ADITYA BIRLA HEALTH INSURANCE CO. LIMITED.
Group Activ Travel – Policy Terms and Conditions
Section A. PREAMBLE
This Policy has been issued on the basis of the Disclosure to Information Norm, including the information provided by You in respect of the Insured Persons in the Proposal Form, any application for insurance cover in respect of any Insured Person and any other information or details submitted in relation to the Proposal Form. This Policy is a contract of insurance between You and Us which is subject to the receipt of premium in full and accepted by Us in respect of the Insured Persons and the terms, conditions and exclusions as specified in the Policy Schedule/Certificate of Insurance/Product Benefit Table of this Policy.
The terms listed in Section D (Definitions) and which have been used elsewhere in the Policy shall have the meaning set out against them in Section D (Definitions), wherever they appear in the Policy.
Section B. BENEFITS UNDER THE POLICY
Benefit B.1. “Medical Cover” is an in-built Benefit and is available to all Insured Persons. The Certificate of Insurance will specify which of the Optional Benefits and Optional Extensions are in force for the Insured Person.
All Claims shall be payable subject to the terms, conditions and exclusions of the Policy and subject to availability of the Sum Insured. Our maximum, total and cumulative liability in respect of an Insured Person for any and all Claims arising under a Benefit/Optional Benefit during the Period of Insurance shall not exceed the benefit amount specified against the applicable Benefit/Optional Benefit in the Certificate of Insurance and subject always to the availability of the Sum Insured of the respective Benefit or Optional Benefit, as the case may be.
Claims made under this Policy will be paid on reimbursement basis only or as may be specifically provided for in the subsequent sections.
Coverage shall be restricted to the Geographical Scope in force for the Insured Person.
The Certificate of Insurance will specify the currency in which claims under the Benefit, Optional Benefits and Optional Extensions will be made.
Claim documents as specified in Section C.4.3 is applicable to each and every claim. Additional Claim documents related to specific Benefit / Optional Benefit / Optional Extension are mentioned against the respective Benefit/Optional Benefit/Optional Extension.
B.1. MEDICAL COVER
a) The Certificate of Insurance will specify whether Section B.1(a.1) applies to the Insured Person.
1. IN-PATIENT CARE WITH DAY/ CARE TREATMENT
If an Insured Person is diagnosed with an Illness or suffers an Injury whilst on a Trip during the Period of Insurance that solely and directly requires the Insured Person’s Hospitalization or the Insured Person to undergo any of the Day Care Treatments specified in Annexure – I at a Day Care Centre or Hospital, then We shall indemnify the Medical Expenses incurred on that Hospitalization or Day Care Treatment provided that:
- The Hospitalization is commenced and continued on the written advice of a Medical Practitioner;
- The treating Medical Practitioner certifies in writing that the treatment taken for that Illness or Injury is Medically Necessary Treatment;
- The treatment for the Illness or Injury commences during the Period of Insurance immediately and not exceeding 15 days following the diagnosis of the Illness or occurrence of the Injury.
For the purpose of this Benefit, ‘treatment’ shall be deemed to include only the following:
- In patient treatment in a local Hospital at the place the Insured Person is staying at the time of occurrence of an insured event or at the nearest suitable Hospital.
- Medical aid that is prescribed by a physician as necessary part of the treatment for broken limbs or injuries by the Insured Person (e.g. plaster casts, bandages and walking aids).
- Radiotherapy, heat therapy or phototherapy and other such treatment prescribed by a physician.
- X-Ray, and other diagnostic tests, provided these pertain to the diagnosed Illness/Injury due to which Hospitalization was deemed medically necessary.
- Cost of transportation, including necessary medical care en-route, by recognized emergency service providers/surface Ambulance for medical attention at the nearest Hospital or at the nearest available Physician.
- Lifesaving unforeseen emergency measures, or measures solely designed to relieve acute pain, provided to the Insured Person by medical practitioners.
B.44.OPTIONAL BENEFIT 43 – COVERAGE IN CITY OF RESIDENCE FOR MEDICAL COVER
Where this Benefit is specified in the Policy Schedule/Certificate of Insurance to be in force and applicable for the Insured Person, the scope of cover for Section B.1(a.1) shall be extended to the duration of transit within the City of Residence while commencing or concluding a Trip, provided that the Geographical Scope is restricted to India. In such case, the definition of Period of Insurance in Section D of the Policy shall stand amended to the limited extent specified in this Benefit.
2. GENERAL CONDITIONS
The following General Conditions shall be applicable to Benefit – ‘Medical Cover’, all Optional Benefits, Optional Extension and Specific Policy Terms & Conditions under the Policy.
C.2.1. The Insured Person’s cover under the Policy shall not attach to any journey that has already commenced prior to the Policy Period Start Date or prior to the commencement of the Insured Person’s cover under the Policy.
C.2.5. This product may be withdrawn / modified by Us after due approval from the IRDA of India. In case this product is withdrawn / modified by Us, this Policy can be extended under the then prevailing product or its nearest substitute filed with and approved by IRDA of India. We shall duly intimate You at least three months prior to the date of such withdrawal / modification of this product and the options available to You at the time of extension of this policy.
C.2.9. Cancellation / Termination – At Your request, the Certificate of Insurance shall be cancelled any time prior to the Period of Insurance End Date specified in the Certificate of Insurance subject to the following conditions:
(b) Cancellation of Certificate of Insurance, issued for a Single Trip, at a date earlier than the Period of Insurance End Date specified in Certificate of Insurance can be done only if the Insured Person returns to the Country of Residence/City of Residence before the Period of Insurance End Date.
Refund of premium shall only be applicable if the difference between the arrival date to the Country of Residence and the Certificate of Insurance End Date is at least 1 day. Premium refunded shall be the difference of the amount of premium paid for the original Period of Insurance and the premium applicable by taking the arrival date as the new Period of Insurance End Date.
(d) No refund of premium shall be eligible in case of cancellation of this Certificate of Insurance where a Claim has been incurred/ registered. We shall have no liability to make payment of any claims which are incurred post cancellation of the Certificate of Insurance.
3. PERMANENT EXCLUSIONS (applicable to Benefit – ‘Medical Cover’, all Optional Benefits & Optional Extensions)
Any Claim in respect of any Insured Person for, arising out of or directly or indirectly due to any of the following
shall not be admissible unless expressly stated to the contrary elsewhere in the Policy terms and conditions:
(a) Any condition or treatment as specified in Annexure – II.
(b) Treatment in any Hospital or by any Medical Practitioner or any other provider of services that We have blacklisted as listed on Our website www.adityabirlacapital.com/healthinsurance
(c) Any events occurring outside the Period of Insurance except for a Claim for Trip Cancellation under Optional Benefit 12.
(d) The Insured Person:
(i) traveling against the advice of a Medical Practitioner; or
(ii) receiving medical treatment (or has planned to receive during the Policy Term for an existing illness/ diagnose/ condition); or
(iii) travelling for the purpose of obtaining medical treatment; or
(iv) taking part or is supposed to participate in a naval, military or air force operation or war like or peace keeping operation.
(v) traveling to any country for which his/her visa is not allotted.
(e) An act of self-destruction or self-inflicted Injury, attempted suicide or suicide while sane or insane.
(f) Any Illness or Injury directly or indirectly resulting or arising from or occurring during the commission of any breach of any law by the Insured Person with any criminal intent.
(g) Any condition directly or indirectly caused by or associated with any sexually transmitted disease, including Genital Warts, Syphilis, Gonorrhoea, Genital Herpes, Chlamydia, Pubic Lice and Trichomoniasis, Acquired Immuno Deficiency Syndrome (AIDS) whether or not arising out of HIV, Human T-Cell Lymphotropic Virus Type III (HTLV–III or IITLB-III) or Lymphadinopathy Associated Virus (LAV) or the mutants derivative or Variations Deficiency Syndrome or any Syndrome or condition of a similar kind.
(h) Any treatment arising from or traceable to pregnancy (including voluntary termination), miscarriage (unless due to an Accident), childbirth, maternity (including caesarean section), abortion or complications of any of these. This exclusion shall not apply to ectopic pregnancy, which is proved by diagnostic means and certification
by a gynaecologist that it is life threatening.
(i) Any treatment arising from or traceable to any fertility, infertility, sub fertility or assisted conception procedure or sterilization or procedure, birth control procedures, hormone replacement therapy, contraceptive supplies or services including complications arising due to supplying services or Assisted Reproductive Technology.
(j) Any treatment or surgery for any dental Illness or Injury.
(k) Treatment taken from anyone who is not a Medical Practitioner or from a Medical Practitioner who is practicing outside the discipline for which he is licensed or any kind of self-medication.
(l) Charges incurred in connection with cost of spectacles and contact lenses, hearing aids, routine eye and ear examinations, laser surgery for correction of refractory errors, dentures, artificial teeth and all other similar external appliances and or devices whether for
diagnosis or treatment.
(m) Unproven / Experimental Treatment which are not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any Illness for which confinement is required at a Hospital. Any Illness or treatment which is a result or a consequence of undergoing such experimental or unproven treatment.
(n) Any expenses incurred on prosthesis, corrective devices, external durable medical equipment of any kind, like wheelchairs, walker, belts, collar, caps, splints, braces, stockings of any kind, diabetic footwear, glucometer or thermometer, crutches, ambulatory devices, instruments used in treatment of sleep apnea syndrome (C.P.A.P) or continuous ambulatory peritoneal dialysis (C.A.P.D.) and oxygen concentrator for asthmatic condition, cost of cochlear implants.
(o) Weight management services and treatment, vitamins and tonics related to weight control programmers, services and supplies including treatment of obesity (including morbid obesity).
(p) Any treatment related to sleep disorder or sleep apnea syndrome, general debility convalescence, cure, rest cure, health hydros, nature cure clinics, sanatorium treatment, rehabilitation measures, private duty nursing, respite care, long-term nursing care, custodial care or any treatment in an establishment that is not a Hospital.
(q) Treatment of all external Congenital Anomalies or Illness or defects or anomalies or treatment relating to external birth defects.
(r) Treatment of mental Illness, stress, psychiatric or psychological disorders.
(s) Aesthetic treatment, cosmetic surgery and plastic surgery or related treatment of any description, including any complication arising from these treatments, other than as may be necessitated due to an Injury.
(t) Any treatment or surgery for change of sex or gender reassignments including any complication arising from
(u) Circumcision unless necessary for treatment of an Illness or as may be necessitated due to an Accident.
(v) All preventive care, vaccination, including inoculation and immunizations (except in case of post-bite treatment), vitamins and tonics.
(w) Artificial life maintenance, including life support machine used to sustain a person, who has been declared brain dead, or is demonstrating any of the following conditions :
1. Deep coma and unresponsiveness to all forms of stimulation; or
2. Absent pupillary light reaction; or
3. Absent oculovestibular and corneal reflexes; or
4. Complete apnea.
(x) All expenses related to donor screening, treatment, including surgery to remove organs from the donor, in case of transplant surgery.
(y) Non-allopathic treatment.
(z) Illness or Injury attributable to the consumption, use, misuse or abuse of tobacco, intoxicating drugs or alcohol.
(aa) Charges incurred at a Hospital primarily for diagnostic, X-ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any Illness or Injury, for which in-patient care or a day care procedure is required.
(bb)War (whether declared or not) and war like occurrence or invasion, acts of foreign enemies, hostilities, civil
war, rebellion, revolutions, insurrections, mutiny, military or usurped power, seizure, capture, arrest, restraints and detainment of all kinds.
(cc) Stem cell implantation, harvesting, storage or any kind of treatment using stem cells.
(dd)Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from or from any other cause or event contributing concurrently or in any other sequence to the loss, claim or expense. For the purpose of this exclusion:
(i) Nuclear attack or weapons means the use of any nuclear weapon or device or waste or combustion of nuclear fuel or the emission, discharge, dispersal, release or escape of fissile or fusion material emitting a level of radioactivity capable of causing any Illness, incapacitating disablement or death.
(ii) Chemical attack or weapons means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing any Illness, incapacitating disablement or death.
(iii) Biological attack or weapons means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organisms and/or biologically produced toxins (including genetically modified organisms and chemically synthesized toxins) which are capable of causing any Illness, incapacitating disablement or death.
In addition to the foregoing, any loss, claim or expense of whatsoever nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection with any action taken in controlling, preventing, suppressing, minimizing or in any way relating to the above is also excluded.
(ee) Impairment of an Insured Person’s intellectual faculties by abuse of stimulants or depressants.
(ff) Any sporting activities in so far as they involve the training or participation in competitions of professional or semi-professional sports persons.
(gg) Any Claim relating to Adventure Sports.
(hh) Any Medical Expenses or other expenses which are not Reasonable and Customary Charges.
(ii) Any procedure or diagnostic test for gender detection of foetus/unborn child.
4. CLAIM INTIMATION, ASSESSMENT AND MANAGEMENT
Upon the occurrence of any event, Illness or Injury that may give rise to a Claim under this Policy, then as a Condition Precedent to Our liability under the Policy, You or Insured Person (or the Nominee or legal heir if the Insured Person is deceased) shall undertake all the following in addition to any specific requirements specified within the Benefit/Optional Benefit/Optional Extension under which the Claim is made:
4.1. Claims Intimation
(a) If any Illness is diagnosed or discovered or any Injury is suffered or any other contingency occurs which has resulted in a Claim or may result in a Claim under the Policy, You or Insured Person (or the Nominee or legal heir if the Insured Person is deceased), shall notify Us either at Our call center or in writing immediately and in any event within the timeframe (if any) specified in the Benefit/Optional Benefit under which the Claim is made.
(b) It is agreed and understood that the following details are to be provided to Us at the time of intimation of the Claim:
(i) Policy Number and Certificate of Insurance;
(ii) Claimant’s Name;
(iii) Name of the Insured Person in respect of whom the Claim is being made;
(iv) Nature of Illness or Injury or contingency for which Claim is being made and the Benefit and/or Optional Benefit and/or Optional Extension under which the Claim is being made;
(v) Date of admission to Hospital or loss;
(vi) Name and address of the attending Medical Practitioner and Hospital (if applicable);
(vii) Any other information, documentation or details requested by Us or the Assistance Service Provider.
(c) Any event that may give rise to a Claim under a Hospitalization benefit has to be notified to Us or the Assistance Service Provider, within 48 hours of Hospitalization or before discharge (whichever is earlier). However, We shall examine and relax the timeframe specified for Claim intimation depending upon whether the reasons for delay are beyond the control of the claimant.
4.2. Claims Procedure
(i) It is agreed and understood that in all cases where intimation of a Claim has been provided under this provision, all the information and documentation specified against the Benefit / Optional Benefit and Section C. 4.3 below shall be submitted (at the Insured Person’s expense) to us immediately and in any event within 30 days of Insured Person’s discharge from Hospital or completion of treatment or date of loss, whichever is later.
4.3. Claim Documentation
You or Insured Person (or Nominee or legal heir if the Insured Person is deceased) shall (at his/her expense) give the documentation specified below and any additional information or documentation specified in the Benefit and/or Optional Benefit and/or Optional Extension under which the Claim is being made to Us or the Assistance Service Provider immediately and in any event within 30 days of the occurrence of the Injury/Illness or treatment or loss.
(i) Duly completed and signed Claim form, in original;
(ii) Copy of first and last page of passport copy with entry/exit stamp;
(iii) Any other document as required by Us or Assistance Service Provider;
(iv) Additional documents as specified for each Benefit.
(v) Original pathological or diagnostic reports, discharge summary, Day Care summary, indoor case papers and prescriptions issued by the treating Medical Practitioner or Hospital as applicable.
(vi) Copy of e-ticket / boarding pass.
(vii) NEFT / banking details along with cancelled cheque copy for Insured Person / Nominee (where applicable) with pre-printed name; if name is not pre-printed please provide copy of bank passbook / bank statement.
Note: All invoices and bills should be in Insured Person’s name or as per the documents mentioned in the respective Benefit/Optional Benefits. Depending on the nature of the Claim, treatment undertaken or illness, there would be a possibility of seeking more information / document from the Claimant concerned without prejudice to his interest and the same shall be requested by any means of recognized communication channels. However, claims filed even beyond the timelines mentioned above will be considered if there are valid reasons for the delay.
4.4. Policyholder’s or Insured Person’s or Claimant’s duty at the time of Claim
It is agreed and understood that as a Condition Precedent to Our liability in respect of a Claim to be considered under this Policy:
(a) All reasonable steps and measures must be taken to avoid or minimize the quantum of any Claim that may be made under this Policy.
(b) The Insured Person shall follow the directions, advice or guidance provided by a Medical Practitioner and We shall not be obliged to make payment that is brought about or contributed to by the Insured Person failing to follow such directions, advice or guidance.
(c) Intimation of the Claim, notification of the Claim and submission or provision of all information and documentation shall be made promptly and in any event in accordance with the procedures and within the timeframes specified in Section C.4 of the Policy and the specific procedures and timeframes specified under the respective Benefit or Optional Benefit or Optional Extension under which the Claim is being made.
(d) The Insured Person shall, at Our request and at Our cost and expense, submit himself / herself for a medical examination by Our/Assistance Service Provider’s nominated Medical Practitioner as often as We consider reasonable and necessary.
(e) We/Assistance Service Provider’s Medical Practitioner and representatives shall be given access and co-operation to inspect the Insured Person’s medical and Hospitalization records and to investigate the facts and examine the Insured Person.
(f) We shall be provided with complete documentation and information which We have requested to establish Our liability for the Claim, its circumstances and its quantum.
(g) Report any information/document which helps the insurance system to eliminate bad practices in the market.
4.5. Claim Assessment
(a) All admissible Claims under this Policy shall be assessed by Us in the following progressive order:
i. If the provisions of the Contribution Section in Section C.13 are applicable, Our liability to make payment under that Claim shall first be apportioned accordingly.
ii. If any sub-limits on Medical Expenses are applicable in accordance with Section B.1 (b) (xi), Our liability to make payment shall be limited to such extent as applicable.
iii. The Deductible shall be applied to each Claim that is either paid or payable (and not excluded), under this Policy. Our liability to make payment shall commence only once the amount of the Claim payable or paid exceeds the Deductible.
iv. Co-payment shall be applicable on the amount payable by Us after applying Section C.4.5(a) (i), (ii) and (iii).
4.6. Payment terms
(a) We may change the Assistance Service Provider or utilize the service of any other assistance service provider by giving written notification to You.
(b)The obligation of the Company to make payments to the Insured Person in respect of claims made shall be to make payment in Indian Rupees and after the Insured Person’s return to India only. For all admissible Claims, the exchange rate as follows shall be applied:
- Reimbursement (indemnity) – Date of Invoice
- Fixed Benefit – Date of occurrence of insured event.
(c) If the Assistance Service Provider or We request that bills or vouchers in a local language or vernacular be accompanied by an appropriate translation into English then the costs of such translation must be borne by You or the Insured Person.
(d) The Sum Insured of the Insured Person shall be reduced by the amount payable or paid under the Policy Terms and Conditions or any Benefit / Optional Benefit / Optional Extension applicable under this Policy and only the balance amount shall be available as the Sum Insured for the unexpired Period of Insurance for the Insured Person.
(e) We shall have no liability to make payment of a Claim under the Policy in respect of an Insured Person, once the Sum Insured for that Insured Person is exhausted or if the benefit amount under the applicable Benefit/Optional Benefit/Optional Extension as specified in the Policy Schedule/Certificate of Insurance is exhausted.
(f) If the Insured Person suffers a relapse within 45 days of the date of discharge from the Hospital for which a Claim has been made, then such relapse shall be deemed to be part of the same Claim and all the limits for Any One Illness under this Policy shall be applied as if they were under a single Claim.
(g) For Cashless Facility Claims, the payment shall be made to the Network Provider whose discharge would be complete and final.
(h) For the reimbursement Claims, We shall pay to the Insured Person unless specified otherwise in the Certificate of Insurance. In the event of death of the Insured Person, unless specified otherwise in the Certificate of Insurance, We shall pay to the Nominee (as named in the Certificate of Insurance) and in case of no Nominee to the legal heir of the Insured Person whose discharge shall be treated as full and final discharge of its liability under the Policy.
(i) All claims will be investigated (as required) and settled or rejected in accordance with the applicable regulatory guidelines, including the IRDAI (Protection of Policyholders Interests) Regulations, 2017. We shall settle or reject any Claim under the Policy within 30 days of receipt of the last necessary document/ information as required for settlement of such Claim and sought by Us. In case there is delay in the payment of any claim that has been admitted as payable by Us under the Policy, beyond the time period as prescribed under IRDAI (Protection of Policyholders Interests) Regulations, 2017, We shall pay additional amount as interest at a rate which is 2% above the bank rate prevalent at the beginning of the financial year in which the claim has fallen due. For the purpose of this clause, ‘bank rate’ shall mean the existing bank rate as notified by Reserve Bank of India, unless the extant regulation requires payment based on some other prescribed interest rate.
(j) No loading based on individual claim experience shall be applicable on Renewal premium payable in case of Annual Trip cover.
5. Disclosure to Information Norm
If any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-disclosure of any material particulars or any material information having been withheld, or if a Claim is fraudulently made or any fraudulent means or devices are used by You, the Insured Person or any one acting on his or their behalf, We shall have no liability to make payment of any Claims and the premium paid shall be forfeited to Us on cancellation of the Policy.
6. Observance of Terms and Conditions
The due observance and fulfilment of the terms and conditions of this Policy (including the realization of premium by their respective due dates and compliance with the specified procedure on all Claims) in so far as they relate to anything to be done or complied with by You or any Insured Person, shall be Condition Precedent to Our liability under the Policy.
7. Reasonable Care
Insured Persons shall take all reasonable steps to safeguard the interests against any Illness or Injury or any other loss that may give rise to a Claim.
8. Material Change
It is a Condition Precedent to Our liability under the Policy that You shall immediately and in any case within 7 days notify Us in writing of any material change in the risk on account of change in occupation or business of the Insured Person at its own expense, as per Annexure -III. We may adjust the scope of cover and / or the premium paid or payable, accordingly.
9. Records to be maintained
You and Insured Person shall keep an accurate record containing all relevant medical records and shall allow Us or Our representatives to inspect such records. You or Insured Person shall furnish such information as We may require under this Policy at any time during the Policy Period or until final adjustment (if any) and resolution of all Claims under this Policy.
10. No constructive Notice
Any knowledge or information of any circumstance or condition in relation to You or Insured Person which is in possession of Us other than that information expressly disclosed in the Proposal Form or otherwise in writing to Us, shall not be held to be binding or prejudicially affect Us.
11. Complete Discharge
Payment made by Us to the Insured Person or the Nominee or the legal heir or representative of the Insured Person, as the case may be, under the Policy shall in all cases be complete and construe as an effectual discharge in favor of Us.
You and Insured Person shall at his/her own expense do or concur in doing or permit to be done all such acts and things that may be necessary or reasonably required by Us for the purpose of enforcing and / or securing any civil or criminal rights and remedies or obtaining relief or indemnity from any other party to which We are or would become entitled upon Us paying for a Claim under this Policy, whether such acts or things shall be or become necessary or required before or after its payment. Neither You nor any Insured Person shall prejudice these subrogation rights in any manner and shall at his/er own expense provide Us with whatever assistance or cooperation is required to enforce such rights. This clause shall not apply to any Benefit or Optional Benefit or Optional Extension offered on a fixed benefit basis.
(a) In case any Insured Person is covered under more than one indemnity insurance policies, with Us or with other insurers, You/Insured Person shall have the right to settle the Claim with any of Us, provided that the Claim amount payable is up to the sum insured of such Policy.
(b) In case the Claim amount under a single policy exceeds the Sum Insured after considering the deductible or co-payment, then the Insured Person shall have the right to choose the companies with whom the Claim is to be settled.
This clause shall not apply to any Benefit or Optional Benefit or Optional Extension offered on a fixed benefit basis.
14. Policy Disputes
Any and all disputes or differences under or in relation to the validity, construction, interpretation and effect to this Policy shall be determined by the Indian Courts and in accordance with Indian law.
15. Cancellation / Termination
We may at any time, cancel this Policy on grounds as specified in Section C.5 and We shall have no liability to make payment of any claims and the premium paid shall be forfeited, by giving 15 days’ notice in writing by Registered Post Acknowledgment Due / recorded delivery to You at Your last known address.
(a) Any communication meant for Us must be in writing and be delivered to Our address shown in the Policy Schedule/Certificate of Insurance. Any communication meant for You or the Insured Person shall be sent by Us to Your last known address or the address as shown in the Policy Schedule/Certificate of Insurance (as applicable).
(b) All notifications and declarations for Us must be in writing and sent to the address specified in the Policy Schedule/ Certificate of Insurance. Agents are not authorized to receive notices and declarations on Our behalf.
(c) Notice and instructions shall be deemed served 10 days after posting or immediately upon receipt in the case of hand delivery, facsimile or e-mail.
17. Alterations in the Policy
This Policy constitutes the complete contract of insurance. No change or alteration shall be valid or effective unless approved in writing by Us, which approval shall be evidenced by a written endorsement signed and stamped by Us.
18. Cause of Action
No Claims shall be payable under this Policy unless the event or occurrence giving rise to the Claim occurs in the Geographical Scope specified in the Certificate of Insurance.
19. Overriding effect of Policy Schedule / Certificate of Insurance
In case of any inconsistency in the terms and conditions in this Policy vis-a-vis the information contained in the Policy Schedule and/or Certificate of Insurance, the information contained in the Policy Schedule or Certificate of Insurance shall prevail.
20. Electronic Transactions
You and Insured Person agrees to adhere to and comply with all such terms and conditions as We may prescribe from time to time, and hereby agrees and confirms that all transactions effected by or through facilities for conducting remote transactions including the Internet, World Wide Web, electronic data interchange, call centers, tele-service operations (whether voice, video, data or combination thereof) or by means of electronic, computer, automated machines network or through other means of telecommunication, established by or on behalf of Us, for and in respect of the Policy or its terms, or Our other products and services, shall constitute legally binding and valid transactions when done in adherence to and in compliance with the Our terms and conditions for such facilities, as may be prescribed from time to time.
In case of a grievance, the Insured Person/ You can contact Us with the details through:
Our website: adityabirlahealth.com/healthinsurance
Toll Free: 1800 270 7000
Address: Aditya Birla Health Insurance Co. Limited
10th Floor, Rtech, Nirlon IT park, Western Express highway,
Goregaon East, Mumbai – 400063
For senior citizens, please contact Our respective branch office or call at 1800 103 1033 or write an e- mail at email@example.com
The Insured Person/You can also walk-in and approach the grievance cell at any of Our branches. If in case the Insured Person/You is not satisfied with the response then they can contact Our Head of Customer Service at the following email firstname.lastname@example.org.
If the Insured Person/You is not satisfied with Our redressal, he/she may use the Integrated Grievance Management Services (IGMS). For registration in IGMS please visit IRDAI website www.irda.gov.in
If the Insured Person/You are still not satisfied, he/she may approach the nearest Insurance Ombudsman. The contact details of the Ombudsman offices are provided on Our website and in this Policy at Annexure A
Section D. DEFINITIONS
The terms and conditions, benefits, exclusions, various procedures and conditions which have been built in to the Policy are to be construed in accordance with the applicable provisions contained in the Policy. The terms defined below have the meanings ascribed to them wherever they appear in this Policy and, where appropriate, references to the singular include references to the plural; references to the male include the female and references to any statutory enactment include subsequent changes to the same and vice versa.
1. Accident is a sudden, unforeseen and involuntary event caused by external, visible and violent means;
2. Adventure Sports shall mean any sport or activity, which is potentially dangerous to the Insured Person whether he is trained or not. Such sport/activity includes racing and competitions, stunt activities of any kind, adventure racing, base jumping, blathlon, big game hunting, black water rafting, BMX stunt/ obstacle riding, bobsleighing/ using skeletons, bouldering, boxing, canyoning, caving/ pot holing, cave tubing, rock climbing/ trekking/ mountaineering, cycle racing, cyclo cross, drag racing, endurance testing, hand gliding, harness racing, hell skiing, high diving (above 5 meters), hunting, ice hockey, ice speedway, jousting, judo, karate, kendo, lugging, risky manual labor, marathon running, martial arts, micro – lighting, modern pentathlon, motor cycle racing, motor rallying, parachuting, paragliding/ parapenting, piloting aircraft, polo, power lifting, power boat racing, quad biking, river boarding, scuba diving, river bugging, rodeo, roller hockey, rugby, ski acrobatics, ski doo ski jumping, ski racing, sky diving, small bore target shooting, speed trials/ time trials, triathlon, water ski jumping, weight lifting, wrestling and activities of similar nature;
3. Age means the completed age of the Insured Person on his last birthday;
4. Ambulance means a road vehicle or aircraft operated by a licensed / authorized service provider only and equipped for the transport and paramedical treatment of the person requiring medical attention;
5. Annual Multi Trip Cover means a cover under the Policy under which there can be more than one Period of Insurance for the Insured Person during the Policy Period, subject to the maximum trip duration (per trip) specified on the Policy Schedule/ Certificate of Insurance or as opted;
6. Any one Illness means a continuous period of illness and it includes relapse within 45 days from the date of last consultation with the Hospital / Nursing Home where the treatment may have been taken;
7. Assistance Service Provider means the service provider specified in the Policy Schedule and/or Certificate of Insurance, appointed by Us from time to time;
8. Cashless facility means a facility extended by the insurer to the insured where the payments, of the costs of treatment undergone by the insured in accordance with the policy terms and conditions, are directly made to the network provider by the insurer to the extent pre-authorization approved;
9. Certificate of Insurance means the certificate We issue to an Insured Person evidencing cover under the Policy;
10. Checked-In Baggage means the baggage (luggage and personal possessions belonging to or in the lawful custody of the Insured Person) offered by the Insured Person and accepted for custody by a Common Carrier for transportation in the same Common Carrier in which the Insured Person is travelling and for which the Common Carrier has provided a baggage receipt, and the contents of the baggage checked-in by the Insured Person as long as such contents do not violate any policy or rule restricting the nature of items that may be carried on board. This shall exclude all the items that are carried/ transported under a contract of affreightment;
11. City of Residence means and includes any city, town or village in which the Insured Person is currently residing in India and as specified in the Insured Person’s corresponding address in the Policy Schedule/Certificate of Insurance;
12. Claim means a demand made in accordance with the terms and conditions of the Policy for payment under a Benefit or Optional Benefit or Optional Extension in respect of an Insured Person;
13. Company (also referred as We/Us/Our) means the Aditya Birla Health Insurance Company Limited;
14. Common Carrier means any civilian land or water conveyance or scheduled aircraft operated under a valid license for the transportation of fare paying passengers under a valid ticket;
15. Condition Precedent means a policy term or condition upon which the Insurer’s liability under the policy is conditional upon;
16. Congenital Anomaly refers to a condition(s) which is present since birth, and which is abnormal with reference to form, structure or position.
a) Internal Congenital Anomaly
Congenital anomaly which is not in the visible and accessible parts of the body
b) External Congenital Anomaly
Congenital anomaly which is in the visible and accessible parts of the body;
17. Co-payment is a cost-sharing requirement under a health insurance policy that provides that the policyholder/insured shall bear a specified percentage of the admissible claim amount. A co-payment does not
reduce the sum insured;
18. Country of Residence means the country in which the Insured Person is currently residing and as specified in the Insured Person’s corresponding address as specified in the Policy Schedule or Certificate of Insurance, which for the purpose of this Policy shall be India;
19. Damages means sums payable following judgments or awards but shall not include fines, penalties, punitive damages, exemplary damages, any non-pecuniary relief, or any other amount for which an Insured Person is not financially liable, or which is without legal recourse to the Insured Person, or any matter that may be deemed to be uninsurable under Indian Law;
20. Day Care Centre means any institution established for day care treatment of illness and/or injuries or a medical setup within a Hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified Medical Practitioner AND must comply with all minimum criteria as under—
a) has qualified nursing staff under its employment;
b) has qualified Medical Practitioner/s in charge;
c) has a fully equipped operation theatre of its own where surgical procedures are carried out;
d) maintains daily records of patients and shall make these accessible to the insurance company’s authorized personnel;
21. Day Care Treatment refers to medical treatment, and/or surgical procedure as specified under Annexure I which is:
a) undertaken under General or Local Anesthesia in a hospital/day care center in less than 24 hours because of technological advancement, and
b) which would have otherwise required a hospitalization of more than 24 hours.
Treatment normally taken on an out-patient basis is not included in the scope of this definition;
22. Deductible means a cost-sharing requirement under a health insurance policy that provides that the insurer will not be liable for a specified rupee / applicable currency amount in case of indemnity policies and for a specified number of days/hours in case of hospital cash policies which will apply before any Benefits are payable by the insurer. A deductible does not reduce the Sum Insured;
23. Dental Treatment means a treatment related to teeth or structures supporting teeth including examinations, fillings (where appropriate), crowns, extractions and surgery;
24. Dependent Child means a child (natural or legally adopted), who is:
a) Financially dependent on the Insured Person;
b) Does not have his independent sources of income; and
c) Has not attained Age 25 years;
25 Disclosure to information norm: The policy shall be void and all premium paid hereon shall be forfeited to the Company, in the event of misrepresentation, mis-description or non-disclosure of any material fact;
26. Emergency Care means management for an illness or injury which results in symptoms which occur suddenly and unexpectedly, and requires immediate care by a medical practitioner to prevent death or serious long term impairment of the insured person’s health;
27. Family means and includes the Insured Person’s legal spouse and upto 2 dependent children upto age 25 years ;
28. Geographical Scope means the countries or geographical boundaries in which the coverage under the Policy is valid as specified in the Policy Schedule/ Certificate of Insurance;
29. Grace Period means the specified period of time immediately following the premium due date during which payment can be made to renew or continue a policy in force without loss of continuity benefits such as waiting periods and coverage of pre-existing diseases. Coverage is not available for the period for which no premium is received;
30. Hijack means any act of unlawful seizure or control of a Common Carrier with a wrongful intent using force or violence or threat thereof;
31. Burglary means any act of actual, forcible and violent entry and or exit from the premises of the Insured Person with intent to commit an act of crime or theft.
32. Hospital means any institution established for in-patient care and day care treatment of illness and/or injuries and which has been registered as a hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under:
a) has qualified nursing staff under its employment round the clock;
b) has at least 10 in-patient beds in towns having a population of less than 10,00,000 and at least 15 inpatient beds in all other places;
c) has qualified medical practitioner(s) in charge round the clock;
d) has a fully equipped operation theatre of its own where surgical procedures are carried out;
e) maintains daily records of patients and makes these accessible to the insurance company’s authorized personnel.
Any institution established for in- patient care and day care and treatment of Injury or Illness and which has been registered as a Hospital or a clinic as per law rules and/or regulations applicable for the country where the contingency arises;
33. Hospitalization means admission in a Hospital for a minimum period of 24 In patient Care consecutive hours except for specified procedures/ treatments, where such admission could be for a period of less than 24 consecutive hours;
34. Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function which manifests itself during the Policy Period and requires medical treatment.
- Acute condition – Acute condition is a disease, illness or injury that is likely to respond quickly to treatment which aims to return the person to his or her state of health immediately before suffering the disease/ illness/ injury which leads to full recovery.
- Chronic condition – A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics:
- it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /or tests
- it needs ongoing or long-term control or relief of symptoms
- it requires rehabilitation for the patient or for the patient to be specially trained to cope with it
- it continues indefinitely
- it recurs or is likely to recur
35. Immediate Family Member means an Insured Person’s lawful spouse, Dependent Children and parents only;
36. Injury means accidental physical bodily harm excluding Illness or disease solely and directly caused by external, violent and visible and evident means which is verified and certified by a Medical Practitioner;
37. Inpatient Care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event;
38. Intensive Care Unit means an identified section, ward or wing of a Hospital which is under the constant supervision of a dedicated Medical Practitioner(s), and which is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards;
39. ICU Charges means the amount charged by a Hospital towards ICU expenses which shall include the expenses for ICU bed, general medical support services provided to any ICU patient including monitoring devices, critical care nursing and intensivist charges.
40. Insured Person means a person whose name specifically appears under Insured in the Certificate of Insurance and is a covered group member;
41. Life Threatening Medical Condition means a medical condition suffered by the Insured Person which has the following characteristics:
a) Markedly unstable vital parameters (blood pressure, pulse, temperature and respiratory rate); or
b) Acute impairment of one or more vital organ systems (involving brain, heart, lungs, liver, kidneys and pancreas); or
c) Critical care being provided, which involves high complexity decision making to assess, manipulate and support vital system functions to treat single or multiple vital organ failures and requires interpretation of multiple physiological parameters and application of advanced technology; or
d) Critical care being provided in critical care area such as coronary care unit, Intensive Care Unit, respiratory care unit, or the emergency department;
and certified in writing by the attending Medical Practitioner as a Life Threatening Medical Condition;
42. Man Day means every completed 24 hrs per Insured Person from the start date of Period of Insurance which falls within the Period of Insurance.
43. Maternity expenses shall include—
a) medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalization).
b) expenses towards lawful medical termination of pregnancy during the policy period;
44. Medical Advice means any consultation or advice from a Medical Practitioner including the issuance of any prescription or follow-up prescription;
45. Medical Evacuation means the removal of the Insured Person from the site of Accident or Illness to a nearest Hospital where necessary medical care can be accorded to him/her, including medical care required en route.
46. Medical Expenses means those expenses that an Insured Person has necessarily and actually incurred for medical treatment on account of Illness or Accident on the advice of a Medical Practitioner, as long as these are no more than would have been payable if the Insured Person had not been insured and no more than other Hospitals or doctors in the same locality would have charged for the same medical treatment;
47. Medical Practitioner means a person who holds a valid registration from the medical council of any State and is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of license. The term Medical Practitioner includes a physician and / or surgeon;
48. Medically Necessary Treatment means any treatment, tests, medication, or stay in Hospital or part of a stay in Hospital which:
i. Is required for the medical management of the Illness or Injury suffered by the Insured Person;
ii. Must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity;
iii. Must have been prescribed by a Medical Practitioner;
iv. Must conform to the professional standards widely accepted in international medical practice or by the medical community in India.
49. Network Provider means Hospitals or Health Care providers enlisted by an insurer or by an Assistance Service Provider and insured together to provide services to an insured on payment by a cashless facility;
50. Nominee means the person named in the Certificate of Insurance to receive the benefits payable under this Policy if the Insured Person is deceased. For the purpose of avoidance of doubt it is clarified that if the Nominee is a minor on the date when payment becomes due under the Policy, payment shall be made to the Appointee named in the Certificate of Insurance;
51. Non-Network Provider means any hospital, day care centre or other provider that is not part of the network;
52. Notification of Claim means the process of notifying a claim to the insurer or TPA through any of the recognized modes of communication;
53. OPD Treatment means the one in which the Insured visits a clinic / hospital or associated facility like a consultation room for diagnosis and treatment based on the advice of a Medical Practitioner. The Insured is not admitted as a day care or in-patient;
54. Period of Insurance means a period within the Policy Period which commences when the Insured Person crosses the international border of the Country of Residence if the Geographical Scope is out of India to leave that country on a Common Carrier or City of Residence if the Geographical Scope is restricted to India to leave that city and expires automatically on the earliest of:
a) the Insured Person crossing the Indian international border to return to the Country of Residence on a Common Carrier if the Geographical Scope is out of India or returning to the City of Residence if the Geographical Scope is restricted to India; or
b) the expiry of the period specified in the Policy Schedule or Certificate of Insurance from the commencement of the Period of Insurance; or
c) the Policy Period End Date.
55. Place of Destination means the destination place where the journey of the Insured Person, forming part of the Trip, is scheduled to be concluded through a scheduled Common Carrier;
56. Place of Origin means the starting point/ place from where the Insured Person’s Trip is scheduled to be undertaken through a Common Carrier by which he finally leaves the Country of Residence or City of Residence;
57. Place of Residence means the dwelling place that the Insured Person is presently resident in as specified as the correspondence address of the Insured Person in the Policy Schedule or Certificate of Insurance;
58. Policy means these Policy Terms & Conditions, Benefit, Optional Benefits, Optional Extensions (if any), the Proposal Form, Policy Schedule, Certificate of Insurance, and Annexures which form part of the policy contract and shall be read together;
59. Policy Schedule means the certificate attached to and forming part of this Policy;
60. Policyholder (also referred as You) means the person who is the Group Administrator and named in the Policy Schedule as the Policyholder;
61. Policy Period means the period commencing from the Policy Period Start Date and ending on the Policy Period End Date as specifically appearing in the Policy Schedule;
62. Policy Period End Date means the date on which the Policy expires, as specified in the Policy Schedule;
63. Policy Period Start Date means the date on which the Policy commences, as specified in the Policy Schedule;
64. Post-natal period is the period beginning immediately after the birth of a child and extending for about six weeks
65. Pre-existing Disease means any condition, ailment or injury or related condition(s) for which the Insured Person had signs or symptoms, and/or were diagnosed, and/or received medical advice or treatment within 48 months to prior to the first policy issued by the Company;
66. Pre-Natal period (also known as antenatal care) refers to the regular medical and nursing care recommended for women during pregnancy
67. Professional Sports means any sporting activity which is undertaken by the Insured Person from which he/she derives earnings, wage, reward, or profit of any kind.
68. Qualified Nurse is a person who holds a valid registration from the Nursing Council in the respective jurisdiction;
69. Reasonable and Customary Charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the Illness / Injury involved;
70. Renewal means the terms on which the contract of insurance can be renewed on mutual consent with a provision of grace period for treating the renewal continuous for the purpose of gaining credit for pre-existing diseases, time-bound exclusions and for all waiting periods;
71. Robbery means an act of taking or attempting to take anything of value by force, threat of force, or by putting an individual in fear.
72. Room Rent means the amount charged by a Hospital towards Room and Boarding expenses and shall include associated Medical Expenses;
73. Single Trip Cover means a cover of the Insured Person under the Policy under which there cannot be more than one Period of Insurance during the Policy Period;
74. Subrogation 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;
75. Sum Insured means:
(a) If the Certificate of Insurance is on individual cover basis, the amount specified in the Certificate of Insurance which represents Our maximum, total and cumulative liability for any and all Claims under any and all Benefit/Optional Benefits/Optional Extensions in respect of the Insured Person for the Policy Period.
(b) If the Certificate of Insurance is on family floater basis, the amount specified in the Certificate of Insurance which represents Our maximum, total and cumulative liability for any and all Claims under any and all Benefit/Optional Benefits/Optional Extensions in respect of any and all Insured Persons named in the Certificate of Insurance for the Policy Period.
76. Surgery / Surgical Procedure means manual and / or operative procedure(s) required for treatment of an Illness or Injury, correction of deformities and defects, diagnosis and cure of diseases, relief of suffering or prolongation of life, performed in a hospital or a day care centre by a medical practitioner;
77. Terrorism/Terrorist Incident means any actual or threatened use of force or violence directed at or causing damage, injury, harm or disruption, or commission of an act dangerous to human life or property, against any individual, property or government, with the stated or unstated objective of pursuing economic, ethnic, nationalistic, political, racial or religious interests, whether such interests are declared or not. Terrorism shall also include any act, which is verified or recognized by the relevant Government as an act of terrorism;
78. Trip means planned journey, which starts and ends in the Country of Residence / City of Residence as mentioned in the Policy Schedule / Certificate of Insurance during the Policy Period except where it is for emigration purpose
79. Unproven / Experimental Treatment means treatment including drug experimental therapy which is not based on established medical practice in India, is treatment experimental or unproven.
80. You/Your/Policyholder means the person named in the Policy Schedule as the policyholder and who has concluded this Policy with Us.
Annexure A: Ombudsmen
|CONTACT DETAILS||JURISDICTION OF OFFICE|
|AHMEDABAD – |
Office of the Insurance Ombudsman,
Jeevan Prakash Building, 6th floor,Tilak Marg, Relief Road,Ahmedabad – 380 001.
Tel.: 079 –25501201/02/05/06
Dadra & Nagar Haveli,
Daman and Diu.
Office of the Insurance Ombudsman,
Jeevan Soudha Building, PID No. 57-27-N-19
Ground Floor, 19/19, 24th Main Road,
JP Nagar, Ist Phase,
Bengaluru – 560 078.
Tel.: 080 – 26652048 / 26652049
Office of the Insurance Ombudsman,
Janak Vihar Complex, 2nd Floor,
6, Malviya Nagar, Opp. Airtel Office,
Near New Market,
Bhopal – 462 003.
Tel.: 0755 – 2769201 / 2769202
Fax: 0755 – 2769203
Office of the Insurance Ombudsman,
62, Forest park,
Bhubneshwar – 751 009.
Tel.: 0674 – 2596461 /2596455
Fax: 0674 – 2596429
|CHANDIGARH – |
Office of the Insurance Ombudsman,
S.C.O. No. 101, 102 & 103, 2nd Floor,
Batra Building, Sector 17 – D,
Chandigarh – 160 017.
Tel.: 0172 – 2706196 / 2706468
Fax: 0172 – 2708274
Jammu & Kashmir,
Office of the Insurance Ombudsman,
Fatima Akhtar Court, 4th Floor, 453,
Anna Salai, Teynampet,
CHENNAI – 600 018.
Tel.: 044 – 24333668 / 24335284
Fax: 044 – 24333664
Pondicherry Town and
Karaikal (which are part of Pondicherry).
Office of the Insurance Ombudsman,
2/2 A, Universal Insurance Building,
Asaf Ali Road,
New Delhi – 110 002.
Tel.: 011 – 23239633 / 23237532
Fax: 011 – 23230858
Office of the Insurance Ombudsman,
Jeevan Nivesh, 5th Floor,
Nr. Panbazar over bridge, S.S. Road,
Guwahati – 781001(ASSAM).
Tel.: 0361 – 2132204 / 2132205
Fax: 0361 – 2732937
Nagaland and Tripura.
Office of the Insurance Ombudsman,
6-2-46, 1st floor, “Moin Court”,
Lane Opp. Saleem Function Palace,
A. C. Guards, Lakdi-Ka-Pool,
Hyderabad – 500 004.
Tel.: 040 – 65504123 / 23312122
Fax: 040 – 23376599
part of Territory of Pondicherry.
Office of the Insurance Ombudsman,
Jeevan Nidhi – II Bldg., Gr. Floor,
Bhawani Singh Marg,
Jaipur – 302 005.
Tel.: 0141 – 2740363
Office of the Insurance Ombudsman,
2nd Floor, Pulinat Bldg.,
Opp. Cochin Shipyard, M. G. Road,
Ernakulam – 682 015.
Tel.: 0484 – 2358759 / 2359338
Fax: 0484 – 2359336
Mahe-a part of Pondicherry.
Office of the Insurance Ombudsman,
Hindustan Bldg. Annexe, 4th Floor,
4, C.R. Avenue,
KOLKATA – 700 072.
Tel.: 033 – 22124339 / 22124340
Fax : 033 – 22124341
Andaman & Nicobar Islands.
Office of the Insurance Ombudsman,
6th Floor, Jeevan Bhawan, Phase-II,
Nawal Kishore Road, Hazratganj,
Lucknow – 226 001.
Tel.: 0522 – 2231330 / 2231331
Fax: 0522 – 2231310
|Districts of Uttar Pradesh :|
Laitpur, Jhansi, Mahoba, Hamirpur, Banda, Chitrakoot, Allahabad, Mirzapur, Sonbhabdra, Fatehpur, Pratapgarh, Jaunpur,Varanasi, Gazipur, Jalaun, Kanpur, Lucknow, Unnao, Sitapur, Lakhimpur, Bahraich, Barabanki, Raebareli, Sravasti, Gonda, Faizabad, Amethi, Kaushambi, Balrampur, Basti, Ambedkarnagar, Sultanpur, Maharajgang, Santkabirnagar, Azamgarh, Kushinagar, Gorkhpur, Deoria, Mau, Ghazipur, Chandauli, Ballia, Sidharathnagar.
Office of the Insurance Ombudsman,
3rd Floor, Jeevan Seva Annexe,
S. V. Road, Santacruz (W),
Mumbai – 400 054.
Tel.: 022 – 26106552 / 26106960
Fax: 022 – 26106052
Mumbai Metropolitan Region
excluding Navi Mumbai & Thane.
Office of the Insurance Ombudsman,
Bhagwan Sahai Palace
4th Floor, Main Road,
Naya Bans, Sector 15,
Distt: Gautam Buddh Nagar,
Tel.: 0120-2514250 / 2514252 / 2514253
|State of Uttaranchal and the following Districts of Uttar Pradesh:|
Agra, Aligarh, Bagpat, Bareilly, Bijnor, Budaun, Bulandshehar, Etah, Kanooj, Mainpuri, Mathura, Meerut, Moradabad, Muzaffarnagar, Oraiyya, Pilibhit, Etawah, Farrukhabad, Firozbad, Gautambodhanagar, Ghaziabad, Hardoi, Shahjahanpur, Hapur, Shamli, Rampur, Kashganj, Sambhal, Amroha, Hathras, Kanshiramnagar, Saharanpur.
Office of the Insurance Ombudsman,
1st Floor, Kalpana Arcade Building,,
Bazar Samiti Road,
Patna 800 006.
Office of the Insurance Ombudsman,
Jeevan Darshan Bldg., 3rd Floor,
C.T.S. No.s. 195 to 198,
N.C. Kelkar Road, Narayan Peth,
Pune – 411 030.
Tel.: 020 – 41312555
Area of Navi Mumbai and Thane
excluding Mumbai Metropolitan Region.
Annexure I – List of Day Care Surgeries
Microsurgical operations on the middle ear
1. Tympanoplasty (closure of an eardrum perforation/reconstruction of the auditory ossicles) for
tympanic membrane injury
Other operations on the middle & internal ear
2. Surgeries for Injuries on middle and inner ear
Operations on the nose & the nasal sinuses
3. Surgeries for nasal injuries
4. Nasal repair due to fracture nasal bone
5. Foreign body removal from nose
Operations on the eyes
6. Excision and destruction of diseased tissue of the eyelid
7. Removal of a foreign body from the conjunctiva
8. Removal of a foreign body from the cornea
9. Removal of a foreign body from the lens of the eye
10. Removal of a foreign body from the posterior chamber of the eye
11. Removal of a foreign body from the orbit and eyeball
12. Diathermy/Cryotherapy to treat retinal tear
13. Enucleation of Eye without Implant
14. Laser Photocoagulation to treat Retinal Tear
Operations on the skin & subcutaneous tissues
15. Surgical wound toilet (wound debridement) and removal of diseased tissue of the skin and subcutaneous tissues
16. Local excision of diseased tissue of the skin and subcutaneous tissues
17. Simple restoration of surface continuity of the skin and subcutaneous tissues
18. Other restoration and reconstruction of the skin and subcutaneous tissues.
Operations on the tongue
19. Reconstruction of the tongue
Operations on the salivary glands & salivary ducts
20. Reconstruction of a salivary gland and a salivary duct
Other operations on the mouth & face
21. Incision, excision and destruction in the mouth
23. Other operations in the mouth
Operations on the female sexual organs
24. Local excision and destruction of diseased tissue of the vagina and the pouch of Douglas
Operations on the testis
25. Surgeries for testicular injury
Operations on the penis
26. Local excision and destruction of diseased tissue of the penis
Operations of bones and joints
27. Surgery for hemoarthrosis / pyoarthrosis
28. Reduction of dislocation under GA
29. Closed reduction on fracture, luxation
30. Reduction of dislocation under GA
31. Arthroscopic knee aspiration
32. Trauma surgery and orthopaedics
33. Incision on bone, septic and aseptic
34. Suture and other operations on tendons and tendon sheath
Annexure II – List of Expenses Generally Excluded “Non-Medical” Expenses
|Sr. No.||List of Non-Medical Expenses|
|1||HAIR REMOVAL CREAM||Not Payable|
|2||BABY CHARGES (UNLESS SPECIFIED/INDICATED)||Not Payable|
|3||BABY FOOD||Not Payable|
|4||BABY UTILITES CHARGES||Not Payable|
|5||BABY SET||Not Payable|
|6||BABY BOTTLES||Not Payable|
|8||COSY TOWEL||Not Payable|
|9||HAND WASH||Not Payable|
|10||MOISTURISER PASTE BRUSH||Not Payable|
|13||SHOE COVER||Not Payable|
|14||BEAUTY SERVICES||Not Payable|
|15||BELTS/ BRACES||Essential and paid specifically for cases that have undergone surgery of thoracic or lumbar Spine.|
|17||BARBER CHARGES||Not Payable|
|19||COLD PACK/HOT PACK||Not Payable|
|20||CARRY BAGS||Not Payable|
|21||CRADLE CHARGES||Not Payable|
|23||DISPOSABLES RAZORS CHARGES ( for site preparations)||Payable|
|24||EAU-DE-COLOGNE / ROOM FRESHNERS||Not Payable|
|25||EYE PAD||Not Payable|
|26||EYE SHEILD||Not Payable|
|27||EMAIL / INTERNET CHARGES||Not Payable|
|28||FOOD CHARGES (OTHER THAN PATIENT’s DIET PROVIDED BY HOSPITAL)||Not Payable|
|29||FOOT COVER||Not Payable|
|31||LEGGINGS||Essential in bariatric and varicose vein surgery and may be considered for at least these conditions where surgery itself is payable.|
|32||LAUNDRY CHARGES||Not Payable|
|33||MINERAL WATER||Not Payable|
|34||OIL CHARGES||Not Payable|
|35||SANITARY PAD||Not Payable|
|37||TELEPHONE CHARGES||Not Payable|
|38||TISSUE PAPER||Not Payable|
|39||TOOTH PASTE||Not Payable|
|40||TOOTH BRUSH||Not Payable|
|41||GUEST SERVICES||Not Payable|
|42||BED PAN||Not Payable|
|43||BED UNDER PAD CHARGES||Not Payable|
|44||CAMERA COVER||Not Payable|
|46||CREPE BANDAGE||Not Payable|
|48||DIAPER OF ANY TYPE||Not Payable|
|49||DVD, CD CHARGES||Not Payable ( However if CD is specifically sought by Insurer/TPA then payable)|
|50||EYELET COLLAR||Not Payable|
|51||FACE MASK||Not Payable|
|52||FLEXI MASK||Not Payable|
|53||GAUSE SOFT||Not Payable|
|55||HAND HOLDER||Not Payable|
|56||HANSAPLAST/ ADHESIVE BANDAGES||Not Payable|
|57||LACTOGEN/ INFANT FOOD||Not Payable|
|58||SLINGS||Reasonable costs for one sling in case of upper arm fractures may be considered.|
|ITEMS SPECIFICALLY EXCLUDED IN THE POLICIES|
|59||WEIGHT CONTROL PROGRAMS/ SUPPLIES/ SERVICES||Not Payable|
|60||COST OF SPECTACLES/ CONTACT LENSES/ HEARING AIDS ETC.,||Not Payable|
|61||DENTAL TREATMENT EXPENSES THAT DO NOT REQUIRE HOSPITALISATION||Not Payable. (We should consider only in accident cases; where Dental Surgery is required)|
|62||HORMONE REPLACEMENT THERAPY||Not Payable|
|63||HOME VISIT CHARGES||Not Payable|
|64||INFERTILITY/ SUBFERTILITY/ ASSISTED CONCEPTION PROCEDURE||Not Payable|
|65||OBESITY (INCLUDING MORBID OBESITY) TREATMENT||Not Payable|
|66||PSYCHIATRIC & PSYCHOSOMATIC DISORDERS||Not Payable|
|67||CORRECTIVE SURGERY FOR REFRACTIVE ERROR||Not Payable|
|68||TREATMENT OF SEXUALLY TRANSMITTED DISEASES||Not Payable|
|69||DONOR SCREENING CHARGES||Not Payable|
|70||ADMISSION/REGISTRATION CHARGES||Not Payable|
|71||HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC PURPOSE||Not Payable|
|72||EXPENSES FOR INVESTIGATION/ TREATMENT IRRELEVANT TO THE DISEASE FOR WHICH ADMITTED OR DIAGNOSED||Not Payable|
|73||ANY EXPENSES WHEN THE PATIENT IS DIAGNOSED WITH RETRO VIRUS + OR SUFFERING FROM /HIV/ AIDS ETC IS DETECTED/ DIRECTLY OR INDIRECTLY||Not Payable|
|74||STEM CELL IMPLANTATION/ SURGERY||Not Payable except Bone Marrow Transplantation where covered by policy|
|ITEMS WHICH FORM PART OF HOSPITAL SERVICES WHERE SEPARATE CONSUMABLES ARE NOT PAYABLE BUT THE SERVICE IS|
|75||WARD AND THEATRE BOOKING CHARGES||Payable under OT Charges, not payable separately|
|76||ARTHROSCOPY & ENDOSCOPY INSTRUMENTS||Not Payable|
|77||MICROSCOPE COVER||Payable under OT Charges, not payable separately|
|78||SURGICAL BLADES,HARMONIC SCALPEL,SHAVER||Not Payable|
|79||SURGICAL DRILL||Not Payable|
|80||EYE KIT||Payable under OT Charges, not payable separately|
|81||EYE DRAPE||Payable under OT Charges, not payable separately|
|82||X-RAY FILM||Payable under Radiology Charges, not as consumable|
|83||SPUTUM CUP||Not Payable|
|84||BOYLES APPARATUS CHARGES||Payable under OT Charges, not payable separately|
|85||BLOOD GROUPING AND CROSS MATCHING OF DONORS SAMPLES||Not Payable|
|86||ANTISEPTIC OR DISINFECTANT LOTIONS||Not Payable|
|87||BAND AIDS, BANDAGES, STERLILE INJECTIONS, NEEDLES, SYRINGES||Not Payable|
|89||COTTON BANDAGE||Not Payable|
|90||MICROPORE/ SURGICAL TAPE||Not Payable|
|94||ORTHOBUNDLE, GYNAEC BUNDLE||Not Payable|
|95||URINE CONTAINER||Not Payable|
|ELEMENTS OF ROOM CHARGE|
|96||LUXURY TAX||Not Payable. If there is no Policy Exclusion, then Actual Tax Levied by Government is Payable -Part of Room Charge for Sub Limits|
|98||HOUSE KEEPING CHARGES||Not Payable|
|99||SERVICE CHARGES WHERE NURSING CHARGE ALSO CHARGED||Not Payable|
|100||TELEVISION & AIR CONDITIONER CHARGES||Payable – If under room charges not if separately levied|
|102||ATTENDANT CHARGES||Not Payable|
|103||IM IV INJECTION CHARGES||Not Payable|
|104||CLEAN SHEET||Not Payable|
|105||EXTRA DIET OF PATIENT(OTHER THAN THAT WHICH FORMS PART OF BED CHARGE)||Not payable, Patient diet provided by Hospital is payable|
|106||BLANKET/WARMER BLANKET||Not Payable|
|ADMINISTRATIVE OR NON-MEDICAL CHARGES|
|107||ADMISSION KIT||Not Payable|
|108||BIRTH CERTIFICATE||Not Payable|
|109||BLOOD RESERVATION CHARGES AND ANTE NATAL BOOKING CHARGES||Not Payable|
|110||CERTIFICATE CHARGES||Not Payable|
|111||COURIER CHARGES||Not Payable|
|112||CONVENYANCE CHARGES||Not Payable|
|113||DIABETIC CHART CHARGES||Not Payable|
|114||DOCUMENTATION CHARGES / ADMINISTRATIVE EXPENSES||Not Payable|
|115||DISCHARGE PROCEDURE CHARGES||Not Payable|
|116||DAILY CHART CHARGES||Not Payable|
|117||ENTRANCE PASS / VISITORS PASS CHARGES||Not Payable|
|118||EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE||Not Payable–To be Claimed by Patient Post -Hospitalisation where admissible|
|119||FILE OPENING CHARGES||Not Payable|
|120||INCIDENTAL EXPENSES / MISC. CHARGES (NOT EXPLAINED)||Not Payable|
|121||MEDICAL CERTIFICATE||Not Payable|
|122||MAINTAINANCE CHARGES||Not Payable|
|123||MEDICAL RECORDS||Not Payable|
|124||PREPARATION CHARGES||Not Payable|
|125||PHOTOCOPIES CHARGES||Not Payable|
|126||PATIENT IDENTIFICATION BAND / NAME TAG||Not Payable|
|127||WASHING CHARGES||Not Payable|
|128||MEDICINE BOX||Not Payable|
|129||MORTUARY CHARGES||Payable – upto 24 hrs, shifting charges not payable|
|130||MEDICO LEGAL CASE CHARGES (MLC CHARGES)||Not Payable|
|EXTERNAL DURABLE DEVICES||Not Payable|
|131||WALKING AIDS CHARGES||Not Payable|
|132||BIPAP MACHINE||Not Payable|
|134||CPAP/ CAPD EQUIPMENTS||Not Payable|
|135||INFUSION PUMP – COST||Not Payable|
|136||OXYGEN CYLINDER (FOR USAGE OUTSIDE THE HOSPITAL)||Not Payable|
|137||PULSEOXYMETER CHARGES||Not Payable|
|140||SPO2 PROBE||Not Payable|
|141||NEBULIZER KIT||Not Payable|
|142||STEAM INHALER||Not Payable|
|145||CERVICAL COLLAR||Not Payable|
|147||DIABETIC FOOT WEAR||Not Payable|
|148||KNEE BRACES ( LONG/ SHORT/ HINGED)||Not Payable|
|149||KNEE IMMOBILIZER/SHOULDER IMMOBILIZER||Not Payable|
|150||LUMBO SACRAL BELT||Payable – If Essential and should be paid at least specifically for cases who have undergone surgery of lumbar spine.|
|151||NIMBUS BED OR WATER OR AIR BED CHARGES||Payable -for any ICU patient requiring more than 3 days in ICU, all patient with paraplegia /quadriplegia or for any major illness requiring prolonged hospitalization. (Prevent Bed Sores & DVT)|
|152||AMBULANCE COLLAR||Not Payable|
|153||AMBULANCE EQUIPMENT||Not Payable|
|155||ABDOMINAL BINDER||Payable – If Essential and should be paid at least in post surgery patients of major abdominal surgery including TAH, LSCS, incisional hernia repair, exploratory laparotomy for intestinal obstruction, liver transplant etc.|
|ITEMS PAYABLE IF SUPPORTED BY A PRESCRIPTION|
|156||BETADINE \ HYDROGEN PEROXIDE\SPIRIT\\ \ DISINFECTANTS ETC||Payable when prescribed for patient, not payable for hospital use in OT or ward or for dressings in hospital|
|157||PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES||Not Payable|
|158||NUTRITION PLANNING CHARGES – DIETICIAN CHARGES / DIET CHARGES||Not Payable|
|159||SUGAR FREE Tablets||Payable – Sugar free variants of admissible medicines are not excluded|
|160||CREAMS POWDERS LOTIONS (Toiletries are not payable, only prescribed medical pharmaceuticals payable)||Payable – If prescribed|
|161||Digestion Gels||Payable – If prescribed|
|162||ECG ELECTRODES||Payable – Upto 5 electrodes are required for every case visiting OT or ICU. For longer stay in ICU, may require a change and at least one set every second day must be payable.|
|163||GLOVES||Payable -Sterilized Gloves Payable.|
Unsterilized Gloves not Payable
|165||LISTERINE/ ANTISEPTIC MOUTHWASH||Payable – If prescribed|
|166||LOZENGES||Payable – If prescribed|
|167||MOUTH PAINT||Payable – If prescribed|
|168||NEBULISATION KIT||Payable – If used during hospitalization is payable reasonably|
|169||NOVARAPID||Payable – If prescribed|
|170||VOLINI GEL/ ANALGESIC GEL||Payable – If prescribed|
|171||ZYTEE GEL||Payable – If prescribed|
|172||VACCINATION CHARGES||Routine Vaccination not Payable / Post Bite Vaccination Payable|
|PART OF HOSPITAL’S OWN COSTS AND NOT PAYABLE|
|174||ALCOHOL SWABES||Not Payable|
|175||SCRUB SOLUTION/STERILLIUM||Not Payable|
|176||VACCINE CHARGES FOR BABY||Not Payable|
|177||AESTHETIC TREATMENT / SURGERY||Not Payable|
|178||TPA CHARGES||Not Payable|
|179||VISCO BELT CHARGES||Not Payable|
|180||ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT, ORTHOKIT, RECOVERY KIT, ETC]||Not Payable|
|181||EXAMINATION GLOVES||Not Payable|
|182||KIDNEY TRAY||Not Payable|
|184||OUNCE GLASS||Not Payable|
|185||OUTSTATION CONSULTANT’S/ SURGEON’S FEES||Not payable|
|186||OXYGEN MASK||Not Payable|
|187||PAPER GLOVES||Not Payable|
|188||PELVIC TRACTION BELT||Not Payable|
|189||REFERAL DOCTOR’S FEES||Not Payable|
|190||ACCU CHECK (Glucometery/ Strips)||Not Payable|
|191||PAN CAN||Not Payable|
|193||TROLLY COVER||Not Payable|
|194||UROMETER, URINE JUG||Not Payable|
|195||AMBULANCE||Payable – Ambulance from home to hospital or inter hospital shifts is payable/ RTA as specific requirement is payable|
|196||TEGADERM / VASOFIX SAFETY||Payable – If maximum of 3 in 48 hrs and then 1 in 24 hrs|
|197||URINE BAG||Payable – where medically necessary till a reasonable cost – maximum 1 per 24 hrs|
|199||STOCKINGS||Payable – If Essential for case like CABG etc. where it should be paid.|