implants
(7)
Emergency Ambulance as a part of overall Sum Insured Limited to Rs 2,000/claim
(8)
Physiotherapy as a part of overall Sum Limited to 10% of Accidental Hospitalisation limit
Insured

Notes:
(5) The coverage under this benefit is limited to the Policyholder
(6) Annual Income for salaried individuals is actual cost to company excluding overtime, bonuses, tips, commissions, allowances special compensations, income from other
sources or any components of variable pay that the Policyholder may have otherwise been eligible to receive. For self-employed individuals, Annual Income is the
Gross Income as per Profit and Loss account statement and / or ITR.
(7) Ambulance charges for carrying insured from site of accident to hospital
(8) Physiotherapy means any form of the following: physical or mechanical therapy; diathermy; ultra-sonic therapy; heat treatment in any form; manipulation or massage
administered by a physician for treatment of injury.

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


Product Benefit Table
Health Assurance - CritiCare
Baseline Cover Benefits under CritiCare
CritiCare(9) (Coverage offered for 20 Critical Illnesses)
Age at Entry For adults 18 to 65 years

Sum Insured (SI) - In Rs. 3/5/7.5/10/15/20/25/30/35/40/45/50/60/75/100/125/150/175/200 lacs

Policy Tenure 1 year , 2 years or 3 years


For Individual: 100% of Sum Insured

For Family Option (on Floater basis):-


Coverage Allocation
Self (policyholder): 100% of Sum Insured
Spouse: 100% of Sum Insured

For Individual Option : Lumpsum equal to 100% of Sum Insured


Option 1 For Floater Option : Coverage for Self - 100% of Sum Insured
; Coverage for Spouse - 100% of Sum Insured ;
(In any policy year claim can be triggered for one life only)
For Individual Option : Lumpsum equal to 100% of Sum Insured + Staggered payout equal to
10% of Sum Insured p.a. subsequently as Income for 5 years
(10)
Option 2
For Floater Option : Lumpsum equal to 100% of Sum Insured + Staggered payout equal to 10%
of Sum Insured p.a. subsequently as Income for 5 years
(In any policy year, claim can be triggered for one life only)

Sum Insured Multiple Sum Insured not to exceed 12/15 times of annual income for salaried/self-employed respectively
Notes:
Customers will have the flexibility to chose any/all of the benefits in any combination. Within each cover they will also have the option of selecting any of the Sum Insured
options
References:
(9) -90 days initial waiting period and PED waiting period of 4 years
-Survival Period:- Standard 30 days for all conditions
-Lifetime renewability
(10) Claim settlement to be done on account transfer basis for all 5 years
Critical Illnesses Covered - 20 illnesses

1. Cancer 6. Kidney Failure 11. Multiple Sclerosis with 16. Aplastic Anemia
Persisting Symptoms
2. Myocardial Infarction (First Heart 7. Stroke 12. Third Degree Burns 17. Loss of Speech
Attack of specific severity)
3. Open Chest CABG 8. Major Organ or bone marrow transplant 13. Fulminant Viral Hepatitis 18. Deafness
4. Open Heart Replacement or Repair of 9. Permanent Paralysis of Limbs 14. End Stage Lung Disease 19. Muscular Dystrophy
Heart Valves
5. Coma 10. Motor Neuron disease 15. End Stage Liver Disease 20. Bacterial Meningitis

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


Product Benefit Table
Health Assurance - HospiCash
Baseline Cover Benefits under HospiCash
Hospital Cash Cover(11)

Age at Entry For adults : 18 years to 65 years, and


For dependant children : 1 day to 21 years

Policy Tenure 1 year, 2 years or 3 years

For Individual: 100% of Daily Cash benefit limit

Coverage Allocation For Family Option (Individual limits):


Adults (Self and/or Spouse): 100% of Daily Cash benefit limit
Children: 50% of Daily Cash benefit limit

Daily Cash Benefit


Rs. 1,000/ 2,000/ 3,000/ 4,000
(In Rs. per day per member)

ICU Cash Benefit Double the applicable daily cash benefit limit for hospitalisation in ICU up to a maximum of
(In Rs. per day per member) 7 days in a policy year

Notes:
Customers will have the flexibility to chose any/all of the benefits in any combination. Within each cover they will also have the option of selecting any of the Sum Insured
options.

References:
(11) Minimum 48 hrs of continuous hospitalisation required for hospital cash claim to become admissible.
- Payment made from day one subject to claim being admissible
- Maximum coverage offered for 45 days/policy year (including 7 days of ICU hospitalization)
- Hospital Cash cover is subject to 48 months waiting period for pre-existing conditions/diseases
- 24 month waiting period for specific illnesses and 30 day initial waiting period
- Lifetime renewability is offered under Hospital Cash

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17


Health Assurance Proposal Form
(URN: 002)

Please fill up this form in CAPITAL LETTERS for self and each proposed insured person. If you require additional space to answer any question on this Proposal
Form, please attach additional sheets of paper and indicate on the additional sheet the question number to which the information being provided pertains.

1. Proposer Details*

Title Mr. Name A MOHAN

Current Address DOOR NO29 BAR 1 FIRST CROSS SECOND MAIN RAM CHANDRAPURAM

Landmark City BENGALURU


District State Karnataka Pin Code 560021
Landline Mobile No. 09972966323
Email ID mohan.mohanssec@gmail.com PAN No.
(Mandatory for premium above Rupees 1 lac)
Nationality Indian Annual Income (Rs.) 600000 Teachers at various levels, Sales and

Bank Details:
Bank Name Branch
City Account No.
IFSC Code Account Type

Details of Electronic Insurance Account (eIA)

Do you wish to have this policy credited to an e-Insurance account? (Please select any one)

If Yes, Please share existing E-Insurance Account No.

Please select Insurance Repository Name (you have opened your account with)
Or
I do not have existing e-Insurance account and I am interested in creating a new e-Insurance account
(Please submit electronic insurance account opening form (eIA form) along with relevant documents).

*Proposer must be covered under the insurance policy and he/she must be more than 18 years of age.

2. Coverage Selection
Benefit Type (Please tick the relevant boxes. You can choose multiple benefits.)

Family Combinations : 1 Adult

AccidentCare# : Yes Sum Insured (Rs) 500000

Accident Temporary Total Disability (TTD) : No Sum Insured^ (Rs) 0

Accident Hospitalization : No

CritiCare# : No Sum Insured (Rs) 0

HospiCash : No Daily HospiCash Limit (Rs) 0

Policy Term : 1 Year


#
For AccidentCare and CritiCare: Maximum sum insured that can be opted would be up to 12 times of the annual income of the proposer if salaried or up to 15
times of the annual income of the proposer if self employed. AccidentCare would not be available to dependent children below 2 years. CritiCare would not be
available for dependent children.
For salaried individuals, annual income considered would be on Fixed CTC (Cost to Company excluding bonuses and commissions) basis.

^
Sum Insured for Total Temporary Disability (TTD) shall be between Rs. 1 lac to Rs. 20 lacs (in multiple of Rs, 50,000), however TTD Sum Insured cannot exceed
lower of 2 times of annual income or AccidentCare Sum Insured. Annual income is actual cost to company excluding overtime, bonuses, tips, commissions,
allowances, special compensations, income from other sources or any components of variable pay that the Primary Insured may have otherwise been eligible to
receive.

Product Name: Health Assurance Product UIN No.: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17.


3. Details of the Proposed Insured Person (s)

Name Date of Birth Height Weight Waistline


(DD/MM/YYYY) (Inch) (Kg) (Inch)
Insured No. 1

A MOHAN 23/04/1983 6'1 95 0

Gender Male Relationship Self Occupation: Teachers at various levels, Sales Education: Graduate Risk RC1
(M/F) with Proposer and Services - any designation Class*

* For risk class II, there will be a 50% loading on the premium. Applicable only in case of AccidentCare coverage basis the occupation of the Policyholder.

4. Nomination (for Primary Insured)

Nominee Name Date of Birth Relationship Address and Contact Details of Appointee Name (if nominee is less than
with Proposer Nominee 18 year of age)

NAGAVENI BAI 15/01/1985 Spouse DOOR NO29 BAR 1 FIRST CROSS


SECOND MAIN RAM
CHANDRAPURAM BENGALURU
Karnataka 560021 09742447176

Nominee Bank Details:

Bank Name Branch IFSC Code

City Account No. Account Type

5. Medical History

Section A: Medical Information


Insured No.(Please provide answer as
To be answered in case of CritiCare and/or HospiCash. I case only AccidentCare is opted, Yes/No against the applicant member)
Please answer Q1 only.
1 2 3 4

1 Are you in good health and/or not suffering from any mental/physical impairment and/or deformity and/or Yes
disablement since or after birth?

2 Have you been advised bed rest or hospitalization for more than 7 days for any symptom that have affected No
your daily activities?

3 Have you suffered or currently suffering from any discomfort/symptom for more than 5 days for which you No
have not taken any consultation or are planing to do so?

4 Have you ever been advised or currently on any treatment or medication on a daily basis lasting longer than 7 No
days or weekly or monthly basis?

5 Have you ever undergone or been advised any of the following investigations (other than routine health check No
up): TMT, angiography, echo cardiography, endoscopy, CT scan, MRI, FNAC, biopsy, etc.?

6 Have you ever undergone or planning to have any operation or surgery? No

7 Do you have hypertension and/or diabetes and /or high cholesterol and /or heart problem and /or thyroid No
disorder?

8 Have you ever been diagnosed with any form of cancer? Have you ever been advised to undergo any screening No
to rule out potential cancer diagnosis other than routine screening?

9 Have your ever consumed or currently consuming any tobacco related products like cigarette /gutkha-paan or No
alcohol or any other narcotics on a daily or a weekly basis lasting longer than a month?

To be answered in case of female life to be insured:


10 Are you currently pregnant and/or undergone/undergoing any form of fertility treatment and/or given birth by No
caesarean section?

Product Name: Health Assurance Product UIN No.: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17.


11 Have you ever had any gynecological complications associated with breast, menstrual cycle, conception and/or No
pregnancy and/or undergone PAP smear, mammogram other than routine examination?

Section B: (applicable only for CritiCare and/or HospiCash) Please provide details if Q1 is answered as 'No' and/or questions from Q2 to Q11 in Section A is/are
answered as 'Yes'.
Name and details of Illness/Medicine/Test/Surgery/Injury/Disability/Deformity/Impairment.

Insured Medical Type of Exact Diagnosis & Diagnosis Date of Details of Treatment/ Doctor & Hospital Name & Phone
Name Question No. Aliment Investigation Done Date Consultant History of Hospitalization No. and whether Hospitalized for it

(If you required additional space to answer any question on this proposal form, please attach additional sheets of paper and indicate on the additional sheet the
question number to which the information is being pertains.)

Section C:
1. Is the Insured Person / Proposer a Politically Exposed Person (PEP)# ? No
(if yes, kindly fill the PEP Questionnaire)

2. Do you have any history of conviction under any criminal proceedings in India and/or abroad? No

# PEP are individuals who are or have been entrusted with prominent public functions i.e. heads/ministers of central or state govt, senior politicians, senior govt,
judicial or military officials, senior executives of govt, companies, important party officials, immediate family member or above persons (would include spouse,
parents, children, spouse's parents or siblings and close associates of PEPs).

Section D: Family History* (applicable for CritiCare and HospiCash coverage)

Have your parents, brothers or sisters had cancer, diabetes, hypertension (high blood pressure), heart of kidney disease, polycstic kidney disease, mental or
nervous disorder (including alzheimer's disease), stoke, multiple sclerosis, motor neuron disease or any other hereditary disorders which is persistent / long in
nature ?

Insured Relationship with the Disease or Disorder Age Age at Cause of Death Age at Death
Name Proposer (if any) (if living) Onset (if applicable) (if applicable)

* To be provided for adult member only

6. Family Physician's Details

Family Physician's Name Contact No. 1 Contact No. 2

7. Existing Insurance Details

Are you or any person(s) proposed to be insured already insured under Health Insurance/Personal Accident Policy with Max Bupa Health Insurance Company
Limited or any other insurance Company.

If yes, since when have you been continuously insured

Insured Insurance Company Name Policy No. / Insured From To Sum Insured Claims Details
Name Application No. (Date) (Date) (if any)

Product Name: Health Assurance Product UIN No.: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17.


List of Generally Excluded Items in Hospitalisation Policy

Toiletries/Cosmetics/ Personal Comfort Or Convenience Item ELEMENTS OF ROOM CHARGE


Not Payable Not Payable
• Hair Removal Cream • Baby Charges (Unless Specified/Indicated) • Baby • Admission kit • Birth certificate • Blood reservation charges and antenatal
Food • Baby Utilites Charges • Baby Set • Baby Bottles • Brush • Cosy Towel booking charges • Certificate charges • Courier charges • Convenyance
• Hand Wash • M01stur1ser Paste Brush • Powder • Shoe Cover • Beauty charges • Diabetic chart charges • Documentation charges / Administrative
Services • Buds • Barber Charges • Caps • Cold Pack/Hot Pack • Carry Bags • expenses • Discharge procedure charges • Daily chart charges • Entrance
Cradle Charges • Comb • Eau-De-Cologne / Room Freshners • Eye Pad • Eye pass / visitors pass charges • File opening charges • Incidental expenses /
Sheild • Email / Internet Charges • Food Charges (Other Than Patient's Diet misc. charges (not explained) • Medical certificate • Maintenance charges •
Provided By Hospital) • Foot Cover • Gown • Laundry Charges • Mineral Medical records • Preparation Charges • Photocopies Charges • Patient
Water • Oil Charges • Sanitary Pad • Slippers • Telephone Charges • Tissue Identification Band / Name Tag • Washing Charges • Medicine Box • Medico
Paper • Tooth Paste • Tooth Brush • Guest Services • Bed Pan • Bed Under Legal Case Charges (MLC Charges) • IM IV Injection Charges (Part Of
Pad Charges • Camera Cover • Cliniplast • Curapore • Diaper Of Any Type • Nursing Charges, Not Payable) • Mortuary Charges (Payable Up To 24 Hrs,
Eyelet Collar • Face Mask • Flexi Mask • Gause Soft • Gauze • Hand Holder • Shifting Charges Not Payable) • Blanket/Warmer Blanket Administrative
Hansaplast/Adhesive Bandages • Infant Food • DVD, CD Charges (Not Or Non- Medical Charges (Not Payable- Part Of Room Charges) • Attendant
Payable ( However if CD is specifically sought by Insurer/TPA then payable) • Charges (Not Payable - Part Of Room Charges) • Clean Sheet (Part Of
Crepe Bandage (Not Payable/ Payable by the patient) Laundry/Housekeeping Not Payable Separately) • Luxury tax (Actual tax
levied by government is payable .Part of room charge for sub-limits) •
Payable
HVAC(Part of room charge not payable separately) • House keeping
• Razor • Disposables Razors Charges (for site preparations) • Leggings charges(Part of room charge not payable separately) • Service charges
(Essential in bariatric and varicose vein surgery and should be considered where nursing charge also charged (Part of room charge not payable
for these conditions where surgery itself is payable.) • Belts/ Braces separately) • Television & air conditioner charges (Payable under room
(Essential and may be paid specifically for cases who have undergone charges not if separately levied) • Surcharges (Part of room charge not
surgery of thoracic or lumbar spine.) • Slings (Reasonable costs for one sling payable separately) • Extra diet of patient (other than that which forms
in case of upper arm fractures should be considered) part of bed charge) (Patient Diet provided by hospital is payable) •
Expense related to prescription on discharge (To be claimed by patient
Items Specifically Excluded In The Policies
under Post Hosp where admissible)
Exclusion in policy unless otherwise specified
EXTERNAL DURABLE DEVICES
• Weight Control Programs/ Supplies/ Services • Cost Of Spectacles/
Contact Lenses/ Hearing Aids Etc. • Dental Treatment Expenses That Do Not
Not Payable
Require Hospitalisation • Hormone Replacement Therapy • Home Visit
Charges • Inferlity/ Subferlity/ Assisted Conception Procedure • Obesity
• Walking Aids Charges • Bipap Machine • Commode • CPAP/ CAPD
(Including Morbid Obesity) Treatment If Excluded In Policy • Psychiatric &
Equipments Device • Infusion Pump - Cost Device • Oxygen Cylinder (For
Psychosomatic Disorders • Corrective Surgery for refractive Error •
Usage Outside The Hospital) • Pulseoxymeter Charges Device • Spacer •
Treatment Of Sexually Transmitted Diseases • Donor Screening Charges •
Spirometre Device • SP0 2prob e • Nebulizer Kit • Steam Inhaler •
Admission/Registration Charges • Hospitalisation For Evaluation/
Armsling • Thermometer (Paid by patient) • Cervical Collar • Splint •
Diagnostic Purpose • Expenses For Investigation/ Treatment Irrelevant To
Diabetic Foot Wear • Knee Braces (Long/ Short/ Hinged)• Knee
The Disease For Which Admitted Or Diagnosed (Not payable - Immobilizer/Shoulder Immobilizer • Lumbosacral Belt (Essential and
Exclusion in policy unless otherwise specified)• Any expenses when should be paid specifically for cases who have undergone surgery of
the patient is diagnosed with retro virus + or suffering from /HIV/ AIDS lumbar spine)• Nimbus Bed Or Water Or Air Bed Charges (Payable for any
etc is detected/ directly or indirectly (Not payable as per HIV/AIDS ICU patient requiring more than 3 days in ICU, all patients with paraplegia
exclusion) • Stem Cell Implantation/ Surgery and storage (Not Payable /quadripiegia for any reason and at reasonable cost of approximately Rs
except Bone Marrow Transplantation where covered by policy) 200/ day )• Ambulance Collar • Ambulance Equipment • Microsheild •
Items Which Form Part Of Hospital Services Where Separate Consumables Abdominal Binder (Essential and should be paid in post surgery patients
Are Not Payable But The Service Is of major abdominal surgery including TAH, LSCS, incisional hernia repair,
exploratory laparotomy for intestinal liver transplant etc. obstruction)
Payable under OT Charges, not payable separately
Items Payable If Supported By A Prescription
• Ward And Theatre Booking Charges • Microscope Cover • Surgical Blades,
Harmonic Scalpel, Shaver • Surgical Drill • Eye Kit • Eye Drape • Boyles Payable when prescribed
Apparatus Charges • Arthroscopy & Endoscopy Instruments (Rental • Creams Powders Loons (Toiletries are not payable, only prescribed
charged by the hospital payable. Purchase of Instruments not payable.) • X- medical pharmaceuticals payable) • Digestion Gels • Listerine/ Antiseptic
RAY Film (Payable under Radiology Charge s, not as consumable) • Sputum Mouthwash • Lozenges • Mouth Paint • Novarapid • Volini Gel/ Analgesic
Cup (Payable under Investigation Charges, not as consumable) • Blood Gel • Zytee Gel • Betadine \ Hydrogen Peroxide\Spirit\Disinfectants Etc
Grouping And Cross Matching Of Donors Samples (Part of Cost of Blood, not (May be payable when prescribed for patient, not payable for hospital use in
payable) • Antiseptic or disinfectant lotions (Not Payable -Part of Dressing OT or ward or for dressings in hospital) • Private Nurses Charges- Special
Charges) • Band Aids, Bandages, Sterlile Injections, Needles,Syringes (Not Nursing Charges (Post hospitalization nursing charges not Payable) •
Payable -Part of Dressing Charges) • Cotton (Not Payable -Part of Dressing Nutrition Planning Charges - Dietician Chargesdiet Charges (Patient Diet
Charges) • Cotton Bandage (Not Payable -Part of Dressing Charges) • provided by hospital is payable) • Sugar Free Tablets (Payable -Sugar free
Micropore/ Surgical Tape (Not Payable-Payable by the patient when variants of admissible medicines are not excluded) • ECG Electrodes (Up to
prescribed , otherwise included as Dressing Charges) • Blade (Not Payable) 5 electrodes are required for every case visiting OT or ICU. For longer stay in
• Apron (Not Payable -Part of Hospital Services/Disposable linen to be part ICU, may require a change and at least one set every second day must be
of OT/ICU charges) • Torniquet (Not Payable (service is charged by hospitals, payable.) • Gloves Sterilized Gloves (payable /unsterilized gloves not
consumables cannot be separately charged)) • Orthobundle, Gynaec payable) • HIV KIT (Payable - payable Preoperative screening) •
Bundle (Part of Dressing Charges) • Urine Container (Not Payable) Nebulisation Kit (If used during hospitalization is payable reasonably) •
Vaccination Charges (Routine Vaccination not Payable / Post Bite
Vaccination Payable)
Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17
Part Of Hospital's Own Costs And Not Payable
Not Payable - Part of Hospital's internal Cost
• AHD • Alcohol Swabes • Scrub Solution/Sterillium
OTHERS
Not Payable
• Aesthetic Treatment / Surgery • TPA Charges • Visco Belt Charges • Any Kit
With No Details Mentioned [Delivery Kit, Orthokit, Recovery Kit, Etc] •
Examination Gloves • Kidney Tray • Mask • Ounce Glass • Oxygen Mask •
Paper Gloves • Referal Doctor's Fees • Pan Can • Sofnet • Trolly Cover •
Urometer, Urine Jug • Softvac • Vaccine Charges For Baby • Outstation
Consultant's/ Surgeon's Fees (Not payable, except for telemedicine
consultants w here covered by policy) • Pelvic Traction Belt (Should be
payable in case of PIVI) requiring traction as this is generally not r e u s e d )
• Accu Check (Glucometer y / S t r i p s ) ( N o t p a y a b l e pre-
hospitalisation or post hospitalisation / Reports and Charts required /
Device not payable) • Tegaderm / Vasofix Safety (Payable - maximum o f 3 in
48 hrs an d then 1 in 24 hrs) • Urine Bag P (Payable where medically
necessary till a reasonable cost - maximum 1 per 24 hrs) • Stockings
(Essential for case like CABG etc. where it should be paid.) • Ambulance

Health Assurance; UIN: IRDAI/HLT/MBHI/P-H/V.II/175/2016-17