Goactive Policy Document

GoActive
Policy Document
1. Preamble
This is a contract of insurance between You and Us which is subject to the payment of the full premium in advance and the terms, conditions and exclusions to
this Policy. 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 and the Information Summary Sheet.
Please inform Us immediately of any change in the address or any other changes affecting You or any Insured Person.
Note: The terms listed in Section 2(Definitions) and used elsewhere in the Policy in Initial Capitals shall have the meaning set out against them in Section 2
wherever they appear in the Policy.
2. Definitions
For the purposes of interpretation and understanding of this Policy, We have defined, herein below some of the important words used in the Policy and for the
remaining language and the words; they shall have the usual meaning as described in standard English language dictionaries. The words and expressions defined
in the Insurance Act 1938, IRDA Act 1999, regulations notified by the IRDAI and circulars and guidelines issued by the IRDAI shall carry the meanings explained
therein.
Note: Where the context permits, the singular will be deemed to include the plural, one gender shall be deemed to include the other genders and references to
any statute shall be deemed to refer to any replacement or amendment of that statute.
2.1. Standard Definitions
I. Accident or Accidental means a sudden, unforeseen and involuntary event caused by external, visible and violent means.
II. AYUSH Treatment refers to the medical and / or hospitalization treatments given under Ayurveda, Yoga and Naturopathy, Unani, Sidha and
Homeopathy systems.
III. AYUSH Hospital:
An AYUSH Hospital is a healthcare facility wherein medical/surgical/para surgical treatment procedures and interventions are carried out by AYUSH
Medical Practitioner(s) comprising of any of the following:
a. Central or State Government AYUSH Hospital; or
b. Teaching Hospital attached to AYUSH College recognized by the Central Government/Central Council of Indian Medicine/Central Council of
Homeopathy; or
c. AYUSH Hospital, standalone or co-located with In-patient healthcare facility of any recognized system of medicine, registered with the local
authorities, wherever applicable, and is under the supervision of a qualified registered AYUSH Medical Practitioner and must comply with all the
following criterion:
i. Having at least 5 in-patient beds
ii. Having qualified AYUSH Medical Practitioner in charge round the clock;
iii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures are to be carried
out;
iv. Maintaining daily records of the patients and making them accessible to the insurance company’s authorized representative
IV. Associated Medical Expenses shall include Room Rent, nursing charges, Medical Practitioners’ fees and operation theatre charges
V. Cashless Facility means a facility extended by the insurer to the insured where the payments, of the costs of treatment undergone by the insured in
accordance with the policy terms and conditions, are directly made to the network provider by the insurer to the extent pre-authorization is approved.
VI. Congenital Anomaly means a condition which is present since birth, and which is abnormal with reference to form, structure or position.
a. Internal Congenital Anomaly: Congenital Anomaly which is not in the visible and accessible parts of the body.
b. External Congenital Anomaly: Congenital Anomaly which is in the visible and accessible parts of the body.
VII. Co-payment means a cost-sharing requirement under a health insurance policy that provides that the Policyholder/insured will bear a specified
percentage of the admissible claim amount. A Co-payment does not reduce the Sum Insured.
VIII. Day Care Center means any institution established for Day Care Treatment of Illness and/or Injuries or a medical set-up with a Hospital and which has
Product Name: GoActiveTM | Product UIN: MAXHLIP21173V022021

been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified Medical Practitioner AND
must comply with all minimum criterion as under:
a. has Qualified Nursing staff under its employment;
b. has qualified Medical Practitioner(s) in charge;
c. has a fully equipped operation theatre of its own where Surgical Procedures are carried out;
d. maintains daily records of patients and will make these accessible to the insurance company’s authorized personnel.
IX. Day Care Treatment refers to medical treatment, and/or Surgical Procedure which is:
a. undertaken under General or Local Anaesthesia in a Hospital/Day Care Center in less than 24 hrs because of technological advancement, and
b. which would have otherwise required a Hospitalization of more than 24 hours.
Treatment normally taken on an OPD basis is not included in the scope of this definition.
X. Deductible means a cost-sharing requirement under a health insurance policy that provides that the Insurer will not be liable for a specified rupee
amount in case of indemnity policies and for a specified number of days/hours in case of hospital cash policies which will apply before any benefits
are payable by the insurer. A deductible does not reduce the Sum Insured.
XI. Dental Treatment means a treatment related to teeth or structures supporting teeth including examinations, fillings (where appropriate), crowns,
extractions and Surgery.
XII. Domiciliary Hospitalization means medical treatment for an Illness/disease/Injury which in the normal course would require care and treatment at a
Hospital but is actually taken while confined at home under any of the following circumstances:
a. the condition of the patient is such that he/she is not in a condition to be removed to a Hospital, or
b. the patient takes treatment at home on account of non availability of room in a Hospital.
XIII. Emergency means a serious medical condition or symptom resulting from Illness or Injury which arises suddenly and unexpectedly and requires
immediate care and treatment by a Medical Practitioner to prevent death or serious long term impairment of the Insured Person’s health.
XIV. Grace Period means the specified period of time immediately following the premium due date during which a payment can be made to Renew or
continue a policy in force without loss of continuity benefits such as Waiting Periods and coverage of Pre-existing Diseases. Coverage is not available
for the period for which no premium is received.
XV. Hospital means any institution established for Inpatient Care and Day Care Treatment of Illness and / or Injuries and which has been registered as a
Hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act, 2010 or under the enactments specified under
the Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under:
a. has Qualified Nursing staff under its employment round the clock;
b. has at least 10 Inpatient beds in towns having a population of less than 10,00,000 and at least 15 Inpatient beds in all other places;
c. has qualified Medical Practitioner(s) in charge round the clock;
d. has a fully equipped operation theatre of its own where Surgical Procedures are carried out;
e. maintains daily records of patients and makes these accessible to the Insurance company’s authorized personnel.
XVI. Hospitalization or Hospitalized means the admission in a Hospital for a minimum period of 24 consecutive Inpatient Care hours except for specified
procedures/treatments, where such admission could be for a period of less than 24 consecutive hours.
XVII. ICU (Intensive Care Unit) Charges means the amount charged by a Hospital towards ICU expenses which shall include the expenses for ICU bed,
general medical support services provided to any ICU patient including monitoring devices, critical care nursing and intensivist charges.
XVIII. Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function and requires medical
treatment.
(a) Acute condition - Acute condition is a disease, illness or injury that is likely to respond quickly to treatment which aims to return the person to his
or her state of health immediately before suffering the disease/ illness/ injury which leads to full recovery
(b) Chronic condition - A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics:
i. it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /or tests
ii. it needs ongoing or long-term control or relief of symptoms
iii. it requires rehabilitation for the patient or for the patient to be specially trained to cope with it
iv. it continues indefinitely
v. it recurs or is likely to recur
XIX. 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.

XX. Intensive / Critical 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.
XXI. Inpatient Care means treatment for which the Insured Person has to stay in a Hospital for more than 24 hours for a covered event.
XXII. Medical Advice means any consultation or advice from a Medical Practitioner including the issuance of any prescription or follow-up prescription.
XXIII. 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.
XXIV. Medical Practitioner means a person who holds a valid registration from the Medical Council of any State or Medical Council of India or Council for
Indian Medicine or for Homeopathy set up by the Government of India or a State Government and is thereby entitled to practice medicine within its
jurisdiction; and is acting within the scope and jurisdiction of his licence.
XXV. Medically Necessary treatment means any treatment, tests, medication, or stay in Hospital or part of a stay in Hospital which:
a. is required for the medical management of the Illness or Injury suffered by the insured;
b. must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity;
c. must have been prescribed by a Medical Practitioner;
d. must conform to the professional standards widely accepted in international medical practice or by the medical community in India.
XXVI. Migration: “Migration” means, the right accorded to health insurance policyholders (including all members under family cover and members of group
health insurance policy), to transfer the credit gained for pre-existing conditions and time bound exclusions, with the same insurer.
XXVII. Network Provider means Hospital enlisted by an insurer, TPA or jointly by an insurer and TPA to provide medical services to an insured by a Cashless
Facility.
XXVIII. Notification of Claim means the process of intimating a claim to the insurer or TPA through any of the recognized modes of communication.
XXIX. Non-Network means any Hospital, Day Care Center or other provider that is not part of the network.
XXX. Pre-existing Disease means any condition, ailment, injury or disease
a. That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement or
b. For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the
policy issued by the insurer or its reinstatement.
XXXI. Pre-hospitalization Medical Expenses means medical expenses incurred during pre-defined number of days preceding the hospitalization of the
Insured Person, provided that:
a. Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalization was required, and
b. The Inpatient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.
XXXII. Post-hospitalization Medical Expenses means medical expenses incurred during pre-defined number of days immediately after the Insured Person
is discharged from the Hospital, provided that:
a. Such Medical Expenses are for the same condition for which the Insured Person’s Hospitalization was required, and
b. The Inpatient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.
XXXIII. Portability means the right accorded to individual health insurance policyholders (including all members under family cover), to transfer the credit
gained for pre-existing conditions and time bound exclusions, from one insurer to another insurer.
XXXIV. Qualified Nurse means a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India.
XXXV. 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.
XXXVI. 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.
XXXVII. Room Rent means the amount charged by a Hospital towards Room and Boarding expenses and shall include the Associated Medical Expenses.
XXXVIII. Surgery or Surgical Procedure means manual and / or operative procedure (s) required for treatment of an Illness or Injury, correction of deformities
and defects, diagnosis and cure of diseases, relief from suffering or prolongation of life, performed in a Hospital or Day Care Center by a Medical
Practitioner.

2.2. Specific Definitions
I. Age means age last birthday.

II. Base Premium means the premium excluding taxes and cess, for the base product benefits mentioned under Section 3. Base Premium will not include
the premium for Optional benefits mentioned under Section 4.
III. Base Sum Insured means the amount stated in the Policy Schedule.
IV. Bone Marrow Transplant is a condition where the Insured Person needs necessary medical treatment to replace malignant or defective bone marrow
with normal bone marrow from healthy donors to stimulate the production of formed blood cells.
V. Break in Policy means the period of gap that occurs at the end of the existing policy term, when the premium due for renewal on a given policy is not
paid on or before the premium renewal date or within 30 days thereof.
VI. Diagnostic Tests means investigations, such as X-Ray or blood tests, to determine the cause of symptoms and/or medical conditions.
VII. Diagnostic Services means a broad range of Diagnostic Tests and exploratory or therapeutic procedures essential for detection, identification and
treatment of medical condition.
VIII. Evidence Based Clinical Practice means process of making clinical decisions for Inpatient Care using current best evidence in conjugation with clinical
expertise.
IX. Family Floater Policy means a Policy described as such in the Policy Schedule where the family members (two or more) named in the Policy Schedule
are insured under this Policy. Only the following family members can be covered under a Family Floater Policy:
a. Insured Person; and/or
b. Insured Person’s legally married spouse (for as long as they continue to be married); and/or
c. Insured Person’s children who are less than 21 years of Age on the commencement of the Policy Period (maximum 4 children can be covered).
X. First Policy means the Policy Schedule issued to the Policyholder at the time of inception of the Policy mentioned in the Policy Schedule with Us.
XI. Home Health Care Services:
Home Health Care is a range of health care services and Medically Necessary treatment that can be given at home for an Illness or Injury. These shall
include services such as nursing care, investigations, medication (including oral and intravenous), chemotherapy, dialysis, transfusions, physiotherapy
and postsurgical care.
XII. Information Summary Sheet means the information and details provided to Us or Our representatives over the telephone for the purposes of applying
for this Policy which has been recorded by Us and confirmed by You.
XIII. Individual Policy means a Policy described as such in the Policy Schedule where the individual named in the Policy Schedule is insured under this
Policy.
XIV. Insured Person means person named as insured in the Policy Schedule.
XV. IRDAI means the Insurance Regulatory and Development Authority of India.
XVI. Medical Devices are devices intended for internal or external use in the diagnosis, treatment, mitigation or prevention of disease or disorder.
XVII. Medical Record means the collection of information as submitted in claim documentation concerning a Insured Person’s Illness or Injury that is created
and maintained in the regular course of management, made by a Medical Practitioners who has knowledge of the acts, events, opinions or diagnoses
relating to the Insured Person’s Illness or Injury, and made at or around the time indicated in the documentation.
XVIII. OPD Consultation means the one in which the Insured Person visits a clinic/ Hospital, or associated facility like a consultation room, for the advice of
a Medical Practitioner.
XIX. Policy means these terms and conditions, the Policy Schedule (as amended from time to time), Your statements in the Proposal and the Information
Summary Sheet and any endorsements attached by Us to the Policy from time to time.
XX. Policy Period is the period between the inception date and the expiry date of the Policy as specified in the Policy Schedule or the date of cancellation
of this Policy, whichever is earlier.
XXI. Policy Year means the period of one year commencing on the date of commencement specified in the Policy Schedule or any anniversary thereof.
XXII. Policy Schedule means a certificate issued by Us, and, if more than one, then the latest in time. The Policy Schedule contains details of the Policyholder,
Insured Persons and the Benefits applicable under the Policy
XXIII. Primary Insured Person means the Policyholder if he/she is covered under the Policy as an Insured Person. In case Policyholder is not an Insured
Person, then Primary Insured Person will be the eldest Insured Person covered under the Policy.
XXIV. Reimbursement means settlement of claims paid directly by Us to the Policyholder/Insured Person.
XXV. Second Medical Opinion means an alternate evaluation of diagnosis or treatment modalities arranged by Us from a Medical Practitioner related to
Specified Illnesses or planned Surgery or Surgical Procedure which the Insured Person has been diagnosed or advised to undergo during the Policy
Year. The Second Medical Opinion will be arranged by Us solely on the Insured Person’s request.
XXVI. Service Provider means any person, organization, institution that has been engaged by Us to provide services specified under the benefits to the
Insured Person.

XXVII. Specified Illness means the following Illnesses or procedures:
a. Cancer:
A malignant tumor characterized by the uncontrolled growth and spread of malignant cells with invasion and destruction of normal tissues. This
diagnosis must be supported by histological evidence of malignancy. The term cancer includes leukemia, lymphoma and sarcoma.
b. Myocardial Infarction (First Heart Attack of specific severity):

I. The first occurrence of heart attack or myocardial infarction, which means the death of a portion of the heart muscle as a result of inadequate
blood supply to the relevant area. The diagnosis for Myocardial Infarction should be evidenced by all of the following criteria:
i. A history of typical clinical symptoms consistent with the diagnosis of acute myocardial infarction (For e.g. typical chest pain)
ii. New characteristic electrocardiogram changes
iii. Elevation of infarction specific enzymes, Troponins or other specific biochemical markers.
II. The following are excluded:
i. Other acute Coronary Syndromes
ii. Any type of angina pectoris
iii. A rise in cardiac biomarkers or Troponin T or I in absence of overt ischemic heart disease OR following an intra-arterial cardiac procedure.
c. Open Chest CABG:
I. The actual undergoing of heart surgery to correct blockage or narrowing in one or more coronary artery(s), by coronary artery bypass
grafting done via a sternotomy (cutting through the breast bone) or minimally invasive keyhole coronary artery bypass procedures. The
diagnosis must be supported by a coronary angiography and the realization of surgery has to be confirmed by a cardiologist.
i. Angioplasty and/or any other intra-arterial procedures
d. Major Organ/Bone Marrow Transplant:
I. The actual undergoing of a transplant of:
i. One of the following human organs: heart, lung, liver, kidney, pancreas, that resulted from irreversible end-stage failure of the relevant
organ, or
ii. Human bone marrow using haematopoietic stem cells. The undergoing of a transplant has to be confirmed by a specialist medical
practitioner.
i. Other stem-cell transplants
ii. Where only islets of langerhans are transplanted
e. Stroke Resulting in Permanent Symptoms:
Any cerebrovascular incident producing permanent neurological sequelae. This includes infarction of brain tissue, thrombosis in an intracranial
vessel, haemorrhage and embolisation from an extracranial source.
Diagnosis has to be confirmed by a specialist medical practitioner and evidenced by typical clinical symptoms as well as typical findings in CT
Scan or MRI of the brain.
Evidence of permanent neurological deficit lasting for atleast 3 months has to be produced.
The following are excluded:
i. Transient ischemic attacks (TIA)
ii. Traumatic Injury of the brain
iii. Vascular disease affecting only the eye or optic nerve or vestibular functions
f. Surgery of Aorta:
Surgery of aorta including graft, insertion of stents or endovascular repair.
Specific Exclusion: Surgery for correction of an underlying Congenital Anomaly.
g. Angioplasty:
I. Coronary Angioplasty is defined as percutaneous coronary intervention by way of balloon angioplasty with or without stenting for treatment
of the narrowing or blockage of minimum 50 % of one or more major coronary arteries. The intervention must be determined to be medically
necessary by a cardiologist and supported by a coronary angiogram (CAG).

II. Coronary arteries herein refer to left main stem, left anterior descending, circumflex and right coronary artery.
III. Diagnostic angiography or investigation procedures without angioplasty/stent insertion are excluded.
h. Primary (Idiopathic) Pulmonary Hypertension:
I. An unequivocal diagnosis of Primary (Idiopathic) Pulmonary Hypertension by a Cardiologist or specialist in respiratory medicine with
evidence of right ventricular enlargement and the pulmonary artery pressure above 30 mm of Hg on Cardiac Cauterization. There must be
permanent irreversible physical impairment to the degree of at least Class IV of the New York Heart Association Classification of cardiac
impairment.
II. The NYHA Classification of Cardiac Impairment are as follows:
i. Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms.
ii. Class IV: Unable to engage in any physical activity without discomfort. Symptoms may be present even at rest.
III. Pulmonary hypertension associated with lung disease, chronic hypoventilation, pulmonary thromboembolic disease, drugs and toxins,
diseases of the left side of the heart, congenital heart disease and any secondary cause are specifically excluded.
i. Brain Surgery:
Any brain (intracranial) Surgery required to treat traumatic or non-traumatic conditions.
Specific Exclusion: Surgery for treating Neurocysticercosis.
XXVIII. Standby Services are services of another Medical Practitioner requested by treating Medical Practitioner and involving prolonged attendance without
direct (face-to-face) patient contact or involvement.
XXIX. Suite Room means
a. a space available for boarding in a Hospital which contains two or more rooms; Or
b. a space available for boarding in a Hospital which contains an extended living/dining/kitchen area
XXX. Sum Insured: In case of Individual Policy, Sum Insured means the total of the Base Sum Insured, re-fill amount as per Section 3.9 and Increased Sum
Insured under I-Protect (if any) as per Section 4.1 which is Our maximum, total and cumulative liability for any and all claims during the Policy Year in
respect of the Insured Person. However in case of a single claim, Our maximum liability for that claim during the Policy Year in respect of the Insured
Person shall be the total of the Base Sum Insured and Increased Sum Insured under I-Protect (if any) as per Section 4.1.
In case of Family Floater Policy, Sum Insured means the total of the Base Sum Insured, re-fill amount as per Section 3.9 and Increased Sum Insured
under I-Protect (if any) as per Section 4.1 which is Our maximum, total and cumulative liability for any and all claims during the Policy Year in respect
of all Insured Persons. However in case of a single claim, Our maximum liability for that claim during the Policy Year shall be the total of the Base Sum
Insured and Increased Sum Insured under I-Protect (if any) as per Section 4.1.
XXXI. Waiting Period means a time-bound exclusion period related to condition(s) specified in the Policy Schedule or the Policy which shall be served
before a claim related to such condition(s) becomes admissible.
XXXII. We/Our/Us means Niva Bupa Health Insurance Company Limited.
XXXIII. You/Your/Policyholder means the person named in the Policy Schedule who has concluded this Policy with Us.
3. Benefits covered under the Policy

a. The Benefits available under this Policy are described below.
b. The Policy covers Reasonable and Customary Charges incurred towards medical treatment or consultation taken by the Insured Person during the Policy
Period for an Illness, Injury or conditions as described in the sections below, provided such Illness, Injury or conditions contracted or sustained by an Insured
Person during the Policy Period. The Benefits listed in the sections below will be payable subject to the terms, conditions and exclusions of this Policy and
the availability of the Sum Insured and subject always to any sub-limits in respect of that Benefit as specified in the Policy Schedule for the Insured Person.
c. All the benefits (including optional benefits) along with the respective limits / amounts for each respective Sum Insured applicable under the product have
been summarized in the Product Benefit Table as specified in Annexure IV.
d. The expenses that are not covered or subsumed into room charges / procedure charges / costs of treatment are mentioned in Annexure II.
e. All claims for any benefits under the Policy must be made in accordance with the process defined under Section 7.2 (XIII) (Claim process & Requirements).
f. All claims paid under any benefit except for those paid under Section 3.8 (Health Checkup / Diagnostic Tests), Section 3.10 (Second Medical Opinion),
Section 3.11 (OPD Consultation), Section 3.12 (Behavioral Assistance Program) and Section 4.3 (Personal Accident Cover) shall reduce the Sum Insured for
that Policy Year in which the claim has been incurred, unless otherwise specified in the respective section and only the balance Sum Insured after payment
of claim amounts admitted shall be available for all future claims arising in that Policy Year.
g. For all the benefits under Section 3.8 (Health Checkup / Diagnostic Tests), Section 3.10 (Second Medical Opinion), Section 3.11 (OPD Consultation), Section
3.12 (Behavioral Assistance Program) and Section 4.3 (Personal Accident Cover), the respective sub-limits or number of consultation / services or Sum
Insured as applicable shall be reduced after payment of claim amounts admitted or utilization of consultation / services.

3.1. Inpatient Care
We will indemnify the Medical Expenses incurred on the Insured Person’s Hospitalization during the Policy Period following an Illness or Injury that occurs
during the Policy Period, provided that:
a. The Hospitalization is Medically Necessary and advised by Medical Practitioner and the treatment follows Evidence Based Clinical Practices and
Standard Treatment Guidelines.
b. The Medical Expenses incurred are Reasonable and Customary Charges for one or more of the following:
i. Room Rent;
ii. Nursing charges for nursing services under Hospitalization through a qualified nursing staff as an Inpatient;
iii. Medical Practitioners’ fees, excluding any charges or fees for Standby Services;
iv. Physiotherapy, investigation and diagnostics procedures directly related to the current event which lead to Hospitalization;
v. Medicines, drugs as prescribed by the treating Medical Practitioner related to the current event that lead to Hospitalization and not otherwise;
vi. Intravenous fluids, blood transfusion, injection administration charges, consumables and/or enteral feedings;
vii. Operation theatre charges;
viii. The cost of prosthetics and other devices or equipment, if implanted internally during Surgery;
ix. Intensive / Critical Care Unit Charges.
c. If the Insured Person is admitted in the Hospital room where the room category opted or Room Rent incurred is higher than the eligibility as specified
in the Policy Schedule, then We shall be liable to pay only a pro-rated portion of the total Associated Medical Expenses (including surcharge or taxes
thereon) in the proportion of the difference between the Room Rent actually incurred and the Room Rent specified in the Policy Schedule or the Room
Rent of the entitled room category to the Room Rent actually incurred.
d. We shall not be liable to pay the visiting fees or consultation charges for any Medical Practitioner visiting the Insured Person unless such:
i. Medical Practitioner’s treatment or advice has been sought by the Hospital; and
ii. Visiting fees or consultation charges are included in the Hospital’s bill
3.2. Pre-hospitalization Medical Expenses
We will indemnify the Insured Person’s Pre-hospitalization Medical Expenses incurred following an Illness or Injury that occurs during the Policy Period
provided that:
a. We have accepted a claim for Inpatient Care under Section 3.1 (Inpatient Care) or Section 3.4 (Day Care Treatment) or Section 3.16 (Modern Treatments)
or Domiciliary Hospitalization covered in Section 3.5 and Pre-hospitalization Medical Expenses are incurred for the same condition for which We have
accepted the Inpatient Care or Day Care Treatment or Domiciliary Hospitalization or Modern Treatments claim.
b. We will not be liable to pay Pre-hospitalization Medical Expenses for more than 90 days immediately preceding the Insured Person’s admission for
Inpatient Care/ Day Care Treatment/ Domiciliary Hospitalization / Modern Treatments or such expenses incurred prior to inception of the First Policy
with Us.
c. Pre-hospitalization Medical Expenses can be claimed under the Policy on a Reimbursement basis only.
d. Pre-hospitalization Medical Expenses incurred on Physiotherapy will also be payable provided that such Physiotherapy is Medically Necessary and
advised by the Medical Practitioner and such Physiotherapy is directly related to current event that led to Hospitalization or Day Care Treatment.
e. Sum Insured for the Policy Year in which In-patient Care/ Day Care Treatment/ Domiciliary Hospitalization/ Modern Treatments claim has been incurred
shall be reduced.
3.3. Post-hospitalization Medical Expenses
We will indemnify the Insured Person’s Post-hospitalization Medical Expenses incurred following an Illness or Injury that occurs during the Policy Period as
advised by the treating Medical Practitioner provided that:
a. We have accepted a claim for Inpatient Care under Section 3.1 (Inpatient Care) or Section 3.4 (Day Care Treatment) or Section 3.16 (Modern Treatments)
or Domiciliary Hospitalization covered in Section 3.5 and Post-hospitalization Medical Expenses are incurred for the same condition for which We have
accepted the Inpatient Care or Day Care Treatment or Domiciliary Hospitalization or Modern Treatments claim.
b. We will not be liable to pay Post-hospitalization Medical Expenses for more than 180 days immediately following the Insured Person’s discharge from
Hospital/ Day Care Treatment/ Domiciliary Hospitalization/ Modern Treatments.
c. Post-hospitalization Medical Expenses can be claimed under the Policy on a Reimbursement basis only.
d. Post-hospitalization Medical Expenses incurred on Physiotherapy will also be payable provided that such Physiotherapy is Medically Necessary and
advised by the treating Medical Practitioner and such Physiotherapy is directly related to current event that led to Hospitalization or Day Care Treatment.

e. Sum Insured for the Policy Year in which In-patient Care/ Day Care Treatment/ Domiciliary Hospitalization/ Modern Treatments claim has been incurred
shall be reduced.
3.4. Day Care Treatment
We will indemnify the Medical Expenses incurred on the Insured Person’s Day Care Treatment during the Policy Period following an Illness or Injury provided
that: :
a. The Day Care Treatment is Medically Necessary and follows the written advice of a Medical Practitioner.
b. The Medical Expenses incurred are Reasonable and Customary Charges for any procedure where such procedure is undertaken by an Insured Person
as Day Care Treatment.
c. We will not cover any OPD Treatment and Diagnostic Services under this Benefit.
d. List of Day Care Treatments which are covered under the Policy are provided in Annexure VI.
3.5. Home Health Care Services and Domiciliary Hospitalization
We will indemnify on a Reimbursement basis the Medical Expenses incurred for Domiciliary Hospitalization during the Policy Period following an Illness or
Injury that occurs during the Policy Period provided that:
a. The Domiciliary Hospitalization continues for at least 3 consecutive days in which case We will make payment under this Benefit in respect of Medical
Expenses incurred from the first day of Domiciliary Hospitalization;
b. For Domiciliary Hospitalization, the treating Medical Practitioner confirms in writing that the Insured Person’s condition was such that the Insured
Person could not be transferred to a Hospital OR the Insured Person satisfies Us that a Hospital bed was unavailable.
For Home Health Care Services, the amount, frequency and time period of the services needs to be reasonable, and in agreement between treating Medical
Practitioner and the Insured Person availing the service. We will cover the Medical Expenses incurred for Home Health Care Services during the Policy Period
and availed through empanelled Service Provider on Cashless Facility basis only if the following conditions are fulfilled:
i. The condition of the Insured Person must be expected to improve in a reasonable and generally-predictable period of time, or
ii. Treatment under this benefit will be provided under the supervision of a Medical Practitioner to safely and effectively administer the treatment plan
for the condition of the Insured Person.
The Home Health Care Services are covered only if We have accepted a claim under Section 3.1 (Inpatient Care) above and Home Health Care Services are
availed immediately after that Hospitalization.
The Home Health Care Services are provided through empanelled Service Provider in selected cities only. Please contact Us or refer to Our website www.
nivabupa.com for updated list of cities where Home Health Care Services are provided.
3.6. Living Organ Donor Transplant
We will indemnify the Medical Expenses incurred for a living organ donor’s Inpatient treatment for the harvesting of the organ donated provided that:
a. The donation conforms to The Transplantation of Human Organs Act 1994 and amendments thereafter and the organ is for the use of the Insured
Person.
b. The recipient Insured Person has been Medically Advised to undergo an organ transplant.
c. We have accepted the recipient Insured Person’s claim under Section 3.1 (Inpatient Care).
d. Medical Expenses incurred are Reasonable and Customary Charges.
We shall not be liable to make any payment in respect of:

a. Stem cell donation whether or not Medically Necessary except for Bone Marrow Transplant.
b. Pre-hospitalization Medical Expenses or Post-hospitalization Medical Expenses of the organ donor.
c. Screening or any other Medical Expenses related to the organ donor which are not incurred during the duration of Insured Person’s hospitalization for
organ transplant.
d. Transplant of any organ/tissue where the transplant is experimental or investigational.
e. Expenses related to organ transportation or preservation.
f. Any other medical treatment or complication in respect of the donor, consequent to harvesting.

3.7. Emergency Ambulance
We will indemnify the Reasonable and Customary Charges for ambulance expenses incurred to transfer the Insured Person by surface transport following
an Emergency provided that:
a. The medical condition of the Insured Person requires immediate ambulance services from the place where the Insured Person is injured or is ill to a
Hospital where appropriate medical treatment can be obtained or from the existing Hospital to another Hospital with advanced facilities as advised by
the treating Medical Practitioner for management of the current Hospitalization.
b. This benefit is available for one transfer per Hospitalization.
c. The ambulance service is offered by a healthcare or ambulance Service Provider.
d. We have accepted a claim under Section 3.1 (Inpatient Care) above.
e. We will cover expenses up to the amount specified in the Policy Schedule.
f. We will not make any payment under this Benefit if the Insured Person is transferred to any Hospital or diagnostic centre for evaluation purposes only.
3.8. Health Checkup / Diagnostic Tests
The Insured Person may avail a health check-up as specified in the Policy Schedule through empanelled Service Provider for this benefit on Cashless Facility
basis provided that:
a. Health check-up shall be requested through Our mobile application or website.
b. The Insured Person is above Age 18 on the commencement of that Policy Year.
c. Any unutilized Health check-up cannot be carry forwarded to the next Policy Year.
d. The list of tests covered under this benefit is as specified in Annexure III.
Instead of availing Health Checkup and if allowed and specified in the Policy Schedule, any Insured Person may undergo the Diagnostic Tests of his/her own
choice at any diagnostic centre of his/her choice and get the expenses reimbursed or avail this benefit on Cashless Facility up to the amount as specified in
the Policy Schedule. Any unutilized amount cannot be carry forwarded to the next Policy Year.
3.9. Re-fill Benefit
If the Base Sum Insured and Increased Sum Insured under I-Protect (if any) has been partially or completely exhausted due to claims made and paid or
claims made and accepted as payable for any Illness / Injury during the Policy Year under Section 3, then We will provide a Re-fill amount of maximum up
to 100% of the Base Sum Insured which may be utilized for claims arising in that Policy Year, provided that:
a. The re-fill amount may be used for only subsequent claims in respect of the Insured Person and shall not be for any Illness / Injury (including its
complications or follow up) for which a claim has been paid or accepted as payable in the current Policy Year for the same Insured Person.
b. For Family Floater Policies, the re-fill amount will be available on a floater basis to all Insured Persons in that Policy Year.
c. If the re-fill amount is not utilized in whole or in part in a Policy Year, it cannot be carried forward to any extent in any subsequent Policy Year.
d. The maximum liability for a single claim after applying Re-fill benefit shall not be more than Base Sum Insured and Increased Sum Insured under
I-Protect (if any).
3.10. Second Medical Opinion
If the Insured Person is diagnosed with a Specified Illness as defined under Section 2.2 (XXVII) or is planning to undergo a planned Surgery or a Surgical
Procedure for any Illness or Injury, the Insured Person can, at the Insured Person’s sole direction, obtain a Second Medical Opinion during the Policy Period
provided that:
a. Second Medical Opinion shall be requested through Our mobile application or website.
b. The Second Medical Opinion will be arranged by Us (without any liabilities) and will be based only on the information and documentation provided by
the Insured Person that will be shared with the Medical Practitioner.
c. This benefit can be availed only once by an Insured Person during a Policy Year for the same Specified Illness or planned Surgery.
d. By seeking the Second Medical Opinion under this Benefit, the Insured Person is not prohibited or advised against visiting or consulting with any other
independent Medical Practitioner or commencing or continuing any treatment advised by such Medical Practitioner.
e. The Insured Person is free to choose whether or not to obtain the Second Medical Opinion, and if obtained then whether or not to act on it in whole
or in part.
f. The Second Medical Opinion under this Benefit shall be limited to defined criteria and not be valid for any medicolegal purposes.

g. We do not represent correctness of the Second Medical Opinion and shall not assume or deem to assume any liability towards any loss or damage
arising out of or in relation to any opinion, advice, prescription, actual or alleged errors, omissions and representations made by the Medical Practitioner.
3.11. OPD Consultation
We will cover OPD Consultation taken by the Insured Person during the Policy Period provided that:
a. We will cover the number of consultations as specified in the Policy Schedule.
b. This benefit can be availed either through a Cashless Facility or on Reimbursement basis through a network.
c. OPD Consultation shall be requested through Our mobile application or website.
d. In case of Reimbursement, a maximum amount limit per consultation as specified in the Policy Schedule shall be applicable under this benefit.
e. The number of consultations will be applicable for all Insured Persons on a cumulative basis for the Policy Year.
f. Any unutilized number of consultations cannot be carried forwarded to the next Policy Year.
3.12. Behavioral Assistance Program
We will cover the counseling sessions through telephonic mode only under this benefit to provide support on pre-marital counseling, nutrition, stress, child
and parenting taken by the Insured Person during the Policy Period provided that:
a. We will cover the number of consultations as specified in the Policy Schedule.
b. This benefit can only be availed through Our empanelled Service Providers on Cashless Facility.
c. Any unutilized number of consultations cannot be carry forwarded to the next Policy Year.
Section 6.2 (X) of the Permanent Exclusions shall not apply to the extent this Benefit is applicable.
3.13. Pharmacy and Diagnostic Services
You may purchase medicines and diagnostic services from Our empanelled Service Provider through Our mobile application or website. The cost for the
purchase of the medicines or diagnostic services shall be borne by You. Further it is made clear that purchase of medicines or diagnostic services from Our
empanelled Service Provider is Your absolute discretion and choice.
3.14. AdvantAGE
There will be a discount of 10% in the First Policy Year Base Premium and all subsequent Renewal Base Premium, if Age of the eldest Insured Person at the
time of inception of the First Policy with Us is less than or equal to 35 years.
In case an Individual Policy is converted into Family Floater Policy at the time of Renewal, then the discount under this benefit shall be available on the
Family Floater Policy only if one of the following conditions is fulfilled:
a. The Insured Persons added in the Family Floater Policy are less than Age 35 years; or
b. The Insured Persons added in the Family Floater Policy are younger than the existing Insured Person.
3.15. Alternative Treatments
We will indemnify the Medical Expenses incurred on the Insured Person’s Hospitalization for Inpatient Care during the Policy Period on treatment taken
under Ayurveda, Unani, Sidha and Homeopathy.
Conditions:
a. The treatment should be taken in a AYUSH Hospital:
b. Pre-hospitalization Medical Expenses incurred for up to 90 days prior to the commencement of treatment and Post-hospitalization Medical Expenses
incurred for up to 180 days following the conclusion of the treatment will also be indemnified under this benefit, provided that these Medical Expenses
relate only to Alternative Treatments and not Allopathy.
c. Section 6.2 (XIV) of the Permanent Exclusions (other than for Yoga) shall not apply to the extent this benefit is applicable.

3.16. Modern Treatments:
What is covered:
a. The following procedures / treatments will be covered either as Inpatient Care or as part of Day Care Treatment as per Section 3.1 and Section 3.4
respectively, in a Hospital :
i. Uterine Artery Embolization and HIFU (High intensity focused ultrasound)
ii. Balloon Sinuplasty
iii. Deep Brain stimulation
iv. Oral chemotherapy
v. Immunotherapy- Monoclonal Antibody to be given as injection
vi. Intra vitreal injections
vii. Robotic surgeries
viii. Stereotactic radio surgeries
ix. BronchicalThermoplasty
x. Vaporisation of the prostrate (Green laser treatment or holmium laser treatment)
xi. IONM - (Intra Operative Neuro Monitoring)
xii. Stem cell therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered.
b. If We have accepted a claim under this benefit, We will also indemnify the Insured Person’s Pre-hospitalization Medical Expenses and Post-
hospitalization Medical Expenses in accordance with Sections 3.2 and 3.3 within the overall benefit sub-limit.
Special condition applicable for robotic surgeries:

A limit of maximum INR 1 Lac will apply to all robotic surgeries, except the following:
a. Robotic total radical prostatectomy
b. Robotic cardiac surgeries
c. Robotic partial nephrectomy
d. Robotic surgeries for malignancies
4. Optional Benefits
The following optional benefits shall apply under the Policy as specified in the Policy Schedule, only if the optional benefit is selected by You. Optional benefits
can be selected only at the time of issuance of the First Policy or at Renewal by You unless otherwise specified, on payment of the corresponding additional
premium. If a loading applies to the premium for the main Policy, such loading will also apply to the premium for the optional benefits selected except under
Section 4.2 (Health Coach) and Section 4.3 (Personal Accident Cover).
The Optional Benefits cover Reasonable and Customary Charges incurred towards the medical treatment or services taken by the Insured Person during the Policy
Period for an Illness, Injury or conditions described in the sections below, if it is contracted or sustained by an Insured Person during the Policy Period.
All the benefits (including optional benefits) along with the respective limits / amounts for each respective Sum Insured applicable under the product have been
summarized in the Product Benefit Table as specified in Annexure IV.
All claims for any benefits under the Policy must be made in accordance with the process defined under Section 7.2 (XIII) (Claim process & Requirements).
4.1. I-Protect
If the Policy is Renewed with Us without a break, each Policy Year We will increase the Sum Insured applicable under the Policy by 10% of the Base Sum
Insured of the immediately preceding Policy Year. The sub-limits applicable to various benefits will remain the same and shall not increase proportionately
with the Sum Insured. This benefit is not applicable for Re-fill Benefit, OPD Consultation, Health check-up / Diagnostic Tests, Second Medical Opinion,
Behavioral Assistance Program and Optional Benefits (if opted for) such as Health Coach and Personal Accident Cover.
a. This benefit can be opted only at inception of the first Policy with Us and not at Renewal of the Policy. If opted at inception, You have the option to opt
out of the benefit at the time of Renewal of the Policy. In such case, the accumulated Increased Sum Insured under I-Protect shall:
i. Not increase further and remain constant, if You pay the same additional percentage of premium as paid in the preceding Policy Year for this
benefit. Or
ii. Be reduced to zero, if You do not pay any additional premium for this benefit.

b. If the Insured Person in the expiring Policy is covered under an Individual Policy and has an accumulated Increased Sum Insured under I-Protect in
the expiring Policy under this benefit, and such expiring Policy is Renewed with Us on a Family Floater Policy, then the I-Protect benefit and the
accumulated Increased Sum Insured under I-Protect shall also be provided to the Family Floater Policy.
c. If the Insured Persons in the expiring Policy are covered on a Family Floater Policy and such Insured Persons Renew their expiring Policy with Us
by splitting the Floater Sum Insured stated in the Policy Schedule in to two or more floater / individual Policy, then the I-Protect benefit and the
accumulated Increased Sum Insured under I-Protect shall also be provided to each of the split Policies.
d. In case the Base Sum Insured under the Policy is reduced at the time of Renewal, the applicable accumulated Increased Sum Insured under I-Protect
shall also be reduced in proportion to the Base Sum Insured.
e. In case the Base Sum Insured under the Policy is increased at the time of Renewal, the applicable accumulated Increased Sum Insured under I-Protect
shall also be increased in proportion to the Base Sum Insured.
4.2. Health Coach
This benefit is available either to the Primary Insured Person or Primary Insured Person along with his/her spouse. Subject to policy terms and conditions
and to encourage good health and well being, We shall provide the following wellness related services to the Insured Person(s) covered under this Benefit
and We shall be assisted in administering these services through Our Service Provider:
a. Personalized health coaching – The Insured Person will have the facility to connect with a personal coach through a mobile application to guide and
motivate the Insured Person to achieve his/her personal health goals. The health coach facility assists in identifying factors relating to the Insured
Person’s lifestyle and habits and also suggests ways to shift these habits to improve activity and wellness and to encourage overall well-being.
The health coaching facility is unlimited and can be availed any number of times during the Policy Year. In order to obtain access to the health coach
facility, the Insured Person would be required to download the mobile application and register his/her specified details through the mobile application.
When registration is complete, the Insured Person’s health coach will notify him/her through the mobile application to set up the Insured Person’s
introductory call where Insured Person will discuss with the health coach to establish his/her short and long term goals. Once these goals are recorded,
the health coach will provide on-going daily support, motivation and interpretation of the Insured Person’s tracking data to help the Insured Person
stay on track to reach his/her goals. The Insured Person and the health coach will also be able to connect frequently to review the progress and revise
the existing goals or set new goals.
The mobile application shall also keep track of Insured Person’s steps taken, daily food logs etc., which can be accessed by the Insured Person, personal
health coach and Our empanelled Medical Practitioners under this Benefit.

b. Calculation of health score - Health Score shall be calculated as per the table below:
Health Score Model

Complete & win
Task Based Tasks to be Completed
(Points/task)
Sign up & Activation 500
Selecting your own goals 500
One time Taking your first Health assessment 750
Completing your first tele-consultation with Our empanelled Medical Practitioner 500
Uploading your first health record 750
Coach engagement (>3 interactions / week) 250
Weekly Walking - Steps count (5000 steps /day --- 5 times /week) 300
Daily food logs (minimum 10 logs/ week) 250
Habit tracking (minimum 15 check in) 500
Monthly
Monthly Coach review - Call 500
Quarterly Health Assessment 500
Tele-consultation with Our empanelled Medical Practitioner 1200
Half Yearly
Sharing your test reports / records 1500
Score - based on your

Performance performance
Parameters for performance review
Based
(Max points / review )
One time Health Assessment at the time of on boarding 2000
Monthly Monthly performance - Quality score by personal health coach 2000
On completion of goal set by personal health coach 500
Quarterly
Based on health assessment results 2000
Annual Health Earn up to 1 lac points in

(Task based points + Performance based points)
score a year
Health assessment is a commonly used health screening tool which captures user’s lifestyle, food, personal health, Emotional heath, Occupational
health and diagnostic data.
One time Task Based points in second and subsequent Policy Year will get replaced with Renewal points awarded on Renewal of the Policy along with
Health Coach Benefit. For Health Score calculation, monthly scores will be calculated and accumulated to arrive at the annual Health Score.
c. Discount in renewal premium basis Health Score:

We will provide You a discount in Renewal Base Premium based on the Insured Person’s Health Score under this Benefit as per following table:
Health Score Discount in Renewal Base Premium
0-9999 0%
10000-69999 5%
70000-79999 10%
80000-89999 15%
90000-100000 20%
The Health Score of the Primary Insured Person (higher of the health scores, if both Primary Insured Person and spouse are covered under this benefit)
shall be considered for calculating the discount in Renewal Base Premium.
For the first Renewal, the Health Score at the end of nine Policy months shall be considered and pro-rated to arrive at the twelve months score for
calculating the discount in Renewal Base Premium. For subsequent Renewals, Health Score for the next twelve Policy months from the date of last
annual Health Score calculation, shall be considered for calculating the discount in Renewal Base Premium.

The above benefits will be subject to following conditions:
i. For services that are availed over phone or through online/ digital mode, the Insured Person will be required to provide the details as sought by
Our Service Provider in order to establish authenticity and validity prior to availing such services.
ii. It is entirely for the Insured Person(s) to decide whether to obtain these services, the extent to which he/she wishes to avail these services and
further to decide whether to use any of these services and if so to which extent.
iii. The services are intended to provide support information to the Insured Person to improve well-being and habits through working towards
personalized health goals. These services are not medical advice and are not meant to substitute the Insured Person’s visit/ consultation to an
independent Medical Practitioner.
iv. The information services provided under this benefit, including information provided through personalized health coaching services, does not
constitute medical advice of any kind and it is not intended to be, and should not be, used to diagnose or identify treatment for a medical
or mental health condition. The information services provided under this benefit, including information provided through personalized health
coaching services, does not substitute for any medical advice as well.
v. The Insured Person shall be free to consider or not consider the suggestions of the health coach and make any lifestyle changes based on
information provided through these services. For any change the Insured Person makes to his lifestyle whether or not on the advice of the health
coach, We or Our Service Provider shall in no manner be liable for any harm or injury, whether bodily or otherwise that may occur as a result
of such lifestyle changes. The Insured Person must seek immediate medical advice if there is any adverse effect or discomfort on making any
lifestyle changes.
vi. We or Our Service Provider do not warrant the validity, accuracy, completeness, safety, quality, or applicability of the content or anything said or
written by any personal health coach or any suggestions provided. We or Our Service Provider will not be liable for any damages sustained due
to reliance by the Insured Person on such information or suggestions provided by any personal health coach.
vii. Health Coaching through a personal health coach and calculation of the Health Score are being provided through Our Service Provider. Kindly
refer to Annexure V for details on terms and conditions for use of health coaching services.
4.3. Personal Accident Cover
This benefit is available either to the Primary Insured Person or Primary Insured Person along with his/her spouse. If the Insured Person covered under this
benefit dies or sustains any Injury resulting solely and directly from an Accident occurring during the Policy Period at any location worldwide, and while the
Policy is in force, We will provide the benefits described below.
a. Accident Death
If the Insured Person suffers an Accidental Injury during the Policy Period, which directly results in the Insured Person’s death within 365 days from
occurrence of the Accident, We will make payment under this benefit as specified in the Policy Schedule. If the claim gets triggered for Accident Death,
the coverage for that Insured Person will cease for all the benefits under the Policy post payment of the benefit to the beneficiary. Any claim incurred
before death of such Insured person shall be admissible subject to terms and conditions under this Policy.
b. Accident Permanent Total Disability (PTD)

Permanent Total Disability means disablement of the Insured Person solely and directly due to an Accident leading to one of the following conditions:
i. Loss of use of Limbs or Sight

The Insured Person suffers from total and irrecoverable loss of:
• The use of two Limbs (including paraplegia and hemiplegia) OR
• The sight of both eyes OR
• The use of one Limb and the sight of one eye
ii. Loss of independent living

The Insured Person is permanently unable to perform independently three or more of the following six activities of daily living.
• Washing: the ability to maintain an adequate level of cleanliness and personal hygiene
• Dressing: the ability to put on and take off all necessary garments, artificial limbs or other surgical appliances that are Medically Necessary
• Feeding: the ability to transfer food from a plate or bowl to the mouth once food has been prepared and made available
• Toileting: the ability to manage bowel and bladder function, maintaining an adequate and socially acceptable level of hygiene
• Mobility: the ability to move indoors from room to room on level surfaces at the normal place of residence
• Transferring: the ability to move from a lying position in a bed to a sitting position in an upright chair or wheel chair and vice versa.

If the Insured Person suffers Permanent Total Disability within 365 days from occurrence of an Accident, We will make payment under this benefit
as specified in the Policy Schedule provided that:
i. The Permanent Total Disability is proved through a disability certificate issued by a Medical Board duly constituted by the Central and/or the
State Government; and
ii. We will admit a claim under this benefit only if the Permanent Total Disability continues for a period of at least 6 continuous calendar months
from the commencement of the Permanent Total Disability. This clause shall not be applicable in case the disability is irreversible, like in case
of amputation of limbs etc.; and
iii. If the Insured Person dies before a claim has been admitted under Accident Permanent Total Disability, no amount will be payable under
this benefit, however We will consider the claim under Accident Death subject to terms and conditions under Accident Death benefit; and
iv. We will not make payment under Accident Permanent Total Disability for any and all Policy Periods more than once in the Insured Person’s
lifetime.
Post payment of benefit under Accident Permanent Total Disability, the coverage for that Insured Person will cease under Personal Accident
Cover. Personal Accident Cover cannot be renewed thereafter for that Insured Person; however, all other benefits can be renewed under the Policy.
c. Accident Permanent Partial Disability (PPD)

If the Insured Person suffers Permanent Partial Disability solely and directly due to an Accident and within 365 days from occurrence of such Accident,
We will make payment under this benefit as specified in the table below which is a percentage of the Personal Accident Cover Sum Insured, provided
that:
i. The Permanent Partial Disability is proved through a disability certificate issued by a Medical Board duly constituted by the Central and/or the
State Government: and
ii. We will admit a claim under this benefit only if the Permanent Partial Disability continues for a period of at least 6 continuous calendar months
from the commencement of the Permanent Partial Disability. This clause shall not be applicable in case the disability is irreversible, like in case of
amputation of finger, thumb etc.; and
iii. If the Insured Person dies before a claim has been admitted under Accident Permanent Partial Disability, no amount will be payable under this
benefit, however We will consider the claim under Accident Death subject to terms and conditions under Accident Death benefit.
iv. If a claim has been admitted under Accident Permanent Total Disability, then no further claim in respect of the same condition will be admitted
under this benefit.
v. If this benefit is triggered and the entire Sum Insured does not get utilized, then the balance Sum Insured shall be available for other Permanent
Partial Disability and other benefits under Personal Accident Cover until the entire Sum Insured is consumed. The Sum Insured limit for Personal
Accident Cover shall be a lifetime limit and once this limit is exhausted whether due to any or more than one of the Permanent Partial Disabilities,
then the coverage for that Insured Person will cease under Personal Accident Cover. Personal Accident Cover cannot be renewed for that Insured
Person thereafter; however, all other benefits can be renewed under the Policy.

The table below shows the amount payable basis the nature of disability.
Permanent Partial Disability Grid
% of Personal Accident Cover
S. No. Nature of Disability Sum Insured
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%
3 Loss or total and permanent loss of use of one hand from the wrist joint and of one foot from 100%
the ankle joint
4 Loss or total and permanent loss of use of one hand from the wrist joint and total and permanent 100%
loss of sight in one eye
5 Loss or total and permanent loss of use of one foot from the ankle joint and total and permanent 100%
loss of sight in one eye
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 fingers 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%
5. Claim Cost Sharing Options / Conditions
The following claim cost sharing options shall apply under the Policy as specified in the Policy Schedule and shall apply to all Insured Persons only if such options
are selected by You and / or applicable under this Policy. These claim cost sharing options can be selected only at the time of issuance of the First Policy or at
Renewal by You.
5.1. Annual Aggregate Deductible
The Insured Person shall bear on his/her own account an amount equal to the Deductible specified in the Policy Schedule for all admissible claim amounts
We assess to be payable by Us in respect of all claims made by that Insured Person under the Policy for a Policy Year. It is agreed that Our liability to make
payment under the Policy in respect of any claim made in that Policy Year will only commence once the Deductible has been exhausted.

It is further agreed that:
a. The provisions in Section 5.2 on Co-payment (if applicable) will apply to any amounts payable by Us in respect of a claim made by the Insured Person
after the Deductible has been exhausted.
b. Deductible will not apply to any claim under Section 3.8 (Health Checkup / Diagnostic Tests), Section 3.10 (Second Medical Opinion), Section 3.11 (OPD
Consultation), Section 3.12 (Behavioral Assistance Program) and Section 4.3 (Personal Accident Cover).
5.2. Co-payment
Co-payment (if applicable) as specified in the Policy Schedule shall be applicable on the amount payable by Us.
Co-payment will not apply to any claim under Section 3.7 (Emergency Ambulance), Section 3.8 (Health Checkup / Diagnostic Tests), Section 3.10 (Second
Medical Opinion), Section 3.11 (OPD Consultation), Section 3.12 (Behavioral Assistance Program) and Section 4.3 (Personal Accident Cover).
If You select Zone 2 (as described under Section 7.2.XI), then 20% Co-payment will apply for treatment in Mumbai, Delhi NCR, Kolkata & Gujarat State. This
Zone-wise Co-payment shall not be applicable on OPD Consultation, Emergency Ambulance, Health Checkup / Diagnostic Tests, Second Medical Opinion,
Behavioral Assistance Program and Personal Accident Cover.
6. Exclusions
6.1. Standard Exclusions
I. Pre-existing Diseases (Code–Excl01):

a. Expenses related to the treatment of a Pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 36 months of
continuous coverage after the date of inception of the first Policy with Us.
b. In case of enhancement of Sum Insured the exclusion shall apply afresh to the extent of Sum Insured increase.
c. If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health Insurance)
regulations, then waiting period for the same would be reduced to the extent of prior coverage.
d. Coverage under the Policy after the expiry of 36 months for any Pre-existing Disease is subject to the same being declared at the time of
application and accepted by Us.
II. Specified disease/procedure waiting period (Code- Excl02):

a. Expenses related to the treatment of the listed conditions, surgeries/treatments shall be excluded until the expiry of 24 months of continuous
coverage after the date of inception of the first Policy with us. This exclusion shall not be applicable for claims arising due to an Accident (covered
from day 1) or Cancer (covered after 30-day waiting period).
b. In case of enhancement of Sum Insured the exclusion shall apply afresh to the extent of Sum Insured increase.
c. If any of the specified disease/procedure falls under the waiting period specified for pre-Existing diseases, then the longer of the two waiting
periods shall apply.
d. The waiting period for listed conditions shall apply even if contracted after the Policy or declared and accepted without a specific exclusion.
e. If the Insured Person is continuously covered without any break as defined under the applicable norms on portability stipulated by IRDAI then
waiting period for the same would be reduced to the extent of prior coverage.
f. List of specific diseases/procedures:
i. Pancreatitis and Stones in biliary and urinary System
ii. Cataract, Glaucoma and other disorders of lens, disorders of retina
iii. Hyperplasia of prostate, hydrocele and spermatocele
iv. Abnormal utero-vaginal bleeding, female genital prolapse, endometriosis/adenomyosis, fibroids, PCOD, or any condition requiring dilation
and curettage or hysterectomy
v. Hemorrhoids, fissure or fistula or abscess of anal and rectal region
vi. Hernia of all sites,
vii. Osteoarthritis, Systemic Connective Tissue disorders, Dorsopathies, Spondylopathies, inflammatory Polyarthropathies, Arthrosis such as RA,
Gout, Intervertebral Disc disorders
viii. Chronic kidney disease and failure

ix. Varicose veins of lower extremities
x. Disease of middle ear and mastoid including Otitis Media, Cholesteatoma, Perforation of Tympanic Membrane
xi. All internal or external benign or In Situ Neoplasms/Tumours, Cyst, Sinus, Polyp, Nodules, Swelling, Mass or Lump
xii. Ulcer, Erosion and Varices of Upper Gastro Intestinal Tract
xiii. Tonsils and Adenoids, Nasal Septum and Nasal Sinuses
xiv. Internal Congenital Anomaly
III. 30-day waiting period (Code- Excl03):

a. Expenses related to the treatment of any Illness within 30 days from the first Policy commencement date shall be excluded except claims arising
due to an Accident, provided the same are covered.
b. This exclusion shall not, however, apply if the Insured Person has continuous coverage for more than twelve months
c. The within referred waiting period is made applicable to the enhanced Sum Insured in the event of granting higher Sum Insured subsequently.
Note: Exc01,Excl02, Excl03 shall not apply to Section 3.8 (Health Checkup / Diagnostic Tests), Section 3.10 (Second Medical Opinion), Section 3.11
(OPD Consultation), Section 3.12 (Behavioral Assistance Program) and optional benefits (if opted) under Section 4.2 (Health Coach) and Section 4.3
(Personal Accident Cover).
IV. Investigation & Evaluation (Code-Excl04)

a. Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.
b. Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.
V. Rest Cure, rehabilitation and respite care (Code-Excl05)

Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:
a. Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing, dressing, moving
around either by skilled nurses or assistant or non-skilled persons.
b. Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.
VI. Obesity/ Weight Control (Code-Excl06)

Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:
a. Surgery to be conducted is upon the advice of the Doctor.
b. The surgery/Procedure conducted should be supported by clinical protocols.
c. The member has to be 18 years of age or older and;
d. Body Mass Index (BMI);
i. greater than or equal to 40 or
ii. greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive methods of weight
loss:
1. Obesity-related cardiomyopathy
2. Coronary heart disease
3. Severe Sleep Apnea
4. Uncontrolled Type2 Diabetes
VII. Change-of-Gender treatments (Code-Excl07)

Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.
VIII. Cosmetic or plastic Surgery (Code-Excl08)

Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident, Burn(s) or Cancer or
as part of medically necessary treatment to remove a direct and immediate health risk to the insured. For this to be considered a medical necessity, it
must be certified by the attending Medical Practitioner.

IX. Hazardous or Adventure sports (Code-Excl09)
Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports, including but not limited to,
para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.
X. Breach of law (Code-Excl10)

Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with
criminal intent.
XI. Excluded Providers (Code-Excl11)

Expenses incurred towards treatment in any Hospital or by any Medical Practitioner or any other provider specifically excluded by Us and disclosed in
Our website / notified to the Policyholders are not admissible. However, in case of life threatening situations or following an Accident, expenses up to
the stage of stabilization are payable but not the complete claim.
The complete list of excluded providers can be referred to on our website.

XII. Treatment for, alcoholism, drug or substance abuse or any addictive condition and consequences thereof. (Code-Excl12)
XIII. Treatments received in heath hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing home attached to such
establishments or where admission is arranged wholly or partly for domestic reasons. (Code-Excl13)
XIV. Dietary supplements and substances that can be purchased without prescription, including but not limited to vitamins, minerals and organic substances
unless prescribed by a Medical Practitioner as part of Hospitalization claim or Day Care procedure (Code-Excl14)
XV. Refractive Error (Code-Excl15)

Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres.
XVI. Unproven Treatments (Code-Excl16)

Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are treatments,
procedures or supplies that lack significant medical documentation to support their effectiveness.
XVII. Sterility and Infertility (Code-Excl17)

Expenses related to sterility and infertility. This includes:
a. Any type of contraception, sterilization
b. Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
c. Gestational Surrogacy
d. Reversal of sterilization
XVIII. Maternity (Code-Excl18)

a. Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during Hospitalization)
except ectopic pregnancy;
b. Expenses towards miscarriage (unless due to an Accident) and lawful medical termination of pregnancy during the Policy Period.
6.2. Specific Exclusions
I. Personal Waiting Periods:

Conditions specified for an Insured Person under Personal Waiting Period in the Policy Schedule will be subject to a Waiting Period of 24 months from
the inception of the First Policy with Us for that Insured Person and will be covered from the commencement of the third Policy Year for that Insured
Person as long as the Insured Person has been insured continuously under the Policy without any break.
II. Ancillary Hospital Charges

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

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

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

Screening, counseling or treatment related to external Congenital Anomaly.
VI. Dental/oral treatment:

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

Treatment for any condition / illness which requires hormone replacement therapy.
VIII. Multifocal Lens and ambulatory devices such as walkers, crutches, splints, stockings of any kind and also any medical equipment which is subsequently
used at home.
IX. Sexually transmitted Infections & diseases (other than HIV / AIDS):
Screening, prevention and treatment for sexually related infection or disease (other than HIV / AIDS).
X. Sleep disorders:
Treatment for any conditions related to disturbance of normal sleep patterns or behaviors.
XI. Any treatment or medical services received outside the geographical limits of India.
XII. Unrecognized Physician or Hospital:

a. Treatment or Medical Advice provided by a Medical Practitioner not recognized by the Medical Council of India or by Central Council of Indian
Medicine or by Central council of Homeopathy.
b. Treatment provided by anyone with the same residence as an Insured Person or who is a member of the Insured Person’s immediate family or
relatives.
c. Treatment provided by Hospital or health facility that is not recognized by the relevant authorities in India.
XIII. Artificial life maintenance for the Insured Person who has been declared brain dead or in vegetative state as demonstrated by:
a. Deep coma and unresponsiveness to all forms of stimulation; or
b. Absent pupillary light reaction; or
c. Absent oculovestibular and corneal reflexes; or
d. Complete apnea.

XIV. AYUSH Treatment
Any form of AYUSH Treatments, except as mentioned under Section 3.15
XV. Permanent Exclusion for Personal Accident Cover

We shall not be liable to make any payment under any benefits under the Personal Accident Cover if the claim is attributable to, or based on, or arise
out of, or are directly or indirectly connected to any of the following:
a. Suicide or self inflicted Injury, whether the Insured Person is medically sane or insane.
b. 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..

c. Service in the armed forces, or any police organization, of any country at war or at peace or service in any force of an international body or
participation in any of the naval, military or air force operation during peace time.
d. Any change of profession after inception of the Policy which results in the enhancement of Our risk, if not accepted and endorsed by Us on the
Policy Schedule.
e. Committing an assault, a criminal offence or any breach of law with criminal intent.
f. Taking or absorbing, accidentally or otherwise, any intoxicating liquor, drug, narcotic, medicine, sedative or poison, except as prescribed by a
Medical Practitioner other than the Policyholder or an Insured Person.
g. 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 airports or ports.
h. 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;
7. General Terms and Clause

7.1. Standard General Terms and Clauses
I. Free Look Period

The Free Look Period shall be applicable on new individual health insurance policies and not on renewals or at the time of porting/migrating the policy.
The insured person shall be allowed free look period of fifteen days (thirty days for policies with a term of 3 years, if sold through distance marketing)
from date of receipt of the policy document to review the terms and conditions of the policy, and to return the same if not acceptable.
lf the insured has not made any claim during the Free Look Period, the insured shall be entitled to
a. a refund of the premium paid less any expenses incurred by the Company on medical examination of the insured person and the stamp duty
charges
II. Cancellation
I. The policyholder may cancel this policy by giving 15 days’ written notice and in such an
event, the Company shall refund premium for the unexpired policy period as detailed below.
Notwithstanding anything contained herein or otherwise, no refunds of premium shall be made in respect of Cancellation where, any claim has
been admitted or has been lodged or any benefit has been availed by the insured person under the policy.
Policy in-force up to Refund Premium (%)

Up to 30 days 75%
31 to 90 days 50%
91 to 180 days 25%
181 to 365 days 0%
II. The Company may cancel the policy at any time on grounds of misrepresentation non-disclosure of material facts, fraud by the insured person by
giving 15 days’ written notice. There would be no refund of premium on cancellation on grounds of misrepresentation, non-disclosure of material
facts or fraud.
In case of death of an Insured, pro-rate refund of the premium for the deceased insured will be refunded, provided there is no history of claim.
III. Renewal of Policy

The policy shall ordinarily be renewable except on grounds of fraud, misrepresentation by the insured person.
I. The Company shall endeavor to give notice for renewal. However, the Company is not under obligation to give any notice for renewal.
II. Renewal shall not be denied on the ground that the insured person had made a claim or claims in the preceding policy years.
III. Request for renewal along with requisite premium shall be received by the Company before the end of the policy period.
IV. At the end of the policy period, the policy shall terminate and can be renewed within the Grace Period of 30 days to maintain continuity of
benefits without break in policy. Coverage is not available during the grace period.
V. No loading shall apply on renewals based on individual claims experience.

IV. Nomination
The policyholder is required at the inception of the policy to make a nomination for the purpose of payment of claims under the policy in the event of
death of the policyholder. Any change of nomination shall be communicated to the company in writing and such change shall be effective only when
an endorsement on the policy is made. ln the event of death of the policyholder, the Company will pay the nominee {as named in the Policy Schedule/
Policy Certificate/Endorsement (if any)} and in case there is no subsisting nominee, to the legal heirs or legal representatives of the policyholder
whose discharge shall be treated as full and final discharge of its liability under the policy.
V. Fraud
lf any claim made by the insured person, is in any respect fraudulent, or if any false statement, or declaration is made or used in support thereof, or if
any fraudulent means or devices are used by the insured person or anyone acting on his/her behalf to obtain any benefit under this policy, all benefits
under this policy and the premium paid shall be forfeited.
Any amount already paid against claims made under this policy but which are found fraudulent later shall be repaid by all recipient(s)/policyholder(s),
who has made that particular claim, who shall be jointly and severally liable for such repayment to the insurer.
For the purpose of this clause, the expression “fraud” means any of the following acts committed by the insured person or by his agent or the hospital/
doctor/any other party acting on behalf of the insured person, with intent to deceive the insurer or to induce the insurer to issue an insurance policy: a)
the suggestion, as a fact of that which is not true and which the insured person does not believe to be true; b) the active concealment of a fact by the
insured person having knowledge or belief of the fact; c) any other act fitted to deceive; and d) any such act or omission as the law specially declares
to be fraudulent
The Company shall not repudiate the claim and / or forfeit the policy benefits on the ground of Fraud, if the insured person / beneficiary can prove
that the misstatement was true to the best of his knowledge and there was no deliberate intention to suppress the fact or that such misstatement of
or suppression of material fact are within the knowledge of the insurer.
VI. Possibility of Revision of Terms of the Policy Including the Premium Rates
The Company, with prior approval of IRDAI, may revise or modify the terms of the policy including the premium rates. The insured person shall be
notified three months before the changes are effected.
VII. Withdrawal of Policy

I. ln the likelihood of this product being withdrawn in future, the Company will intimate the insured person about the same 90 days prior to expiry
of the policy.
II. lnsured Person will have the option to migrate to similar health insurance product available with the Company at the time of renewal with all the
accrued continuity benefits such as cumulative bonus, waiver of waiting period as per IRDAI guidelines, provided the policy has been maintained
without a break.
VIII. Redressal of Grievance:

ln case of any grievance the insured person may contact the company through
Website: www.nivabupa.com
Toll free: 1860-500-8888
E-mail: customercare@nivabupa.com (Senior citizens may write to us at: seniorcitizensupport@nivabupa.com)
Fax : +91 11 41743397
Courier: Customer Services Department
Niva Bupa Health Insurance Company Limited
D-5, 2nd Floor, Logix Infotech Park
opp. Metro Station, Sector 59, Noida, Uttar Pradesh, 201301

lnsured person may also approach the grievance cell at any of the company’s branches with the details of grievance lf lnsured person is not satisfied
with the redressal of grievance through one of the above methods, insured person may contact the grievance officer at
Head – Customer Services
Customer Helpline No: 1860-500-8888
Fax No.: +91 11 41743397
Email ID: customercare@nivabupa.com
For updated details of grievance officer, kindly refer the link https://www.nivabupa.com/customer-care/health-services/grievance-redressal.aspx
If the Insured person is not satisfied with the above, they can escalate to GRO@nivabupa.com.
lf lnsured person is not satisfied with the redressal of grievance through above methods, the insured person may also approach the office of lnsurance
Ombudsman of the respective area/region for redressal of grievance as per lnsurance Ombudsman Rules 2017 (at the addresses given in Annexure I).
Grievance may also be lodged at IRDAI lntegrated Grievance Management System - https:/igms. irda.qov.in/
IX. Claim settlement (Provision for Penal interest)

I. The Company shall settle or reject a claim, as the case may be, within 30 days from the date of receipt of last necessary document.
II. ln the case of delay in the payment of a claim, the Company shall be liable to pay interest to the policyholder from the date of receipt of last
necessary document to the date of payment of claim at a rate 2% above the bank rate.
III. However, where the circumstances of a claim warrant an investigation in the opinion of the Company, it shall initiate and complete such
investigation at the earliest, in any case not later than 30 days from the date of receipt of last necessary document- ln such cases, the Company
shall settle or reject the claim within 45 days from the date of receipt of last necessary document.
IV. ln case of delay beyond stipulated 45 days, the Company shall be liable to pay interest to the policyholder at a rate 2% above the bank rate from
the date of receipt of last necessary document to the date of payment of claim.
(Explanation: “Bank rate” shall mean the rate fixed by the Reserve Bank of lndia (RBl) at the beginning of the financial year in which claim has fallen
due)
X. Moratorium Period
After completion of eight continuous years under the Policy no look back to be applied. This period of eight years is called as moratorium period. The
moratorium would be applicable for the sums insured of the first Policy and subsequently completion of 8 continuous years would be applicable from
date of enhancement of sums insured only on the enhanced limits. After the expiry of Moratorium Period no health insurance claim shall be contestable
except for proven fraud and permanent exclusions specified in the Policy contract. The policies would however be subject to all limits, sub limits, co-
payments, deductibles as per the Policy contract.
XI. Multiple Policies

I. ln case of multiple policies taken by an insured person during a period from one or more insurers to indemnify treatment costs, the insured person
shall have the right to require a settlement of his/her claim in terms of any of his/her policies. ln all such cases the insurer chosen by the insured
person shall be obliged to settle the claim as long as the claim is within the limits of and according to the terms of the chosen policy.
II. lnsured person having multiple policies shall also have the right to prefer claims under this policy for the amounts disallowed under any other
policy / policies even if the sum insured is not exhausted. Then the insurer shall independently settle the claim subject to the terms and conditions
of this policy.
III. lf the amount to be claimed exceeds the sum insured under a single policy, the insured person shall have the right to choose insurer from whom
he/she wants to claim the balance amount.
IV. Where an insured person has policies from more than one insurer to cover the same risk on indemnity basis, the insured person shall only be
indemnified the treatment costs in accordance with the terms and conditions of the chosen policy

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

The terms and conditions of the policy must be fulfilled by the insured person for the Company to make any payment for claim(s) arising under the
policy.
XIV. Portability
The insured person will have the option to port the policy to other insurers by applying to such insurer to port the entire policy along with all the
members of the family, if any, at least 45 days before, but not earlier than 60 days from the policy renewal date as per IRDAI guidelines related to
portability. lf such person is presently covered and has been continuously covered without any lapses under any health insurance policy with an lndian
General/Health insurer, the proposed insured person will get the accrued continuity benefits in waiting periods as per IRDAI guidelines on portability
For Detailed Guidelines on portability, kindly refer the link https://www.irdai.gov.in/ADMINCMS/cms/whatsNew_Layout.aspx?page=PageNo3987&flag=1
XV. Migration
The insured person will have the option to migrate the policy to other health insurance products/plans offered by the company by applying for
migration of the policy atleast 30 days before the policy renewal date as per IRDAI guidelines on Migration. lf such person is presently covered and
has been continuously covered without any lapses under any health insurance product/plan offered by the company, the insured person will get the
accrued continuity benefits in waiting periods as per IRDAI guidelines on migration.
For Detailed Guidelines on migration, kindly refer the link https://www.irdai.gov.in/ADMINCMS/cms/whatsNew_Layout.aspx?page=PageNo3987&flag=1
7.2. Specific Terms and Clauses
I. Automatic Cancellation:
I. Individual Policy:
The Policy shall automatically terminate in the event of death of the Insured Person.
II. For Family Floater Policies:

The Policy shall automatically terminate in the event of the death of all the Insured Persons. .
III. Refund:
A refund in accordance with the table in Section 7.1 (II) shall be payable if there is an automatic cancellation of the Policy provided that no claim
has been made and the Health Checkup / Diagnostic Tests, Second Medical Opinion, OPD Consultation or Behavioral Assistance Program have
not been availed under the Policy by or on behalf of any Insured Person. We will pay the refund of premium to the Nominee named in the Policy
Schedule or Your legal heirs or legal representatives holding a valid succession certificate.
II. Loading on Premium

a. Based on Our discretion, upon the disclosure of the health status of the persons proposed for insurance and declarations made in the Proposal or
Insurance Summary Sheet, We may apply a risk loading on the premium payable (excluding statutory levies and taxes) or Special Conditions on
the Policy. The maximum risk loading applicable shall not exceed 180%.
b. These loadings will be applied from inception date of the First Policy including subsequent Renewal(s) with Us.
c. If a loading applies to the premium for the main Policy, such loading will also apply to the premium for the optional benefits selected except
under Section 4.2 (Health Coach) and Section 4.3 (Personal Accident Cover).

III. Other Renewal Conditions:
a. Continuity of Benefits on Timely Renewal:
i. The Renewal premium is payable on or before the due date and in any circumstances before the expiry of Grace Period.
ii. Renewal premium rates for this Policy may be further altered by Us including in the following circumstances:
A. You proposed to add an Insured Person to the Policy
B. You change any coverage provision
C. You change Your residence to different zip code
iii. Renewal premium will alter based on individual Age. The reference of Age for calculating the premium for Family Floater Policies shall be the
Age of the eldest Insured Person.
b. Reinstatement:
i. The Policy shall lapse after the expiration of the Grace Period. If the Policy is not Renewed within the Grace Period then We may agree to
issue a fresh Policy subject to Our underwriting criteria, as per Our Board approved underwriting policy and no continuing benefits shall be
available from the expired Policy.
ii. We will not pay for any Medical Expenses which are incurred happen between the date the Policy expires and the date immediately before
the reinstatement date of Your Policy.
iii. If there is any change in the Insured Person’s medical or physical condition, We may add exclusions or charge an extra premium from the
reinstatement date.
c. Disclosures on Renewal:
You shall make a full disclosure to Us in writing of any material change in the health condition or geographical location of any Insured Person at
the time of seeking Renewal of this Policy, irrespective of any claim arising or made. The terms and condition of the existing Policy will not be
altered.
d. Renewal for Insured Persons who have achieved Age 22:

If any Insured Person who is a child and has completed Age 22 years at the time of Renewal, then such Insured Person will have to take a separate
policy based on Our underwriting guidelines, as per Our Board approved underwriting policy as he/she will no longer be eligible to be covered
under a Family Floater Policy. In such cases, the credit of the Waiting Periods served under the Policy will be passed on to the separate policy
taken by such Insured Person.
e. Addition of Insured Persons on Renewal:

Where an individual is added to this Policy, either by way of endorsement or at the time of Renewal, the Pre-existing Disease clause, exclusions,
loading (if any) and Waiting Periods will be applicable considering such Policy Year as the first year of the Policy with Us.
f. Changes to Sum Insured on Renewal:

You may opt for enhancement of Sum Insured at the time of Renewal, subject to underwriting. All Waiting Periods shall apply afresh for this
enhanced limit from the effective date of such enhancement.
IV. Change of Policyholder

a. The Policyholder may be changed only at the time of Renewal. The new Policyholder must be a member of the Insured Person’s immediate
family. Such change would be solely subject to Our discretion and payment of premium by You. The Renewed Policy shall be treated as having
been Renewed without break. The Policyholder may be changed upon request in case of Your death, Your emigration from India or in case of
Your divorce during the Policy Period.
b. Any alteration in the Policy due to unavoidable circumstances as in case of the Policyholder’s death, emigration or divorce during the Policy
Period should be reported to Us immediately. Coverage of Benefits in such scenario will be limited to current Policy Year.
c. Renewal of such Policies will be according to terms and conditions of existing Policy.
V. Obligations in case of a minor

If an Insured Person is less than 18 years of Age, You or another adult Insured Person or legal guardian (in case of Your and all other adult Insured
Person’s demise) shall be completely responsible for ensuring compliance with all the terms and conditions of this Policy on behalf of that minor
Insured Person.

VI. Authorization to obtain all pertinent records or information:
As a Condition Precedent to the payment of benefits, We and/or Our Service Provider shall have the authority to obtain all pertinent records or
information from any Medical Practitioner, Hospital, clinic, insurer, individual or institution to assess the validity of a claim submitted by or on behalf
of any Insured Person.
VII. Policy Disputes

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

All benefits are available in India only and all claims shall be payable in India in Indian Rupees only.
IX. Notices
Any notice, direction or instruction given under this Policy shall be in writing and delivered by hand, post, or facsimile to:
a. You/the Insured Person at the address specified in the Policy Schedule or at the changed address of which We must receive written notice.
b. Us at the following address:
Fax No.: +91 11 41743397
c. No insurance agents, brokers or other person/entity is authorized to receive any notice on Our behalf.
d. In addition, We may send You/the Insured Person other information through electronic and telecommunications means with respect to Your
Policy from time to time.
X. Alteration to the Policy

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

For the purpose of calculating premium, following zones are available:
• Zone 1: All India coverage
• Zone 2: All India coverage (Co-payment applicable for Mumbai, Delhi NCR, Kolkata & Gujarat State)
If You select Zone 2, then 20% Co-payment will apply for Inpatient treatment in Mumbai, Delhi NCR, Kolkata & Gujarat State. This Zone-wise Co-
payment shall not be applicable on OPD Consultation, Emergency Ambulance, Health Checkup / Diagnostic Tests, Second Medical Opinion, Behavioral
Assistance Program and Personal Accident Cover.
XII. Assignment:
The policy can be assigned subject to applicable laws.
XIII. Claims Process & Requirements

The fulfillment of the terms and conditions of this Policy (including payment of full premium in advance by the due dates mentioned in the Policy
Schedule) in so far as they relate to anything to be done or complied with by You or any Insured Person, including complying with the following in
relation to claims, shall be Condition Precedent to admission of Our liability under this Policy.
A. Claims Administration:
On the occurrence or discovery of any Illness or Injury that may give rise to a claim under this Policy, the Claims Procedure set out below shall be followed:
a. The directions, advice and guidance of the treating Medical Practitioner shall be strictly followed.
b. We/Our representatives must be permitted to inspect the medical and Hospitalization records pertaining to the Insured Person’s treatment and to
investigate the circumstances pertaining to the claim.

c. We and Our representatives must be given all reasonable co-operation in investigating the claim in order to assess Our liability and quantum in respect
of the claim.
d. It is hereby agreed and understood that no change in the Medical Record provided under the Medical Advice information, by the Hospital or the Insured
Person to Us or Our Service Provider during the period of Hospitalization or after discharge by any means of request will be accepted by Us. Any
decision on request for acceptance of change will be at Our discretion.
B. Claims Procedure: On the occurrence or the discovery of any Illness or Injury that may give rise to a claim under this Policy, then as a Condition Precedent
to Our liability under the Policy the following procedure shall be complied with:
a. For Availing Cashless Facility: Cashless Facility can be availed only at Our Network Providers or Service Providers. The complete list of Network
Providers is available on Our website and at Our branches and can also be obtained by contacting Us over the telephone. In order to avail Cashless
Facility, the following process must be followed:
i. Process for Obtaining Pre-Authorization

A. For Planned Treatment:
We must be contacted to pre-authorize Cashless Facility for planned treatment at least 72 hours prior to the proposed treatment. Once the
request for pre-authorisation has been granted, the treatment must take place within 15 days of the pre-authorization date at a Network
Provider.
B. In Emergencies
If the Insured Person has been Hospitalized in an Emergency, We must be contacted to pre-authorize Cashless Facility within 48 hours of the
Insured Person’s Hospitalization or before discharge from the Hospital, whichever is earlier.
C. Pre-authorization through digital platform:
Pre-authorization in respect to Health Checkup, Second Medical Opinion and OPD Consultation (on Cashless Facility) should be requested
through Our mobile application or website.
All final authorization requests, if required, shall be sent at least six hours prior to the Insured Person’s discharge from the Hospital.
Each request for pre-authorization except for Health Checkup, Second Medical Opinion, OPD Consultation and Behavioral Assistance Program
must be accompanied with completely filled and duly signed pre-authorization form including all of the following details:
I. The health card We have issued to the Insured Person at the time of inception of the Policy (if available) supported with KYC document;
II. The Policy Number;
III. Name of the Policyholder;
IV. Name and address of Insured Person in respect of whom the request is being made;
V. Nature of the Illness/Injury and the treatment/Surgery required;
VI. Name and address of the attending Medical Practitioner;
VII. Hospital where treatment/Surgery is proposed to be taken;
VIII. Date of admission;
IX. First and any subsequent consultation paper / Medical Record since beginning of diagnosis of that treatment/Surgery;
X. Admission note;
XI. Treating doctor certificate for disease / event history with justification of hospitalization.
If these details are not provided in full or are insufficient for Us to consider the request, We will request additional information or documentation
in respect of that request.
When We have obtained sufficient details to assess the request, We will issue the authorization letter specifying the sanctioned amount,
any specific limitation on the claim, applicable Deductibles / Co-payment and non-payable items, if applicable, or reject the request for pre-
authorisation specifying reasons for the rejection.
In case of preauthorization request where chronicity of condition is not established as per clinical evidence based information We may reject the
request for preauthorization and ask the claimant to claim as reimbursement. Claim documents submission for reimbursement should not be
considered as an admission of liability.

Once the request for pre-authorisation has been granted, the treatment must take place within 15 days of the pre-authorization date and pre-
authorization shall be valid only if all the details of the authorized treatment, including dates, Hospital, locations, indications and disease details,
match with the details of the actual treatment received. For cashless Hospitalization, We will make the payment of the amount assessed to be
due, directly to the provider.
We reserve the right to modify, add or restrict any Network Provider or Service Provider for Cashless Facility in Our sole discretion. Before availing
Cashless Facility, please check the applicable updated list of providers. The complete list of providers is available on Our website and at Our
branches and can also be obtained by contacting Us over the telephone.
ii. Reauthorization
Cashless Facility will be provided subject to re-authorization is requested for either change in the line of treatment or in the diagnosis or for any
procedure carried out on the incidental diagnosis/finding prior to the discharge from the Hospital.
b. For Reimbursement Claims:

For all claims for which Cashless Facility have not been pre-authorized or for which treatment has not been taken at a Network Provider, We shall be
informed of the claim along with the following details within 48 hours of admission to the Hospital or before discharge from the Hospital, whichever
is earlier:
i. The Policy Number;
ii. Name of the Policyholder;
iii. Name and address of the Insured Person in respect of whom the request is being made;
iv. Nature of Illness or Injury and the treatment/Surgery taken;
v. Name and address of the attending Medical Practitioner;
vi. Hospital where treatment/Surgery was taken;
vii. Date of admission and date of discharge;
viii. Any other information that may be relevant to the Illness/ Injury/ Hospitalization.
C. Claims Documentation: We shall be provided with the following necessary information and documentation in respect of all claims at Your/Insured Person’s
expense within 30 days of the Insured Person’s discharge from Hospital (in the case of Pre-hospitalization Medical Expenses and Hospitalization Medical
Expenses) or within 30 days of the completion of the Post-hospitalization Medical Expenses period (in the case of Post-hospitalization Medical Expenses)
or within 30 days of death or disability due to accident (in case of Personal Accident Cover). For claims for which the use of Cashless Facility has been
authorised, We will be provided these documents by the Network Provider immediately following the Insured Person’s discharge from Hospital:
a. Claim form duly completed and signed by the claimant.
Please provide mandatorily following information if applicable
i. Current diagnosis and date of diagnosis;
ii. Past history and first consultation details;
iii. Previous admission/Surgery if any.
b. Age / Identity proof document: Of Insured Person in case of cashless claim (not required if submitted at the time of pre-authorization request) and
Policyholder in case of Reimbursement claim.
i. Self attested copy of valid age proof (passport / driving license / PAN card / class X certificate / birth certificate);
ii. Self attested copy of identity proof (passport / driving license / PAN card / voter identity card);
iii. Recent passport size photograph
c. Cancelled cheque/ bank statement / copy of passbook mentioning account holder’s name, IFSC code and account number printed on it of Policyholder
/ nominee ( in case of death of Policyholder).
d. Original discharge summary.
e. Additional documents required in case of Surgery/Surgical Procedure.
i. Bar code sticker and invoice for implants and prosthesis (if used);
f. Original final bill from Hospital with detailed break-up and paid receipt.
g. Room tariff of the entitled room category (in case of a Non-Network provider and if room tariff is not a part of Hospital bill): duly signed and stamped
by the Hospital in which treatment is taken.

(In case You are unable to submit such document, then We shall consider the Reasonable and Customary Charges of the Insured Person’s eligible room
category of Our Network Provider within the same geographical area for identical or similar services.)
h. Original bills of pharmacy/medicines purchased, or of any other investigation done outside Hospital with reports and requisite prescriptions.
i. Copy of death certificate (in case of demise of the Insured Person).
j. Original certificate of Disability issued by a Medical Board duly constituted by the Central and the State Government (in case of Personal Accident
Cover)
k. For Medico-legal cases (MLC) or in case of Accident
i. MLC/First Information Report (FIR) copy attested by the concerned Hospital / police station (if applicable);
ii. Original self-narration of incident in absence of MLC / FIR.
l. Original laboratory investigation, diagnostic & pathological reports with supporting prescriptions.
m. Original X-Ray/ MRI / ultrasound films and other radiological investigations.
In the event of the Insured Person’s death during Hospitalization, written notice accompanied by a copy of the post mortem report (if any) shall be given to
Us regardless of whether any other notice has been given to Us.
Claim documentation for Personal Accident Cover under Section 4.3:

a. Accident Death
i. Duly filled and signed claim form and Age / Identity proof documents
ii. Copy of Death Certificate (issued by the office of Registrar of Births and Deaths or any other authorized legal institution)
iii. Copy of First Information Report (FIR) / Panchnama, if applicable
iv. Copy of Medico Legal Certificate duly attested by the concerned hospital, if applicable.
v. Copy of hospital record, if applicable
vi. Copy of Post Mortem report wherever applicable
b. Accident Permanent Total Disability

ii. Hospital Discharge Summary (in original) / self attested copies if the originals are submitted with another insurer.
iii. Final Hospital Bill (in original) / self attested copies if the originals are submitted with another insurer.
iv. Medical consultations and investigations done from outside the hospital.
v. Certificate of Disability issued by a Medical Board duly constituted by the Central and/or the State Government.
vi. Copy of First Information Report (FIR) / Panchnama if applicable
vii. Copy of Medico Legal Certificate duly attested by the concerned hospital, if applicable.
c. Accident Permanent Partial Disability

ii. Hospital Discharge Summary (in original) / self attested copies if the originals are submitted with another insurer.
iii. Final Hospital Bill (in original) / self attested copies if the originals are submitted with another insurer.
iv. Medical consultations and investigations done from outside the hospital.
v. Certificate of Disability issued by a Medical Board duly constituted by the Central and/or the State Government.
vi. Copy of First Information Report (FIR) / Panchnama if applicable
vii. Copy of Medico Legal Certificate duly attested by the concerned hospital, if applicable.
D. Claims Assessment & Repudiation:
a. At Our discretion, We may investigate claims to determine the validity of a claim. All costs of investigation will be borne by Us and all investigations
will be carried out by those individuals/entities that are authorized by Us in writing.
b. Payment for Reimbursement claims will be made to You. In the unfortunate event of Your death, We will pay the Nominee named in the Policy
Schedule or Your legal heirs or legal representatives holding a valid succession certificate.
c. If a claim is made which extends in to two Policy Periods, then such claim shall be paid taking into consideration the available Sum Insured in these
Policy Periods including the Deductible for each Policy Period. Such eligible claim amount will be paid to the Policyholder/Insured Person after
deducting the extent of premium to be received for the Renewal/due date of premium of the Policy, if not received earlier.

d. All admissible claims under this Policy shall be assessed by Us in the following progressive order:-
i. If a room has been opted in a Hospital for which the room category is higher than the eligible limit as applicable for that Insured Person as
specified in the Policy Schedule, then the Associated Medical Expenses payable shall be pro-rated as per the applicable limits in accordance with
Section 3.1c.
ii. The Deductible (if applicable) shall be applied to the aggregate of all claims that are either paid or payable under this Policy. Our liability to make
payment shall commence only once the aggregate amount of all eligible claims as per policy terms and conditions exceeds the Deductible limit
within the same Policy Year.
iii. Co-payment (if applicable) as specified in the Policy Schedule shall be applicable on the amount payable by Us.
e. The claim amount assessed above would be deducted from the amount mentioned against each benefit and Sum Insured as specified in the Policy
Schedule. The re-fill amount will be applied only once the Base Sum Insured and Increased Sum Insured under I-Protect (if applicable) are exhausted
in the Policy Year.
E. Delay in Claim Intimation or Claim Documentation:

If the claim is not notified to Us or claim documents are not submitted within the stipulated time as mentioned in the above sections, then We shall
be provided the reasons for the delay, in writing. We will condone such delay on merits where the delay has been proved to be for reasons beyond the
claimant’s control.
F. Claims process and documentation for Section 3.8 (Health Checkup / Diagnostic Tests), Section 3.10 (Second Medical Opinion), Section 3.11 (OPD
Consultation) and 3.12 (Behavioral Assistance Program)
a. Insured Person shall submit the request through Our mobile application or website.
b. After validation of Insured Person and Policy details, We will evaluate the information of the Insured Person from the perspective to check eligibility
of cover only and if the request is approved, We will facilitate arrangement as per the conditions specified under respective benefits admissible to the
Insured Person.
c. The Insured Person shall avail the service on the scheduled time. The Insured Person shall need to produce the health card, identity proof and
prescription from the Medical Practitioner (wherever applicable) at the time of availing this service.
d. Any difference in amount (in case of sub-limit or additional procedure) will be paid by the Insured Person directly to the respective provider.
e. In case of Health checkup, Insured Person can avail pre-defined list of medical tests whereas in case of Diagnostic Tests, Insured Person can customize
or personalize their list of medical tests. However where Diagnostic Tests are availed, We will either reimburse the amount incurred by the Insured
Person or provide it on Cashless Facility, up to the amount as specified in the Policy Schedule.
f. In case of OPD Consultation on Reimbursement basis, We will reimburse up to the amount per consultation as specified in the Policy Schedule.
g. Reimbursement claims for Diagnostic Tests and/or OPD Consultation shall be submitted within 30 days from end of the Policy Year.
h. Reports / prescription can be collected directly from the respective centre or provider.
Disclaimer: Niva Bupa Health Insurance Company Limited (formerly known as Max Bupa Health Insurance Company Limited) (IRDAI Registration No. 145). ‘Bupa’ and
‘HEARTBEAT’ logo are registered trademarks of their respective owners and are being used by Niva Bupa Health Insurance Company Limited under license. Registered Office
Address: C-98, First Floor, Lajpat Nagar, Part 1, New Delhi-110024, Customer Helpline No.: 1860-500-8888. Fax: +91 11 41743397. Website: www.nivabupa.com.
CIN: U66000DL2008PLC182918. For more details on risk factors, terms and conditions, please read sales brochure carefully before concluding the sale.

Annexure I
List of Insurance Ombudsmen
Office Details Jurisdiction

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

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

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

3rd Floor, Jeevan Seva Annexe,
S. V. Road, Santacruz (W),
Mumbai - 400 054.
Tel.: 022 -69038800/69038812
Email: inscoun@cioins.co.in

Annexure II
The expenses that are not covered or subsumed into room charges / procedure charges / costs of treatment
List I – Expenses not covered
Sl. No. Item Sl. No. Item

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

List II – Items that are to be subsumed into Room Charges
Sl. No. Item

1 Baby Charges (Unless Specified/Indicated) 20 Luxury Tax
2 Hand Wash 21 Hvac
3 Shoe Cover 22 House Keeping Charges
4 Caps 23 Air Conditioner Charges
5 Cradle Charges 24 Im Iv Injection Charges
6 Comb 25 Clean Sheet
7 Eau-De-Cologne / Room Freshners 26 Blanket/Warmer Blanket
8 Foot Cover 27 Admission Kit
9 Gown 28 Diabetic Chart Charges
10 Slippers 29 Documentation Charges / Administrative Expenses
11 Tissue Paper 30 Discharge Procedure Charges
12 Tooth Paste 31 Daily Chart Charges
13 Tooth Brush 32 Entrance Pass / Visitors Pass Charges
14 Bed Pan 33 Expenses Related To Prescription On Discharge
15 Face Mask 34 File Opening Charges
16 Flexi Mask 35 Incidental Expenses / Misc. Charges (Not Explained)
17 Hand Holder 36 Patient Identification Band / Name Tag
18 Sputum Cup 37 Pulseoxymeter Charges
19 Disinfectant Lotions
List III – Items that are to be subsumed into Procedure Charges
Sl. No. Item

1 Hair Removal Cream 13 Surgical Drill
2 Disposables Razors Charges (For Site Preparations) 14 Eye Kit
3 Eye Pad 15 Eye Drape
4 Eye Sheild 16 X-Ray Film
5 Camera Cover 17 Boyles Apparatus Charges
6 Dvd, Cd Charges 18 Cotton
7 Gause Soft 19 Cotton Bandage
8 Gauze 20 Surgical Tape
9 Ward And Theatre Booking Charges 21 Apron
10 Arthroscopy And Endoscopy Instruments 22 Torniquet
11 Microscope Cover 23 Orthobundle, Gynaec Bundle
12 Surgical Blades, Harmonicscalpel,Shaver

List IV – Items that are to be subsumed into costs of treatment
Sl. No. Item

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

ANNEXURE III
List of tests covered under health check-up
(Not applicable for 1 Lac and 2 Lac Sum Insured)
Tests / Sum Insured 3 Lac 4 Lac 5 Lac 7.5 Lac 10 Lac 15 Lac 25 Lac
Urine Routine Analysis Available Available Available

CBC (Hemoglobin,PCV,TLC,RBC Count,MCV,MCH,MCHC,Platelet Available Available
Available
Count,Automated DLC,Absolute Differential Counts,RDW)
TSH Ultrasensitive Not Applicable Available Available
Phosphorous Not Applicable Available Available
Calcium Not Applicable Available Available
Alkaline Phosphate Not Applicable Available Available
SGPT Not Applicable Available Available
SGOT Not Applicable Available Available
Total Cholestrol Available Available Available
Not
HbA1C Available Not Applicable
Applicable
Uric Acid Not Applicable Available Available
Sugar (F) Not Applicable Available Available
Liver function test: (SGOT, SGPT, GGTP, Bilirubin-Total & Direct, Protein-
Total,Alkaline Phosphatase) Kidney function test: (Urea,Creatinine,Uric
Not Applicable Not Applicable Available
Acid, Protein-Total,Albumin,A:G Ratio,Alkaline Phosphatase,Calcium,
Phosphorus)

ANNEXURE IV
Product Benefit Table
GoActive (all amounts are in INR unless defined as percentage or number)

Base Sum Insured (SI) per Policy Year
1 lacs 2 lacs 3 lacs 4 lacs 5 lacs 7.5 lacs 10 lacs 15 lacs 25 lacs
Base Covers:
In-patient treatment
Nursing charges for Hospitalization as an inpatient
excluding Private Nursing charges
Medical Practitioners’ fees, excluding any charges or
fees for Standby Services
Physiotherapy, investigation and diagnostics
procedures directly related to the current admission
Covered up to Sum Insured
Medicines, drugs and consumables as prescribed by
the treating Medical Practitioner
Intravenous fluids, blood transfusion, injection
administration charges and /or consumables
Operation theatre charges
The cost of prosthetics and other devices or
equipment if implanted internally during Surgery
No restriction (except suite or above room category)
Room Rent (per day) Up to 1% of Base Sum Insured
(Limit included in Inpatient Care SI)
Intensive Care Unit / Critical Care Unit charges
Up to 2% of Base Sum Insured Covered up to Sum Insured
(per day)
Pre-Hospitalization Medical Expenses (90
days)
Post-Hospitalization Medical Expenses (180
days)
Day Care Treatment Covered up to Sum Insured
Living Organ Donor Transplant Covered up to Sum Insured
Alternative Treatment Covered up to Sum Insured
Modern Treatment Covered up to Sum Insured with sub-limit of Rs. 1Lac on few robotic surgeries
Emergency Ambulance Up to Rs.3,000 per hospitalization
1. Home Health Care
Services and Domiciliary Covered up to Sum Insured
Hospitalization
Re-fill Benefit(1) Base Sum Insured
Pharmacy and Diagnostic Services Available through provider network
OPD Consultation(2)
(For 1A, 1A+1C, 1A+2C: Consultations limits Not available 2 3 4 4 6 6 6
per policy, per policy year)
OPD Consultation(2)
(For 2A and more: Consultations limits per Not available 4 5 6 8 10 10 10
policy, per policy year)
Health check-up(3) Not available Available
Diagnostic Tests(3)
(Limits mentioned are per adult member)
(Diagnostic tests applicable in lieu of Not available 1,000 1,500 2,500
Health check-up through cashless and
reimbursement facility)

Behavioral Assistance Program 3 consultations per adult per policy year
Not available Covered, One opinion per Insured Person per Specified Illness / planned Surgery / Surgical
Second medical opinion Procedure
Enter at or before the age of 35 years (as on last birthday) and receive a 10% discount in the First Policy Year Base
AdvantAGE
Premium and all subsequent Renewal Base Premium
Optional Covers:
Deductible 25,000 / 50,000 / 1 lac / 2 lacs / 3 lacs / 5 lacs / 10 lacs
Additional 10% of Base Sum Insured every policy year at renewal for policy lifetime. This option can be opted only at
inception. On renewal of the policy, this option can be opted out post which this option will not be available. In such
case, the accumulated Increased Sum Insured under I-Protect shall:
I-Protect
a. Not increase further and remain constant, if the you pay the same additional percentage of premium as paid in the
preceding Policy Year for this benefit; OR
b. Be reduced to zero, if you do not pay any additional premium for this benefit.
Health Coach (4) Personalized health coaching
Personal Accident cover
- Accident Death
10 lacs 25 lacs 25 lacs / 50 lacs
- Accident Permanent Total Disability
- Accident Permanent Partial Disability
Notes:
– Entry age for Adults is 18 years - 65 Years (last birthday) and from 91 days to 21 years (last birthday) for children (dependent children).
– All benefits are provided on policy year basis
– Family combinations allowed: 1A, 2A , 2A+1C , 2A+2C , 2A+3C , 2A+4C, 1A+1C, 1A+2C. Relationship allowed is husband, wife and children.
– Policy term: 1 year
(1) Re-fill Benefit: Reinstate up to base Sum Insured. Applicable for different illness.
(2) OPD Consultation can be availed either through a Cashless Facility or on Reimbursement basis through a network. For Reimbursement, the maximum per
consultation limit is Rs. 600 for Zone 1 coverage and Rs. 500 for Zone 2 coverage
(3) Health check-up benefit – Defined list of tests. Applicable for Adults only.
In lieu of Health check up, if diagnostics are taken, it will be on both reimbursement and cashless facility basis up the specified amount. The amount of diagnostics
tests shall be per adult basis, however the utilization can be done by any of the insured persons including dependent child.
(4) Health Coach: Available to Primary Insured or Primary insured with spouse. Discount in renewal base premium up to 20% shall be provided based on the health
score.

ANNEXURE V
Terms and Conditions for use of health coaching services under Section 4.2 (Health Coach)
1. Use of services
The Insured Person must be 18 years of age to access and use the health coaching service and should be able to contract per applicable law. The Insured
Person may use the services only in compliance with these terms.
In order to register an account and access or use the services, the Insured Person may be required to provide certain information such as the full name,
email address, password, gender, profile picture, contact details, address, date of birth, height, weight, dietary information, fitness and exercise details,
medical history and conditions and medication details. The Insured Person shall be responsible for maintaining the accuracy and completeness of this
information provided.
The Insured Person may register for use of the services through his/her existing email accounts (such as Gmail, Hotmail etc.) The email address will
constitute the username for the account. The Insured Person shall be responsible for maintaining the confidentiality of the username and password. The
Insured Person is encouraged to use “strong” passwords (passwords that use a combination of upper and lower case letters, numbers and symbols) for
the account. The Insured Person shall be fully responsible for all activities that occur under such account, including activities of others to whom the Insured
Person has provided his/her username or password. The Insured Person should notify us immediately of any unauthorized use of his/her account or any
other breach of security.
2. No Provision of Medical Advice

This service is not to be construed as medical advice and in no case shall this be considered as substitute to medical expert opinion. The Insured Person
shall not use the site or the services for any medical or mental health needs. If the Insured Person thinks that he/she may be a danger to themselves or
others, or if the Insured Person is having a medical or mental health emergency, the Insured Person should call the emergency medical services closest
to him/her. The services provided herein including information provided through personalized coaching services, does not constitute medical advice of
any kind and it is not intended to be, and should not be, used to diagnose or identify treatment for a medical or mental health condition. Nothing in the
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Annexure VI - Day Care Treatments
S.No. Header Procedure Name S.No. Header Procedure Name

I Cardiology Related: 38 Other Operations On The Middle And Inner Ear
1 Coronary Angiography 39 Excision And Destruction Of Diseased Tissue Of The Nose
II Critical Care Related: 40 Other Operations On The Nose
2 Insert Non- Tunnel Cv Cath 41 Nasal Sinus Aspiration
3 Insert Picc Cath ( Peripherally Inserted Central Catheter ) 42 Foreign Body Removal From Nose
43 Other Operations On The Tonsils And Adenoids
4 Replace Picc Cath ( Peripherally Inserted Central Catheter )
44 Adenoidectomy
5 Insertion Catheter, Intra Anterior
45 Labyrinthectomy For Severe Vertigo
6 Insertion Of Portacath
46 Stapedectomy Under Ga
III Dental Related:
47 Stapedectomy Under La
7 Splinting Of Avulsed Teeth
48 Tympanoplasty (Type Iv)
8 Suturing Lacerated Lip
49 Endolymphatic Sac Surgery For Meniere's Disease
9 Suturing Oral Mucosa
50 Turbinectomy
10 Oral Biopsy In Case Of Abnormal Tissue Presentation
51 Endoscopic Stapedectomy
11 Fnac
52 Incision And Drainage Of Perichondritis
12 Smear From Oral Cavity
53 Septoplasty
IV ENT Related:
54 Vestibular Nerve Section
13 Myringotomy With Grommet Insertion
55 Thyroplasty Type I
Tympanoplasty (Closure Of An Eardrum Perforation/
14 56 Pseudocyst Of The Pinna - Excision
Reconstruction Of The Auditory Ossicles)
57 Incision And Drainage - Haematoma Auricle
15 Removal Of A Tympanic Drain
58 Tympanoplasty (Type Ii)
16 Keratosis Removal Under Ga
59 Reduction Of Fracture Of Nasal Bone
17 Operations On The Turbinates (Nasal Concha)
Tympanoplasty (Closure Of An Eardrum Perforation/ 60 Thyroplasty Type Ii
18
Reconstruction Of The Auditory Ossicles) 61 Tracheostomy
19 Removal Of Keratosis Obturans 62 Excision Of Angioma Septum
20 Stapedotomy To Treat Various Lesions In Middle Ear 63 Turbinoplasty
21 Revision Of A Stapedectomy 64 Incision & Drainage Of Retro Pharyngeal Abscess
22 Other Operations On The Auditory Ossicles 65 Uvulo Palato Pharyngo Plasty
Myringoplasty (Postaura/Endaural Approach As Well As 66 Adenoidectomy With Grommet Insertion
23
Simple Type -I Tympanoplasty) 67 Adenoidectomy Without Grommet Insertion
24 Fenestration Of The Inner Ear
68 Vocal Cord Lateralisation Procedure
25 Revision Of A Fenestration Of The Inner Ear
69 Incision & Drainage Of Para Pharyngeal Abscess
26 Palatoplasty
70 Tracheoplasty
27 Transoral Incision And Drainage Of A Pharyngeal Abscess V Gastroenterology Related:
28 Tonsillectomy Without Adenoidectomy Cholecystectomy And Choledocho-Jejunostomy/

71
29 Tonsillectomy With Adenoidectomy Duodenostomy/Gastrostomy/Expl Oration Common Bile Duct
30 Excision And Destruction Of A Lingual Tonsil Esophagoscopy, Gastroscopy, Duodenoscopy With
31 Revision Of A Tympanoplasty 72 Polypectomy/ Removal Of Foreign Body/Diathermy Of
Bleeding Lesions
32 Other Microsurgical Operations On The Middle Ear
73 Pancreatic Pseudocyst Eus & Drainage
33 Incision Of The Mastoid Process And Middle Ear
74 Rf Ablation For Barrett's Oesophagus
34 Mastoidectomy
75 Ercp And Papillotomy
35 Reconstruction Of The Middle Ear
76 Esophagoscope And Sclerosant Injection
36 Other Excisions Of The Middle And Inner Ear
Incision (Opening) And Destruction (Elimination) Of The Inner 77 Eus + Submucosal Resection
37
Ear

78 Construction Of Gastrostomy Tube 122 Maximal Anal Dilatation
79 Eus + Aspiration Pancreatic Cyst 123 Piles
80 Small Bowel Endoscopy (Therapeutic) 124 A)Injection Sclerotherapy
81 Colonoscopy ,Lesion Removal 125 B)Piles Banding
82 Ercp 126 Liver Abscess- Catheter Drainage
83 Colonscopy Stenting Of Stricture 127 Fissure In Ano- Fissurectomy
84 Percutaneous Endoscopic Gastrostomy 128 Fibroadenoma Breast Excision
85 Eus And Pancreatic Pseudo Cyst Drainage 129 Oesophageal Varices Sclerotherapy
86 Ercp And Choledochoscopy 130 Ercp - Pancreatic Duct Stone Removal
87 Proctosigmoidoscopy Volvulus Detorsion 131 Perianal Abscess I&D
88 Ercp And Sphincterotomy 132 Perianal Hematoma Evacuation
89 Esophageal Stent Placement 133 Ugi Scopy And Polypectomy Oesophagus
90 Ercp + Placement Of Biliary Stents 134 Breast Abscess I& D
91 Sigmoidoscopy W / Stent 135 Feeding Gastrostomy
92 Eus + Coeliac Node Biopsy 136 Oesophagoscopy And Biopsy Of Growth Oesophagus
Ugi Scopy And Injection Of Adrenaline, Sclerosants Bleeding 137 Ercp - Bile Duct Stone Removal
93
Ulcers 138 Ileostomy Closure
VI General Surgery Related: 139 Colonoscopy
94 Incision Of A Pilonidal Sinus / Abscess 140 Polypectomy Colon
95 Fissure In Ano Sphincterotomy 141 Splenic Abscesses Laparoscopic Drainage
Surgical Treatment Of A Varicocele And A Hydrocele Of The 142 Ugi Scopy And Polypectomy Stomach
96
Spermatic Cord
143 Rigid Oesophagoscopy For Fb Removal
97 Orchidopexy
144 Feeding Jejunostomy
98 Abdominal Exploration In Cryptorchidism
145 Colostomy
99 Surgical Treatment Of Anal Fistulas
146 Ileostomy
100 Division Of The Anal Sphincter (Sphincterotomy)
147 Colostomy Closure
101 Epididymectomy
148 Submandibular Salivary Duct Stone Removal
102 Incision Of The Breast Abscess
149 Pneumatic Reduction Of Intussusception
103 Operations On The Nipple
150 Varicose Veins Legs - Injection Sclerotherapy
104 Excision Of Single Breast Lump
151 Rigid Oesophagoscopy For Plummer Vinson Syndrome
105 Incision And Excision Of Tissue In The Perianal Region
152 Pancreatic Pseudocysts Endoscopic Drainage
106 Surgical Treatment Of Hemorrhoids
153 Zadek's Nail Bed Excision
107 Other Operations On The Anus
154 Subcutaneous Mastectomy
108 Ultrasound Guided Aspirations
155 Excision Of Ranula Under Ga
109 Sclerotherapy,
156 Rigid Oesophagoscopy For Dilation Of Benign Strictures
110 Therapeutic Laparoscopy With Laser
157 Eversion Of Sac Unilateral/Bilateral
111 Infected Keloid Excision
158 Lord's Plication
112 Axillary Lymphadenectomy
159 Jaboulay's Procedure
113 Wound Debridement And Cover
160 Scrotoplasty
114 Abscess-Decompression
161 Circumcision For Trauma
115 Cervical Lymphadenectomy
162 Meatoplasty
116 Infected Sebaceous Cyst
163 Intersphincteric Abscess Incision And Drainage
117 Inguinal Lymphadenectomy
164 Psoas Abscess Incision And Drainage
118 Incision And Drainage Of Abscess
165 Thyroid Abscess Incision And Drainage
119 Suturing Of Lacerations
166 Tips Procedure For Portal Hypertension
120 Scalp Suturing
167 Esophageal Growth Stent
121 Infected Lipoma Excision
168 Pair Procedure Of Hydatid Cyst Liver

169 Tru Cut Liver Biopsy 213 Culdotomy
Photodynamic Therapy Or Esophageal Tumour And Lung 214 Salpingo-Oophorectomy Via Laparotomy
170
Tumour 215 Endoscopic Polypectomy
171 Excision Of Cervical Rib
216 Hysteroscopic Removal Of Myoma
172 Laparoscopic Reduction Of Intussusception
217 D&C
173 Microdochectomy Breast
218 Hysteroscopic Resection Of Septum
174 Surgery For Fracture Penis
219 Thermal Cauterisation Of Cervix
175 Sentinel Node Biopsy
220 Mirena Insertion
176 Parastomal Hernia
221 Hysteroscopic Adhesiolysis
177 Revision Colostomy
222 Leep (Loop Electrosurgical Excision Procedure)
178 Prolapsed Colostomy- Correction
223 Cryocauterisation Of Cervix
179 Testicular Biopsy
224 Polypectomy Endometrium
180 Laparoscopic Cardiomyotomy( Hellers)
225 Hysteroscopic Resection Of Fibroid
181 Sentinel Node Biopsy Malignant Melanoma
226 Lletz (Large Loop Excision Of Transformation Zone)
182 Laparoscopic Pyloromyotomy( Ramstedt)
227 Conization
183 Excision Of Fistula-In-Ano
228 Polypectomy Cervix
184 Excision Juvenile Polyps Rectum
229 Hysteroscopic Resection Of Endometrial Polyp
185 Vaginoplasty
230 Vulval Wart Excision
186 Dilatation Of Accidental Caustic Stricture Oesophageal
231 Laparoscopic Paraovarian Cyst Excision
187 Presacral Teratomas Excision
232 Uterine Artery Embolization
188 Removal Of Vesical Stone
233 Laparoscopic Cystectomy
189 Excision Sigmoid Polyp
234 Hymenectomy( Imperforate Hymen)
190 Sternomastoid Tenotomy
235 Endometrial Ablation
191 Infantile Hypertrophic Pyloric Stenosis Pyloromyotomy
236 Vaginal Wall Cyst Excision
192 Excision Of Soft Tissue Rhabdomyosarcoma
237 Vulval Cyst Excision
193 Mediastinal Lymph Node Biopsy
238 Laparoscopic Paratubal Cyst Excision
194 High Orchidectomy For Testis Tumours
239 Repair Of Vagina ( Vaginal Atresia )
195 Excision Of Cervical Teratoma
240 Hysteroscopy, Removal Of Myoma
196 Rectal-Myomectomy
241 Turbt
197 Rectal Prolapse (Delorme's Procedure)
242 Ureterocoele Repair - Congenital Internal
198 Detorsion Of Torsion Testis
243 Vaginal Mesh For Pop
199 Eua + Biopsy Multiple Fistula In Ano
244 Laparoscopic Myomectomy
200 Cystic Hygroma - Injection Treatment
245 Surgery For Sui
VII Gynecology Related:
246 Repair Recto- Vagina Fistula
201 Operations On Bartholin’s Glands (Cyst)
247 Pelvic Floor Repair( Excluding Fistula Repair)
202 Incision Of The Ovary
248 Urs + Ll
203 Insufflations Of The Fallopian Tubes
249 Laparoscopic Oophorectomy
204 Other Operations On The Fallopian Tube
250 Normal Vaginal Delivery And Variants
205 Dilatation Of The Cervical Canal
VIII Neurology Related:
206 Conisation Of The Uterine Cervix
251 Facial Nerve Physiotherapy
Therapeutic Curettage With Colposcopy/Biopsy/Diathermy/
207 252 Nerve Biopsy
Cry Osurgery/
253 Muscle Biopsy
208 Laser Therapy Of Cervix For Various Lesions Of Uterus
254 Epidural Steroid Injection
209 Other Operations On The Uterine Cervix
Local Excision And Destruction Of Diseased Tissue Of The 255 Glycerol Rhizotomy
210
Vagina And The Pouch Of Douglas 256 Spinal Cord Stimulation
211 Incision Of Vagina 257 Motor Cortex Stimulation
212 Incision Of Vulva 258 Stereotactic Radiosurgery

259 Percutaneous Cordotomy 305 Conditioning Radiothearpy For Bmt
260 Intrathecal Baclofen Therapy
306 Extracorporeal Irradiation To The Homologous Bone Grafts
261 Entrapment Neuropathy Release
307 Radical Chemotherapy
262 Diagnostic Cerebral Angiography
308 Neoadjuvant Radiotherapy
263 Vp Shunt
309 Ldr Brachytherapy
264 Ventriculoatrial Shunt
310 Palliative Radiotherapy
IX Oncology Related:
311 Radical Radiotherapy
265 Radiotherapy For Cancer
312 Palliative Chemotherapy
266 Cancer Chemotherapy
313 Template Brachytherapy
267 Iv Push Chemotherapy
314 Neoadjuvant Chemotherapy
268 Hbi-Hemibody Radiotherapy
315 Adjuvant Chemotherapy
269 Infusional Targeted Therapy
316 Induction Chemotherapy
270 Srt-Stereotactic Arc Therapy
317 Consolidation Chemotherapy
271 Sc Administration Of Growth Factors
318 Maintenance Chemotherapy
272 Continuous Infusional Chemotherapy
319 Hdr Brachytherapy
273 Infusional Chemotherapy
X Operations on the salivary glands & salivary ducts:
274 Ccrt-Concurrent Chemo + Rt
275 2d Radiotherapy 320 Incision And Lancing Of A Salivary Gland And A Salivary Duct
276 3d Conformal Radiotherapy Excision Of Diseased Tissue Of A Salivary Gland And A Salivary
321
277 Igrt- Image Guided Radiotherapy Duct
278 Imrt- Step & Shoot 322 Resection Of A Salivary Gland
279 Infusional Bisphosphonates 323 Reconstruction Of A Salivary Gland And A Salivary Duct
280 Imrt- Dmlc
324 Other Operations On The Salivary Glands And Salivary Ducts
281 Rotational Arc Therapy
XI Operations on the skin & subcutaneous tissues:
282 Tele Gamma Therapy
325 Other Incisions Of The Skin And Subcutaneous Tissues
283 Fsrt-Fractionated Srt
284 Vmat-Volumetric Modulated Arc Therapy Surgical Wound Toilet (Wound Debridement) And Removal Of
326
285 Sbrt-Stereotactic Body Radiotherapy Diseased Tissue Of The Skin And Subcutaneous Tissues
286 Helical Tomotherapy Local Excision Of Diseased Tissue Of The Skin And
327
287 Srs-Stereotactic Radiosurgery Subcutaneous Tissues
288 X-Knife Srs 328 Other Excisions Of The Skin And Subcutaneous Tissues
289 Gammaknife Srs Simple Restoration Of Surface Continuity Of The Skin And
329
Subcutaneous Tissues
290 Tbi- Total Body Radiotherapy
330 Free Skin Transplantation, Donor Site
291 Intraluminal Brachytherapy
331 Free Skin Transplantation, Recipient Site
292 Electron Therapy
332 Revision Of Skin Plasty
293 Tset-Total Electron Skin Therapy
Other Restoration And Reconstruction Of The Skin And
294 Extracorporeal Irradiation Of Blood Products 333
Subcutaneous Tiss
295 Telecobalt Therapy 334 Chemosurgery To The S
296 Telecesium Therapy Destruction Of Diseased Tissue In The Skin And Subcutaneous
335
297 External Mould Brachytherapy Tissues
298 Interstitial Brachytherapy 336 Reconstruction Of Deformity/Defect In Nail Bed
299 Intracavity Brachytherapy 337 Excision Of Bursirtis
300 3d Brachytherapy 338 Tennis Elbow Release
301 Implant Brachytherapy XII Operations on the Tongue:
302 Intravesical Brachytherapy Incision, Excision And Destruction Of Diseased Tissue Of The
339
Tongue
303 Adjuvant Radiotherapy
340 Partial Glossectomy
304 Afterloading Catheter Brachytherapy

341 Glossectomy 379 Closed Reduction On Fracture, Luxation
342 Reconstruction Of The Tongue 380 Reduction Of Dislocation Under Ga
343 Small Reconstruction Of The Tongue 381 Epiphyseolysis With Osteosynthesis
XIII Ophthalmology Related: 382 Excision Of Various Lesions In Coccyx
344 Surgery For Cataract 383 Arthroscopic Repair Of Acl Tear Knee
345 Incision Of Tear Glands 384 Closed Reduction Of Minor Fractures
346 Other Operations On The Tear Ducts 385 Arthroscopic Repair Of Pcl Tear Knee
347 Incision Of Diseased Eyelids 386 Tendon Shortening
348 Excision And Destruction Of Diseased Tissue Of The Eyelid 387 Arthroscopic Meniscectomy - Knee
349 Operations On The Canthus And Epicanthus 388 Treatment Of Clavicle Dislocation
350 Corrective Surgery For Entropion And Ectropion 389 Haemarthrosis Knee- Lavage
351 Corrective Surgery For Blepharoptosis 390 Abscess Knee Joint Drainage
352 Removal Of A Foreign Body From The Conjunctiva 391 Carpal Tunnel Release
353 Removal Of A Foreign Body From The Cornea 392 Closed Reduction Of Minor Dislocation
354 Incision Of The Cornea 393 Repair Of Knee Cap Tendon
355 Operations For Pterygium 394 Orif With K Wire Fixation- Small Bones
356 Other Operations On The Cornea 395 Release Of Midfoot Joint
357 Removal Of A Foreign Body From The Lens Of The Eye 396 Orif With Plating- Small Long Bones
Removal Of A Foreign Body From The Posterior Chamber Of 397 Implant Removal Minor
358
The Eye
398 K Wire Removal
359 Removal Of A Foreign Body From The Orbit And Eyeball
399 Pop Application
Correction Of Eyelid Ptosis By Levator Palpebrae Superioris
360 400 Closed Reduction And External Fixation
Resection (Bilateral)
401 Arthrotomy Hip Joint
361 Correction Of Eyelid Ptosis By Fascia Lata Graft (Bilateral)
402 Syme's Amputation
362 Diathermy/Cryotherapy To Treat Retinal Tear 403 Arthroplasty
404 Partial Removal Of Rib
Anterior Chamber Paracentesis/ Cyclodiathermy/
363 Cyclocryotherap Y/ Goniotomy/Trabeculotomy And Filtering 405 Treatment Of Sesamoid Bone Fracture
And Allied Operations To Treat Glaucoma 406 Shoulder Arthroscopy / Surgery
364 Enucleation Of Eye Without Implant 407 Elbow Arthroscopy
408 Amputation Of Metacarpal Bone
365 Dacryocystorhinostomy For Various Lesions Of Lacrimal Gland
409 Release Of Thumb Contracture
366 Laser Photocoagulation To Treat Ratinal Tear 410 Incision Of Foot Fascia
367 Biopsy Of Tear Gland 411 Calcaneum Spur Hydrocort Injection
368 Treatment Of Retinal Lesion 412 Ganglion Wrist Hyalase Injection
XIV Orthopedics Related: 413 Partial Removal Of Metatarsal
369 Surgery For Meniscus Tear 414 Repair / Graft Of Foot Tendon
370 Incision On Bone, Septic And Aseptic 415 Revision/Removal Of Knee Cap
Closed Reduction On Fracture, Luxation Or Epiphyseolysis 416 Amputation Follow-Up Surgery
371
With Osteosynthesis
417 Exploration Of Ankle Joint
372 Suture And Other Operations On Tendons And Tendon Sheath 418 Remove/Graft Leg Bone Lesion
373 Reduction Of Dislocation Under Ga 419 Repair/Graft Achilles Tendon
374 Arthroscopic Knee Aspiration 420 Remove Of Tissue Expander
375 Surgery For Ligament Tear 421 Biopsy Elbow Joint Lining
376 Surgery For Hemoarthrosis/Pyoarthrosis 422 Removal Of Wrist Prosthesis
377 Removal Of Fracture Pins/Nails 423 Biopsy Finger Joint Lining
378 Removal Of Metal Wire 424 Tendon Lengthening
425 Treatment Of Shoulder Dislocation

426 Lengthening Of Hand Tendon XVIII Urology Related:
427 Removal Of Elbow Bursa 469 Haemodialysis
428 Fixation Of Knee Joint 470 Lithotripsy/Nephrolithotomy For Renal Calculus
429 Treatment Of Foot Dislocation 471 Excision Of Renal Cyst
430 Surgery Of Bunion 472 Drainage Of Pyonephrosis/Perinephric Abscess
431 Intra Articular Steroid Injection 473 Incision Of The Prostate
432 Tendon Transfer Procedure
474 Transurethral Excision And Destruction Of Prostate Tissue
433 Removal Of Knee Cap Bursa
434 Treatment Of Fracture Of Ulna 475 Transurethral And Percutaneous Destruction Of Prostate Tissue
435 Treatment Of Scapula Fracture
476 Open Surgical Excision And Destruction Of Prostate Tissue
436 Removal Of Tumor Of Arm/ Elbow Under Ra/Ga
437 Repair Of Ruptured Tendon 477 Radical Prostatovesiculectomy
438 Decompress Forearm Space 478 Other Excision And Destruction Of Prostate Tissue
439 Revision Of Neck Muscle (Torticollis Release ) 479 Operations On The Seminal Vesicles
440 Lengthening Of Thigh Tendons 480 Incision And Excision Of Periprostatic Tissue
441 Treatment Fracture Of Radius & Ulna 481 Other Operations On The Prostate
442 Repair Of Knee Joint 482 Incision Of The Scrotum And Tunica Vaginalis Testis
XV Other operations on the mouth & face: 483 Operation On A Testicular Hydrocele
External Incision And Drainage In The Region Of The Mouth, 484 Excision And Destruction Of Diseased Scrotal Tissue
443
Jaw And Face
485 Other Operations On The Scrotum And Tunica Vaginalis Testis
444 Incision Of The Hard And Soft Palate
486 Incision Of The Testes
445 Excision And Destruction Of Diseased Hard And Soft Palate
487 Excision And Destruction Of Diseased Tissue Of The Testes
446 Incision, Excision And Destruction In The Mouth
488 Unilateral Orchidectomy
447 Other Operations In The Mouth
489 Bilateral Orchidectomy
XVI Plastic Surgery Related:
490 Surgical Repositioning Of An Abdominal Testis
448 Construction Skin Pedicle Flap
491 Reconstruction Of The Testis
449 Gluteal Pressure Ulcer-Excision Implantation, Exchange And Removal Of A Testicular
492
450 Muscle-Skin Graft, Leg Prosthesis
451 Removal Of Bone For Graft 493 Other Operations On The Testis
452 Muscle-Skin Graft Duct Fistula 494 Excision In The Area Of The Epididymis
453 Removal Cartilage Graft 495 Operations On The Foreskin
454 Myocutaneous Flap Local Excision And Destruction Of Diseased Tissue Of The
496
455 Fibro Myocutaneous Flap Penis
497 Amputation Of The Penis
456 Breast Reconstruction Surgery After Mastectomy
498 Other Operations On The Penis
457 Sling Operation For Facial Palsy
499 Cystoscopical Removal Of Stones
458 Split Skin Grafting Under Ra
500 Catheterisation Of Bladder
459 Wolfe Skin Graft
501 Lithotripsy
460 Plastic Surgery To The Floor Of The Mouth Under Ga
502 Biopsy Oftemporal Artery For Various Lesions
XVII Thoracic surgery Related:
503 External Arterio-Venous Shunt
461 Thoracoscopy And Lung Biopsy
504 Av Fistula - Wrist
462 Excision Of Cervical Sympathetic Chain Thoracoscopic
505 Ursl With Stenting
463 Laser Ablation Of Barrett's Oesophagus
506 Ursl With Lithotripsy
464 Pleurodesis
507 Cystoscopic Litholapaxy
465 Thoracoscopy And Pleural Biopsy
508 Eswl
466 Ebus + Biopsy
509 Bladder Neck Incision
467 Thoracoscopy Ligation Thoracic Duct
510 Cystoscopy & Biopsy
468 Thoracoscopy Assisted Empyaema Drainage

511 Cystoscopy And Removal Of Polyp 524 Anderson Hynes Operation (Open Pyelopalsty )
512 Suprapubic Cystostomy 525 Kidney Endoscopy And Biopsy
513 Percutaneous Nephrostomy 526 Paraphimosis Surgery
514 Cystoscopy And "Sling" Proced 527 Injury Prepuce- Circumcision
515 Tuna- Prostate 528 Frenular Tear Repair
516 Excision Of Urethral Diverticulum 529 Meatotomy For Meatal Stenosis
517 Removal Of Urethral Stone 530 Surgery For Fournier's Gangrene Scrotum
518 Excision Of Urethral Prolapse 531 Surgery Filarial Scrotum
519 Mega-Ureter Reconstruction 532 Surgery For Watering Can Perineum
520 Kidney Renoscopy And Biopsy 533 Repair Of Penile Torsion
521 Ureter Endoscopy And Treatment 534 Drainage Of Prostate Abscess
522 Vesico Ureteric Reflux Correction 535 Orchiectomy
523 Surgery For Pelvi Ureteric Junction Obstruction 536 Cystoscopy And Removal Of Fb

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GoActive

2.1. Standard Definitions

Product Name: GoActiveTM | Product UIN: MAXHLIP21173V022021

Product Name: GoActiveTM | Product UIN: MAXHLIP21173V022021

Product Name: GoActiveTM | Product UIN: MAXHLIP21173V022021

I. Age means age last birthday.

Product Name: GoActiveTM | Product UIN: MAXHLIP21173V022021

b. Myocardial Infarction (First Heart Attack of specific severity):

Product Name: GoActiveTM | Product UIN: MAXHLIP21173V022021

3. Benefits covered under the Policy

Product Name: GoActiveTM | Product UIN: MAXHLIP21173V022021

3.2. Pre-hospitalization Medical Expenses

Product Name: GoActiveTM | Product UIN: MAXHLIP21173V022021

3.4. Day Care Treatment

3.5. Home Health Care Services and Domiciliary Hospitalization

3.6. Living Organ Donor Transplant

We shall not be liable to make any payment in respect of:

Product Name: GoActiveTM | Product UIN: MAXHLIP21173V022021

3.8. Health Checkup / Diagnostic Tests

3.9. Re-fill Benefit

3.10. Second Medical Opinion

Product Name: GoActiveTM | Product UIN: MAXHLIP21173V022021

3.11. OPD Consultation

3.12. Behavioral Assistance Program

3.13. Pharmacy and Diagnostic Services

3.15. Alternative Treatments

Product Name: GoActiveTM | Product UIN: MAXHLIP21173V022021

Special condition applicable for robotic surgeries:

Product Name: GoActiveTM | Product UIN: MAXHLIP21173V022021

4.2. Health Coach

Product Name: GoActiveTM | Product UIN: MAXHLIP21173V022021

Health Score Model

Score - based on your

Annual Health Earn up to 1 lac points in

c. Discount in renewal premium basis Health Score:

Product Name: GoActiveTM | Product UIN: MAXHLIP21173V022021

4.3. Personal Accident Cover

b. Accident Permanent Total Disability (PTD)

i. Loss of use of Limbs or Sight

ii. Loss of independent living

Product Name: GoActiveTM | Product UIN: MAXHLIP21173V022021

c. Accident Permanent Partial Disability (PPD)

Product Name: GoActiveTM | Product UIN: MAXHLIP21173V022021

5. Claim Cost Sharing Options / Conditions

5.1. Annual Aggregate Deductible

Product Name: GoActiveTM | Product UIN: MAXHLIP21173V022021

6.1. Standard Exclusions

I. Pre-existing Diseases (Code–Excl01):

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

Product Name: GoActiveTM | Product UIN: MAXHLIP21173V022021

III. 30-day waiting period (Code- Excl03):

IV. Investigation & Evaluation (Code-Excl04)

V. Rest Cure, rehabilitation and respite care (Code-Excl05)

VI. Obesity/ Weight Control (Code-Excl06)

VII. Change-of-Gender treatments (Code-Excl07)

VIII. Cosmetic or plastic Surgery (Code-Excl08)

Product Name: GoActiveTM | Product UIN: MAXHLIP21173V022021

X. Breach of law (Code-Excl10)

XI. Excluded Providers (Code-Excl11)