Accident Armour Policy Wording

ACCIDENT ARMOUR - POLICY TERMS AND CONDITIONS
1. Preamble
This Policy covers Death & Injury solely and directly from Accidents. Expense incurred outside the Policy Period will NOT be
covered. Unutilized Sum Insured will expire at the end of policy year. All applicable benefits, details and limits are mentioned
in your Certificate of Insurance.
2. Definitions
2.1 Standard definitions
2.1.1 Accident or Accidental means a sudden, unforeseen and involuntary event caused by external, visible and violent means.
2.1.2 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.
2.1.3 Condition Precedent means a policy term or condition upon which the Insurer's liability under the policy is conditional upon.
2.1.4 Cumulative Bonus means any increase or addition in the Sum Insured granted by the insurer without an associated increase
in premium.
2.1.5 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.
2.1.6 Disclosure to information norm: The policy shall be void and all premium paid thereon shall be forfeited to the Company in
the event of misrepresentation, mis-description or non-disclosure of any material fact.
2.1.7 Emergency care means management for an illness or Injury which results in symptoms which occur suddenly and
unexpectedly, and requires immediate care by a Medical Practitioner to prevent death or serious long term impairment of
the Insured Person’s health.
2.1.8 Grace Period means the specified period of time, immediately following the premium due date during which premium
payment can be made to renew or continue a policy in force without loss of continuity benefits pertaining to waiting periods
and coverage of pre-existing diseases. Coverage need not be available during the period for which no premium is received.
The grace period for payment of the premium for all types of insurance policies shall be: fifteen days where premium
payment mode is monthly and thirty days in all other cases.
2.1.9 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.
2.1.10 Hospitalization means admission in a Hospital for a minimum period of 24 consecutive ‘In-patient Care’ hours except for
specified procedures/treatments, where such admission could be for a period of less than 24 consecutive hours.
2.1.11 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:
1. it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /or tests 2. it needs
ongoing or long-term control or relief of symptoms
Product Name: Accident Armour | Product UIN: NBHPAGP24166V012324

3. it requires rehabilitation for the patient or for the patient to be specially trained to cope with it
4. it continues indefinitely
5. it recurs or is likely to recur
2.1.12 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.
2.1.13 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.
2.1.14 Inpatient Care means treatment for which the Insured Person has to stay in a Hospital for more than 24 hours for a covered
event.
2.1.15 Intensive Care Unit means an identified section, ward or wing of a Hospital which is under the constant supervision of a
dedicated Medical Practitioner(s), and which is specially equipped for the continuous monitoring and treatment of patients
who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably
more sophisticated and intensive than in the ordinary and other wards.
2.1.16 Medical Advice means any consultation or advice from a Medical Practitioner including the issuance of any prescription or
follow-up prescription.
2.1.17 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.
2.1.18 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.
2.1.19 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.
2.1.20 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.
2.1.21 Non-Network Provider means any Hospital, Day Care Centre or other provider that is not part of the network.
2.1.22 Notification of Claim means the process of intimating a claim to the insurer or TPA through any of the recognized modes of
communication.
2.1.23 OPD Treatment means the one in which the Insured visits a clinic / Hospital or associated facility like a consultation room
for diagnosis and treatment based on the advice of a Medical Practitioner. The Insured is not admitted as a day care or In-
patient.
2.1.24 Pre-existing Disease means any condition, ailment, Injury or disease:
a. That is/are diagnosed by a physician not more than 36 months prior to the date of commencement of the policy issued by
the insurer, or
b. For which medical advice or treatment was recommended by, or received from, a physician not more than 36 months prior
to the date of commencement of the policy
2.1.25 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.
2.1.26 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.

2.1.27 Portability means a facility provided to the health insurance policyholders (including all members under family cover), to
transfer the credits gained for, pre-existing disease and specific waiting periods from one insurer to another.
2.1.28 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.
2.1.29 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.
2.1.30 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.
2.1.31 Room Rent means the amount charged by a Hospital towards Room and Boarding expenses and shall include the associated
medical expenses.
2.1.32 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 Centre by a Medical Practitioner.
2.2 Specific definitions
2.2.1 Accidental Death means the Insured Person has deceased, solely and directly, due to an Injury sustained in an Accident
within 365 days from the date of the Accident.
2.2.2 Accidental Hospitalization means admission in a Hospital for injuries sustained in an Accident for a minimum period of 24
consecutive ‘In-patient Care’ hours except for specified procedures/treatments, where such admission could be for a period
of less than 24 consecutive hours.
2.2.3 Age means age as on last birthday.
2.2.4 Assault means any willful or unlawful use of force inflicted upon an Insured Person that is a criminal offence in the
jurisdiction in which it occurs and which results in Injury to an Insured Person.
2.2.5 Base Sum Insured means the amount stated in the Certificate of Insurance.
2.2.6 Break in Policy means the period of gap that occurs at the end of the existing policy term/instalment premium due date,
when the premium due for renewal on a given policy or instalment premium due is not paid on or before the premium
renewal date or grace period..
2.2.7 Broken Bone or Fracture means a break in the continuity of the bone. This does not include hairline Fracture. This has to be
confirmed by a Doctor and imaging investigations like an X-ray.
2.2.8 Coma: An Insured Person is said to be in Comatose State (Coma) if:
a. Has been in a State of Comatose for continuous 96 hours
b. Is on Life support systems
c. Condition is confirmed by the treating Doctor
2.2.9 Common Carrier refers to any commercial public airline, railway, motor transport, or water borne vessel (including ocean
going and/or coastal vessels and/or vessels engaged for official or personal purposes), operating under license issued by the
appropriate authority for transportation of passengers and/or cargo.
2.2.10 Complete & Irrecoverable loss of limb means physical separation or complete loss of functionality of the limb, within 365
days from the date of the Accident. This will include Paralysis including Paraplegia, Quadriplegia with loss of functional use
of limb.
2.2.11 Dependent Child refers to the legal Child of the Insured; whose age is less than or equal to 21 years (as on the last birthdate)
with respect to the Date of Loss or Accident.
2.2.12 Immediate Family Member means Insured Person’s Spouse, Parents, Sibling, Mother In-Law, Father In-Law, and Child.
2.2.13 Insured Event means any event specifically mentioned as covered under this Policy.
2.2.14 Insured Person means person(s) named as Insured Persons in the Certificate of Insurance.
2.2.15 Miscarriage means the spontaneous or unplanned expulsion of a fetus from the womb before it is able to survive
independently, due to an Accident.
2.2.16 Permanent Partial Disability means the Insured Person has suffered a Permanent loss of physical function or anatomical
loss of use of a body part due to injury sustained in an Accident and within 365 days from the date of the Accident. Provided
that the condition is substantiated by diagnosis of a Medical Practitioner. Conditions for Permanent Partial Disability are as
per below table –

Condition for Permanent Partial Disability – Loss of:
arm at the shoulder joint
arm to a point above elbow joint
arm below elbow joint
hand at the wrist
Thumb
Index Finger
other Finger
leg above center of the femur
leg up to a point below the femur
leg to a point below the knee
foot at the ankle
big toe
other toe
eye
Hearing in ear
Sense of smell
Sense of taste
2.2.17 Permanent Total Disability means the Insured Person has suffered a total and permanent loss of physical function or
anatomical loss of use of a body part due to injury sustained in an Accident and within 365 days from the date of the Accident.
Provided that the condition is substantiated by diagnosis of a Medical Practitioner. Conditions for Permanent Total Disability
are as per below table –
Condition for Permanent Total Disability - Complete & Irrecoverable loss of:
 Any 2 Limbs
 Sight of both eyes
 Speech & hearing of both Ears
 Combination of One Limb & Sight of One Eye
 1 Limb
 Sight of 1 Eye

2.2.18 Physiotherapy means any form of physical or mechanical therapy; diathermy; ultrasonic therapy; heat treatment in any
form; manipulation or massage administered by a Medical Practitioner for treatment of Injury.
2.2.19 Policy means these terms and conditions, the Certificate of Insurance (as amended from time to time), Your statements in
the Proposal and any endorsements attached by Us to the Policy from time to time.
2.2.20 Policy Period is the period between the inception date and the expiry date of the Policy as specified in the Certificate of
Insurance or the date of cancellation of this Policy, whichever is earlier.
2.2.21 Policy Year means the period of one year commencing on the date of commencement specified in the Certificate of
Insurance or any anniversary thereof.
2.2.22 Reconstructive surgery means surgery to treat body parts affected aesthetically or functionally by an Accident or Burns.
2.2.23 Reimbursement means settlement of claims paid directly by Us to the Policyholder/Insured Person.
2.2.24 Service Provider means any person, organization, institution that has been empanelled with Us to provide services specified
under the benefits to the Insured Person.
2.2.25 Sum Insured:
In case of Individual Policy, Sum Insured means the total of the Base Sum Insured and No Claim Bonus (if applicable) for that
Insured Person. Our maximum, total and cumulative liability for all claims during the Policy Year in respect of the Insured
Person will be Sum Insured and amount provided under Refill benefit.
In case of Family Floater Policy, Sum Insured means the total of the Base Sum Insured and No Claim Bonus (if applicable).
Our maximum, total and cumulative liability for all claims during the Policy Year in respect of all Insured Persons taken
together will be Sum Insured and amount provided under Refill benefit.
The sequence of utilization of Sum Insured will be as below:
i. Base Sum Insured followed by;

ii. Accumulated No Claim Bonus (if applicable) followed by;
iii. Refill benefit (if applicable)
If the Policy Period is 2 years or 3 years, then the Sum Insured shall be applied separately for each Policy Year in the Policy
Period. All claims paid (except for Health Check-up) will reduce the Sum Insured for the Policy Year in which the Insured
event has occurred. Any claim admitted under Pre & Post Hospitalization shall reduce the Sum Insured for the Policy Year in
which Hospital admission claim has incurred.
2.2.26 Temporary Total Disability means a disability caused due to injury sustained in an Accident which temporarily incapacitates
and prevents Insured Person from engaging in any employment or occupation of any description whatsoever.
2.2.27 Terrorism means an Act, including but not limited to the use of force or violence and/ or the threat thereof, of any person
or group(s) of Persons whether acting alone or on behalf of or in connection with any organization(s) or government(s),
committed for political, religious, ideological or similar purpose including the intention to influence any government and/or
to put the public, or any section of the public in fear.
2.2.28 We/Our/Us means Niva Bupa Health Insurance Company Limited.
2.2.29 You/Your/Policyholder means the person named in the Certificate of Insurance who has concluded this Policy with Us.

3. Scope of Cover:
a. The terms, conditions and exclusions governing the Benefits under this Policy are described below and the Benefits listed in
this section will be payable accordingly.
b. The Certificate of Insurance will specify the Benefits, Sum Insured, pay outs, limits, sub limits, Deductible and/or Franchise
applicable to the respective benefits available for the Insured Person.
c. Policy will be active only during the date and/or time as specified in Certificate of Insurance.
d. Claim under this policy will be paid only if the underlying cause of claim is solely and directly due to an Accident caused
during the Policy/Coverage Period.
e. Any claim payable towards Dependent Child, where the Dependent Child is a minor, shall be payable to the legal guardian
of the Dependent Child.
f. All benefits can be taken either in India or/and outside India, as mentioned in your Certificate of Insurance.
3.1 Accidental Death Benefit
If the Insured Person dies within 365 days from the date of the Accident, then We will pay the Sum Insured under Accidental
Death (AD) benefit. The benefit also covers for Disappearance of the Insured Member.
For the purpose of this benefit, Disappearance means that Insured body is missing for at least 365 days following an Accident
or natural disaster during the Policy Period. If at any time, after the payment of the Death benefit, it is discovered that the
Insured Person is still alive, all payments shall be reimbursed in full to the Company.
NOTE: If we have paid any claim under Permanent Total Disability, Permanent Partial Disability or Temporary Total Disability
(if applicable) then for any subsequent Accidental Death claim in the same policy year, we will pay claim amount after
adjusting the amount already paid.
The policy will terminate for the member for whom we have paid the claim under this benefit.
3.2 Permanent Total Disability Benefit
a. If the Insured Person suffers a Permanent Total Disability (PTD), within 365 days from the date of the Accident, then We will
pay the benefit as per the Table 1.
Table 1:
Condition for Permanent Total Disability % of Sum Insured
Complete & Irrecoverable loss of:
 Any 2 Limbs
 Sight of both eyes 100%
 Speech & hearing of both Ears
 Combination of One Limb & Sight of One Eye

Complete & Irrecoverable loss of: 50%

 1 Limb
 Sight of 1 Eye
b. Complete & Irrecoverable loss of limb means physical separation or complete loss of functionality of the limb, within 365
days from the date of the Accident. This will include Paralysis including Paraplegia, Quadriplegia with loss of functional use
of limb.
The policy will terminate for the member for whom we have paid a total of 100% PTD Sum Insured claim in a lifetime of
the Insured.
3.3 Permanent Partial Disability Benefit
a. If the Insured Person suffers a Permanent Partial Disability (PPD), within 365 days from the date of the Accident, then We
will pay the benefit as per the Table 2.
Table 2:
Condition for Permanent Partial Disability % of Sum Insured
Each arm at the shoulder joint 70%
Each arm to a point above elbow joint 65%
Each arm below elbow joint 50%
Each hand at the wrist 50%
Each Thumb 20%
Each Index Finger 10%
Each other Finger 5%
Each leg above center of the femur 70%
Each leg up to a point below the femur 65%
Each leg to a point below the knee 50%
Each foot at the ankle 40%
Each big toe 5%
Each other toe 2%
Each eye 50%
Hearing in each ear 30%
Sense of smell 10%
Sense of taste 5%

b. If a loss is not mentioned in the table above, then We will internally assess the degree of disablement and determine the
amount of payment to be made.
c. If there is more than one Permanent Partial Disability loss, then the total claim amount put together for all losses will not
exceed the total Sum Insured available under this benefit.
3.4 Temporary Total Disablement Benefit
If an Insured Person suffers a Temporary Total Disability (TTD) due to an Accident and it temporarily incapacitates the Insured
Person from engaging in any employment or occupation of any description whatsoever, then We will pay the Sum Insured
as mentioned in the Certificate of Insurance.
Conditions:
a. Earning and Non-Earning members (if applicable) would be covered as per separate limits mentioned in the Certificate of
Insurance.
b. If the Insured is disabled for part of a week, then proportionate amount will be paid.
c. TTD caused due to Broken bones or Fractures, Coma or Burns will also be covered.
d. TTD is NOT applicable for Dependent Children.
e. Claim is payable ONLY if bed rest is prescribed by treating Medical Practitioner.
f. We will not pay for Hairline fractures of any kind.
g. TTD benefit can be taken only once for any single event.
h. We reserve the right to stop making any further payments, if we are satisfied that you can engage in your occupation again,
or when we have made payments for a maximum period of 100 weeks from the date you met with the Accidental Bodily
Injury, whichever is earlier.
3.5 Accidental Hospitalization
If an Insured Person is hospitalized (24 Hours or more) due to injuries sustained in an Accident during the Policy Period, then
We will pay the expenses incurred by the Insured on Medically Necessary Treatment up to the limits mentioned in the
Certificate of Insurance.
Naturally this excludes expenses not linked to treatment like food, beverage, toiletries and cosmetics. Refer Annexure 1 for
expenses that are not covered or subsumed into room charges / procedure charges / costs of treatment.
Conditions:
a. Expenses before and after hospitalization (Pre & Post hospitalization): We will pay expenses incurred on consultations,
medicines, diagnostic tests up to 30 days before date of admission and up to 60 days after date of discharge, if these are
related to the Accident for which hospital admission claim is paid.
b. We will NOT pay, even if you were admitted, if there was no treatment and only investigations were done. Example:
Admission only for investigations like MRI, CT Scan, Endoscopy, Colonoscopy etc.
c. We will pay for hospitalization within India ONLY.
Either Accidental Hospitalization or Animal Attack cover can be offered. Both the benefits cannot be offered together.
3.6 Refill
The first claim paid under Accidental Hospitalization, will trigger the Refill benefit.
Conditions:

a. Accidental Hospitalization Sum Insured will be triggered on partial/complete utilization of Accidental Hospitalization Sum
Insured up to an amount mentioned in your Certificate of Insurance.
b. The Refill Benefit will be triggered as mentioned in your Certificate of Insurance.
c. The Refill Benefit can be used by either the same person for same illness or/and for different illness as mentioned in the
Certificate of Insurance
d. The unutilized Refill Benefit Sum Insured cannot be carried forward to the next Policy year.
e. Any single claim cannot be more than the base Accidental Hospitalization Sum Insured.
f. The accumulated Sum Insured under this benefit can be utilized ONLY for Accidental Hospitalization benefit of this policy.
The benefit can be offered ONLY if Accidental Hospitalization Benefit is offered.
3.7 No Claim Bonus
We will provide a No Claim Bonus equal to a percentage of expiring policy’s Accidental Hospitalization Sum Insured for every
Accidental Hospitalization claim free year. The percentage and limit up to which No Claim Bonus can accumulate is defined
in your Certificate of Insurance.
The benefit can be offered ONLY if Accidental Hospitalization Benefit is offered. This benefit can only be utilized for
Accidental Hospitalization.
3.8 Serious Illness Benefit
We will pay an amount as mentioned in the Certificate of Insurance basis number of days of hospitalization (24 Hours or
more) of Insured due to injuries following an Accident in the Policy Period.
Note: Coverage in a policy year can be given for any number of days, maximum up to 365 days.
Conditions:
a. The payout under this benefit will be made as per the minimum and maximum number of days of hospitalization as mention
in the Certificate of Insurance.
b. The Hospitalization is Medically Necessary and is carried out on the written advice of a Medical Practitioner.
The payout of this benefit can be a lump sum amount or can be linked to specific payouts as mentioned in your Certificate
of Insurance.
3.9 Safeguard+
Claim Safeguard: If We have accepted an Accidental Hospitalization claim, then the items which are not payable as per List
I, II, III, IV – ‘Expenses not covered’ under Annexure I related to that particular claim will become payable.
The benefit can be offered ONLY if Accidental Hospitalization Benefit is offered.
3.10 Out-patient Expenses Cover
If the Insured Person sustains an Accidental Injury during the Policy Period, then We will reimburse as per the sum insured
mentioned in the Certificate of Insurance for the expenses incurred on Outpatient (OPD) treatment of the Insured.
Outpatient Expenses includes ONLY:
a. Procedures that require less than 24 hours of hospitalization. This excludes day care treatment.

b. Diagnostic Tests for Accident related injury or procedure
c. Vaccinations/Vaccinations for Animal Bites
d. Plaster cast and/or crutches
Either Out-patient Expense Cover or Animal Attack cover can be offered. Both the benefits cannot be offered together.
3.11 Physiotherapy Cover
mentioned in the Certificate of Insurance for the expenses incurred on Physiotherapy of Insured Person.
Conditions:
a. The physiotherapy is Medically Necessary for Treatment of the Injury and prescribed by a Medical Practitioner.
b. Only that Physiotherapy treatment will be considered that is directly related to any Accident that had happened within 90
days from the start of the Physiotherapy sessions.
c. For the purpose of this benefit, Physiotherapy means any form of physical or mechanical therapy; diathermy; ultrasonic
therapy; heat treatment in any form; manipulation or massage administered by a Medical Practitioner for treatment of
Injury.
Either Rehabilitation Cover or Physiotherapy Cover can be offered. Both the benefits cannot be offered together.
3.12 Transportation of Imported Medicine Cover
mentioned in the Certificate of Insurance for the expenses incurred on the freight charges for importing medicines to India.
Conditions:
a. Then Insured is hospitalized (for 24 hours or more) for the Injury sustained due to the Accident.
b. Such medicines, formulations or their alternatives are not available in India.
c. Such medicines are necessary for the medical or surgical treatment of the Insured Person in a Hospital and are prescribed
by a Medical Practitioner.
d. Such medicines shall not include any drugs under clinical trial or medicines, formulations or molecules of unproven efficacy.
3.13 Purchase of Blood Cover
If the Insured Person sustains an Accidental Injury during the Policy Period which results in Accidental Hospitalization (for
24 hours or more), then We will reimburse as per the sum insured mentioned in the Certificate of Insurance for the expenses
incurred on purchase of blood from blood bank.
3.14 Prosthesis Device Cover

mentioned in the Certificate of Insurance for the expenses incurred on purchasing medically necessary Prosthetics Device(s)
to resume normal living post Injury due to Accident.
Conditions:
a. The Prosthetic device must be Medically Necessary for Treatment and prescribed by a Medical Practitioner.

b. The Insured suffers Accidental Hospitalization, Permanent Total Disability, Permanent Partial Disability, Burns, Coma or
Broken Bones due to the Accident.
c. For the purpose of this benefit, Prosthetic device means artificial devices replacing body parts including but not limiting to
artificial limbs or eyes, orthopedic braces, intra-ocular lenses, spectacles, hearing aids, dentures, artificial teeth and durable
medical equipment such as wheelchair, crutches, hospital beds, traction equipment, Walkers, tri-cycles.
3.15 Hospital Daily Cash Benefit
If the Insured Person is hospitalized (for 24 hours or more) following an Accidental Injury during the Policy Period, then We
will pay either a fixed amount on per hospitalization day basis or a lump sum amount as mentioned in Certificate of
Insurance.
3.16 Road Ambulance Cover
If the Insured Person sustains an Accidental Injury during the Policy Period which results in Accidental Hospitalization (for
24 hours or more), then We will reimburse as per the sum insured mentioned in the Certificate of Insurance for the expenses
incurred on availing Road Ambulance to reach hospital post-Accident
NOTE: Must use a registered ambulance provider Only.
3.17 Air Ambulance Cover
If the Insured Person is hospitalized (for 24 hours or more) following an Accidental Injury during the Policy Period, then We
will reimburse as per the sum insured mentioned in the Certificate of Insurance for the expenses incurred on availing Air
Ambulance to reach a hospital.
NOTE: Must use a registered ambulance provider Only. Air ambulance is available ONLY for Emergency care, in case a Road
Ambulance is not available.
3.18 Second Medical Opinion Benefit
If the Insured Person is undergoing a treatment for an Accidental Injury, the Insured Person can, at the Insured Person’s
choice, obtain a Second Medical Opinion during the Policy Period.
Conditions:
a) The Second Medical Opinion if arranged by Our Service Provider, will be based only on the information and documentation
provided by the Insured Person with the Medical Practitioner.
b) This benefit can be availed as per the times mentioned in your Certificate of Insurance.
3.19 Burns Benefit
If the Insured Person suffers from Burns due to an Accident, then We will pay the claim as per Table 3. Total Sum Insured
for this benefit will be mentioned in the Certificate of Insurance.
The Degree of the burns and total body surface area burnt has to be certified by a Medical Practitioner.

Table 3:
Condition for Burns Percentage of Burns Sum Insured
3rd degree burns of 30% or more of the total body surface 100%
2nd degree burns of 30% or more of the total body surface 50%
3rd degree burns of 20% or more, but less than 30% of the total body surface 80%
2nd degree burns of 20% or more, but less than 30% of the total body surface 40%
The coverage under this Benefit would terminate for the Insured Member (for lifetime) for whom we have paid a total of
100% Burns Sum Insured claim in the lifetime of the Insured.
3.20 Broken Bones Benefit
If the Insured Person suffers from Broken Bone or Fracture due to an Accident, then We will pay claim as per Table 4. Total
Sum Insured for this benefit is as mentioned in Certificate of Insurance.
Table 4:
Percentage of Broken Bone

Condition for Broken Bone
Sum Insured
Pelvis, Vertebral body resulting in spinal cord Injury 100%
Shoulder (collar bone & shoulder blade), Chest (all ribs & breast bone), Arm, Leg,
30%
Vertebra (excluding Coccyx)
Fracture to any other bone in the body 10%
NOTE: For the purpose of this benefit, Broken Bone or Fracture will mean a break in the continuity of the bone. This does
not include hairline Fractures. This has to be confirmed by a Medical Practitioner and imaging investigations like an X-ray.
3.21 Coma Benefit
If the Insured Person is in Comatose (coma) State within one month from date of Accident, then We will pay the Sum Insured
An Insured Person is said to be in Comatose State (Coma) if:
a. Has been in a State of Comatose for continuous 96 hours

b. Is on Life support systems
c. Condition is confirmed by the treating Doctor
NOTE: We will NOT pay for coma which results from alcohol or drug abuse.
The coverage under this Benefit would terminate for the Insured Member (for lifetime) for whom we have paid a total of
100% Coma Sum Insured claim in the lifetime of the Insured.
3.22 Animal Attack Cover
We will cover cost of treatment as per per the sum insured mentioned in the Certificate of Insurance for treatment of
Accidental Injury caused by an animal. We will also cover cost of vaccinations if prescribed by Medical Practitioner.
NOTE: The benefit does NOT cover diseases spread through an insect bite by transfer of organisms for which the insect is a
known carrier or host.
If Out-patient Expense Cover or Accidental Hospitalization offered, then this benefit cannot be offered.
3.23 Rehabilitation Cover
We will cover cost of treatment as per the sum insured mentioned in the Certificate of Insurance for the Rehabilitation of
the Insured Person following an Accident.
Conditions:
a. Rehabilitation to start within 3 weeks of date of Accident.

b. Treatment by a licensed, registered, or certified therapist; or
c. Treatment in an institution which is licensed to provide such treatment, when the treatment is intended to prepare the
Insured Person for work in any gainful occupation, including the Insured Person’s regular occupation.
d. The Rehabilitation is Medically Necessary for Treatment and prescribed by a Medical Practitioner.
Either Rehabilitation Cover or Physiotherapy Cover can be offered. Both the benefits cannot be offered together.
3.24 Reconstructive Surgery Cover
We will cover cost of treatment as per the sum insured mentioned in the Certificate of Insurance for the Reconstructive
Surgery following an Accident. Provided that the Accidental Injury results in Accidental Hospitalization, Permanent Total
Disability, Permanent Partial Disability or Burns.
Conditions:
a. The Surgery must be conducted within six months of date of Accident.

b. The Reconstructive Surgery is Medically Necessary for Treatment of the Injury and prescribed by a Medical Practitioner.
c. We shall NOT be liable to make any payment in respect of any Insured Person for:
 Any Reconstructive Surgery not performed by a registered and licensed Medical Practitioner.
 Any Reconstructive Surgery an Insured Person elects to have even if it is not medically necessary.

NOTE: For the purpose of this benefit, Reconstructive surgery means surgery to treat body parts affected aesthetically or
functionally by Accident or Burns.
3.25 Accidental Miscarriage Benefit
If an Accidental Injury leads to miscarriage within 3 months of date of Accident, then We will provide a lump sum coverage
Conditions:
a. This benefit is applicable ONLY to the female Insured Member covered under this Policy.
b. Coverage under this Benefit is available ONLY once in a policy year.
c. This benefit is applicable ONLY if Insured is minimum five weeks pregnant at the time of the Accident event.
3.26 Domestic Travel for Medical Treatment Cover
If the Insured Person sustains an Accidental Injury during the Policy Period which requires the Insured to move to another
city for treatment, then We will reimburse as per the sum insured mentioned in the Certificate of Insurance for the expenses
incurred on the following –
a. Reasonable travel expenses incurred to move to another city.

b. Travel expenses incurred on return from outside the city of residence, including the modification of carrier for convenient
transportation post discharge.
Conditions:
a. The distance between the place of residence and the place of treatment facility must be at least 50 KMs.
b. Travel to another city is Medically Necessary for Treatment of the Injury due to unavailability of such treatment in the city
of residence and the same is carried out on the written advice of a Medical Practitioner.
c. The Insured is hospitalized (for 24 hours or more) for the treatment of the Injury.
3.27 Repatriation Cover
In case of Accidental Death of Insured Person during the Policy Period, we will reimburse as per the sum insured mentioned
in Certificate of Insurance towards transportation of mortal remains from the place of death to the residence of the deceased
Insured Person.
3.28 Funeral Benefit
In case of Accidental Death of Insured Person, we will pay Sum Insured as mentioned in the Certificate of Insurance towards
funeral expenses of the deceased Insured Person.
3.29 Home and Vehicle Modification Benefit
We will pay Sum Insured as mentioned in the Certificate of Insurance towards modification of residential accommodation
and/or vehicle of the Insured Person following an Accident which resulted into Permanent Total Disability or Permanent
Partial Disability of Insured Person. Provided that the modifications have been carried out in India and certified by a Doctor
as necessary for treatment and resume normal living.
3.30 Personal liability
We will pay Sum Insured as mentioned in the Certificate of Insurance for expenses incurred by the Insured Person for:

a. Any actual legal liability of the Insured for causing an unintentional Injury or death of a third party due to any involvement
of the Insured in an Accident.
b. All costs, fees and expenses in the investigation, defense or settlement of any claim.
Special conditions:
1. You shall:
a. Give Us written notice within 10 days of any claim or demand made against you
b. Not admit liability/ settle/ compromise/ make any payment without Our prior written consent.
c. Allow Us, in Our sole and absolute discretion, to take over and conduct investigation, defence and/or settlement of any
claim. You shall provide all the cooperation and assistance We may require. Having taken over the defence of any claim, we
may in Our sole and absolute discretion relinquish the same.
2. We will not settle any claim without your consent. But if you refuse settlement recommend by Us and choose to contest or
continue any legal proceedings, then Our liability will not exceed the amount for which the claim could have been settled
plus the defence costs incurred with Our consent up to the date of such refusal.
3. For us to cover the costs, claim shall be made on you by the third parties during the Period of Insurance or within 60 days
from the date of expiry of the insurance.
Conditions:
What is NOT covered?
1. Any fines or exemplary damages aimed at punishing you rather than awarding compensation to third party
2. Liability arising from:
a. Violation of operating/safety guidelines published by the service provider contracted by you.
b. Action of any type by any other person accompanying you.
c. Loss of or damage to property which belongs to you or is under your control or the control of a member of your household
or the control of people who work for you.
d. Your job/profession/professional activities/trade/business/employment or occupation.
e. Any willful, malicious, criminal or unlawful act, error, or omission.
f. Liability assumed by you by an agreement / contract which would not have attached in the absence of such agreement /
contract.
g. Personal injuries including but not limited to libel, slander, false arrest, sexual molestation, corporal punishment, wrongful
eviction, wrongful detention, defamation, any mental Injury, anguish, or shock resulting therefrom.
h. Ownership and / or Occupation of any land and / or building, unless you are occupying any temporary holiday
accommodation, which is not owned by you.
i. Ownership and / or Usage of any of the following:
 livestock (except domestic animals);
 firearms (except sporting guns used for clay-pigeon shooting);
 motorized vehicles, aircraft of any description, including unpowered flight
 vessels (except manually-propelled watercraft); or
j. Your participation in any leisure activity or activity-based holiday or adventure sports where Personal Liability is specifically
excluded.
k. Transmission of illness or disease by the Insured
l. Any family member, relative, friend, travel companion or close business associate
3. Any Claim paid or compromised or commitment made without our prior written consent
3.31 Emergency Hotel Requirement Cover

If the Insured Person sustains Accidental Injury which results in Accidental Hospitalization (for 24 hours or more) during the
Policy Period, then We will reimburse as per the sum insured and limits mentioned in the Certificate of Insurance for the
expenses incurred on hotel stay for the Insured Person and any one Immediate Family Member travelling with the Insured
Person for treatment.
Conditions:
a. We shall NOT accept more than one claim under this Benefit during the Policy Period.
b. For the purpose of this benefit, Immediate Family Member relationship with respect to the Insured Person applicable are -
Spouse, Parents, Sibling, Mother In-Law, Father In-Law, and Child.
3.32 Home Convalescence Cover
If the Insured Person sustains Accidental Injury which results in Accidental Hospitalization (for 24 hours or more) during the
Policy Period, then We will reimburse as per the sum insured mentioned in the Certificate of Insurance for the expenses
incurred on engaging one qualified nurse at residence immediately after discharge from the hospital. Provided that the
qualified nurse is prescribed by a Medical Practitioner and is appointed for a period that is medically necessary for treatment
of the Insured.
3.33 Loss of Activities of Daily Living Benefit
If the Insured Person is unable to perform three or more Activities of Daily Living for a period of at least six consecutive
months following an Accidental Injury within the Policy Period, then We will pay Sum Insured as mentioned in the Certificate
of Insurance. Provided that the Accidental Injury results in Permanent Total Disability, Permanent Partial Disability, Burns,
Coma or Broken Bones.
Conditions:
a. This loss of ability to perform Activities of Daily Living and its duration should be certified by a Medical Practitioner.
b. This cover is NOT applicable for Insured aged seventy-five or above.
c. For the purpose of this benefit, the Activities of Daily Living are –
i. Washing: the ability to wash in the bath or shower (including getting into and out of the bath or shower) or wash satisfactorily
by other means;
ii. Dressing: the ability to put on, take off, secure and unfasten all garments and, as appropriate, any braces, artificial limbs or
other surgical appliances;
iii. Transferring: the ability to move from a bed to an upright chair or wheelchair and vice versa;
iv. Mobility: the ability to move indoors from room to room on level surfaces;
v. Toileting: the ability to use the lavatory or otherwise manage bowel and bladder functions so as to maintain a satisfactory
level of personal hygiene;
vi. Feeding: the ability to feed oneself once food has been prepared and made available.
3.34 Monthly Needs Benefit
In case of Accidental Death or Permanent Total Disability of Insured Person due to an Accident, we will pay Sum Insured as
mentioned in the Certificate of Insurance towards monthly needs of the insured for up to twelve months. Provided that the
condition is certified by a Medical Practitioner.
3.35 Education for Dependent Children Benefit

In case of Accidental Death or Permanent Total Disability of Insured Person due to an Accident, we will pay Sum Insured as
mentioned in the Certificate of Insurance towards the Education of the dependent children
Conditions:
a. Dependent child is a full-time student in any recognized Educational Institute at the time of occurrence of the Accident
event.
b. For the purpose of this benefit, Educational Institute means any accredited institution that provides education or training,
including but not limited to, any technical / vocational school.
c. The age of the child at the time of occurrence of the Accident event would be considered to validate of the child is
dependent.
d. We will make a single payment, irrespective of the number of Children.
e. The claim under this benefit would payable only once in the lifetime for the Insured Member.
3.36 Marriage Fund for Children Benefit
In case of Accidental Death or Permanent Total Disability of Insured Person due to Accident, we will pay Sum Insured as
mentioned in the Certificate of Insurance towards the marriage expenses of the adult and unmarried children of the Insured.
Conditions:
a. We will make a single payment, irrespective of the number of Children.

b. The claim under this benefit would payable only once in the lifetime for the Insured Member.
3.37 Orphan Benefit
Following the Accidental Death of both parents in same or different Accident event(s) in a policy year, we will pay Sum
Insured as mentioned in the Certificate of Insurance towards the care of orphan children.
Conditions:
a. Both the parents have to be covered as Insured Members under this policy.
b. We will make a single payment, irrespective of the number of children.
3.38 Spouse Care Benefit
Following Accidental Death of Insured Person, we will pay Sum Insured as mentioned in the Certificate of Insurance towards
the care of living spouse of the Insured.
The spouse of the Insured need NOT be covered in the policy.
NOTE: For the purpose of this benefit, Spouse means an individual legally married to the Insured Person.
3.39 Compassionate Visit Benefit
In case of Accidental Hospitalization (for 24 hours or more) of Insured Person, we will pay Sum Insured as mentioned in the
Certificate of Insurance, towards the travel expense of one Immediate Family member of the Insured Person to the place of
Hospitalization.

Conditions:
a. The place of Hospitalisation must be at least 50 KMs from the place of residence of the Insured.
b. For the purpose of this benefit, Immediate Family Member relationship with Insured Person applicable are - Spouse,
Parents, Sibling, Mother In-Law, Father In-Law, and Child.
c. The Immediate Family Member must be an Adult (18 years or more).
3.40 Medical Insurance Premium Cover
In case of Accidental Death or Permanent Total Disability of Insured Person, we will reimburse as per the sum insured
mentioned in the Certificate of Insurance towards one time immediate and annual medical insurance premium for the
Insured Person’s surviving Spouse and Dependent Children combined.
NOTE: The claim under this benefit would payable only once in the lifetime for the Insured Member.
3.41 Parental Care Benefit
In case of Accidental Death or Permanent Total Disability of Insured Person, we will pay Sum Insured as mentioned in the
Certificate of Insurance towards the care of parents of the Insured Person.
Conditions:
a. Elderly parent has to be above the age of 60 years and alive.

b. We will make a single payment, irrespective of the number of parents above 60 years of age and alive.
c. The claim under this benefit would payable only once in the lifetime for the Insured Member.
3.42 Family Counselling Benefit
In case of Accidental Death, Permanent Total Disability or Coma of Insured Person, we will pay Sum Insured as mentioned
in the Certificate of Insurance towards Professional Counselling for Insured Person’s Spouse and Dependent Child. Provided
that the counselling is prescribed by a Medical Practitioner.
3.43 Loss of Personal Material Cover
If the Insured Person suffers an Accidental Injury during the Policy Period, then We will reimburse as per the sum insured
mentioned in the Certificate of Insurance towards the Loss or Theft of Personal Material of the Insured caused due to the
Accident event.
Coverage as per the following options would be applicable as mentioned in the Certificate of Insurance –
 Coverage for Electronic Equipment, like Cellphone, laptop, headphones

 Coverage for Books, Bag, Course Material, Study Material
 Coverage for Uniform (outfit provided by an employer to a professional)
 Any one or Combination of the above option can be offered
Conditions:
a. We would NOT cover the damage caused by wear and tear, gradual deterioration, moths, vermin, inherent vice or damage
sustained due to any process initiated by the Insured Person to repair, clean or alter the property.

b. The Insured Person provides Us with a written proof of to validate the ownership of the item under consideration.
3.44 On Duty Cover
This benefit provides inclusion in the Policy to the members with risky professions as classified under Risk Class 4 of the
Annexure 3 – Risk Class Grid. The Coverage will be provided to the Insured as per the benefits offered in the Certificate of
Insurance while the Insured is on Professional Duty during the official work hours (and not for all the 24 hours of the day
& night).
3.45 Common Carrier Benefit
If the Insured Person sustains Accidental Injury while travelling in a common carrier as a fare-paying passenger (including
boarding and alighting from that Common Carrier) during the Policy Period which results in Accidental Death or Permanent
Total Disability of Insured, then We will pay Sum Insured as mentioned in the Certificate of Insurance.
3.46 Terrorism Cover
This benefit provides extension of scope of coverage under this policy by providing a waiver of the exclusion 4.1.3.
Such extension will not result into any increase in Sum Insured of the respective Coverages.
3.47 Common Accident Benefit
In case of Accidental Death of Insured Person and his/her spouse in same Accidental event during the Policy Period, we will
pay Sum Insured as mentioned in the Certificate of Insurance. Provided that both the Insured and his/her Spouse must be
covered under the Policy.
3.48 Adventure Sport Cover
This benefit provides extension of scope of coverage under this policy by providing a waiver of the exclusion 4.1.6. Provided
that the Adventure Sports are performed in non-professional capacity, under the supervision of a trained professional and
for leisure purpose ONLY.
For the purpose of this benefit, Adventure Sports includes:
I. Sky Sports: Sky Diving, Hang Gliding, Ballooning, Parasailing, Paragliding, Bungee Jumping, Bridge Swinging, Zip Lining, Zip
Trekking
II. Mountain Sports: Skiing, Snowboarding, Rock Climbing, Rock Scrambling, Rappelling, Via Ferrata, Fell Running, Fell Walking,
Gorge Walking, Indoor Rock Climbing, Mountain Biking, Cannoning, Mountaineering
III. Water Sports: Fishing, Deep Sea Fishing, Kite Surfing, Body Boarding, Paddle Boarding, Kayaking, Canoeing, Scuba Diving,
Shark Diving, Swimming with Dolphins, diving with Whales, Wakeboarding, Surfing, white water rafting, Snorkeling,
Waterskiing, Whale Watching
IV. Racing Sports: Auto (car) racing, Motor rallying, Motorcycle racing, Air racing, Kart racing, Boat racing, Hovercraft racing,
Lawn, mower racing, Snowmobile racing, Truck racing, Off Road 4x4
V. Earth Sport: Land Windsurfing, Zorbing, Sand Boarding
3.49 Head & Spinal Injury Benefit

If the Insured Person sustains head or spinal injury due to an Accident during the Policy Period which results in Permanent
Total Disability, Permanent Partial Disability or Coma of Insured, then We will pay Sum Insured as mentioned in the
Certificate of Insurance.
NOTE: Head or Spinal Injury has to be confirmed by a confirmed by a Doctor and imaging investigations like an X-
ray, CT-Scan, MRI, Ultrasound.
For the Purpose of this benefit, Coma means When an Insured fall into Comatose State within one month of Accident.
Insured is said to be in Coma is in the same state for a continuous 96 hours.
3.50 Loan Protect Benefit
We will pay up to sum Insured as mentioned in the Certificate of Insurance.
Conditions:
1. We will not pay for any arrears or penalties levied by the bank or financial institution.
2. The loan has to be in the name of the Insured Person and from a Financial Institution.
3. It is the responsibility of the Insured Person to inform us in case the loan is transferred from one financer to another.
4. No refunds will be made, In case of early closure of the Loan during the Policy period.
4. Permanent Exclusions
4.1 Specific exclusions
We will not cover the following conditions in the policy and no claims will be made for them.
4.1.1 Self-inflicted Injury, Suicide or attempted suicide.

4.1.2 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)
4.1.3 Acts of Terrorism
4.1.4 Committing an assault, a criminal offence or any breach of law with criminal intent.
4.1.5 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.
4.1.6 Adventure Sports
4.1.7 Maternity, Pregnancy or Child birth or in consequence thereof.
4.1.8 Any non-allopathic treatment.
4.1.9 Diseases spread/ caused through an insect bite by transfer of organisms for which the insect is a known carrier or host.
4.1.10 Cosmetic or plastic surgery or any treatment to change appearance not arising out of Accident or Burns.
4.1.11 Circumcision unless necessary for the treatment of a disease or necessitated by an Accident.
4.1.12 Costs which are not Reasonable and Customary and treatments which are not Medically Necessary.
5. General Terms and Conditions
5.1 Standard General Terms and Conditions
5.1.1 Free look period

The Free Look Period shall be applicable on individual health insurance policies and not on renewals.
The insured person shall be allowed free look period of thirty days from date of receipt of the policy document to review
the terms and conditions of the policy.. If he/she is not satisfied with any of the terms and conditions , he/she has the
option to cancel his/her policy.

In the event the policyholder disagrees to any of the policy terms or conditions, or otherwise and has not made any claim,
he/she shall have the option to retun the policy to the insurer for cancellation, stating the reasons for the same.
Irrespective of the reasons mentioned, the policyholder shall be entitled to a refund of the premium paid subject only to a
deduction of a proportionate risk premium for the period of cover and the expenses, if any, incurred by the insurer on
medical examination of the proposer and stamp duty charges.
5.1.2 Cancellation
The policy holder may cancel his/her policy at any time during the term, by giving 7 days’ notice in writing. The
insurer shall:
a. Refund proportionate premium for unexpired policy period, if the term of the policy upto one year and
there is no claim(s) made during the policy period.
b. Refund premium for the unexpired policy period, in respect of policies with term more than 1 year and risk
coverage for such policy years are not commenced.
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.
a. 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.
A. Automatic Cancellation –
The Certificate of Insurance coverage shall automatically terminate in the event of death of the Insured Person.
B. Cancellation in case of Credit Linked Cases:
i. In cases the Policy is linked to the credit/ loan tenure, the coverage will continue till the end of loan tenure subject to
maximum tenure of 5 years, closure of the loan or Policy Period/ Coverage Period Term whichever is earlier. The Insured
Person shall inform Us of such closure of the loan immediately in order to cancel the cover under the Policy.
5.1.3 Renewal of Policy
A health insurance policy shall be renewable except on grounds of established fraud or non-disclosure or misrepresentation
by the insured.
An insurer shall not deny the renewal of a health insurance policy on the ground that the insured had made a claim or
claims in the preceding policy years, except for benefit based policies where the policy terminates following payment of
the benefit covered under the policy.
a. Request for renewal along with requisite premium shall be received by the Company before the end of the policy
period.
b. At the end of the policy period, the policy shall terminate and can be renewed within the Grace Period of 30 days
(annual installment) to maintain continuity of benefits without break in policy.
c. Coverage is available during the grace period.
d. No loading shall apply on renewals based on individual claims experience. However, discount in premium may be
provided by insurers to individual policyholders for good claims experience.

e. Insurer shall not resort to fresh underwriting by calling for medical examination, fresh proposal form etc at renewal
stage where there is no change in sum insured offered. In case increase in sum insured is requested by the
policyholder, the Insurer may underwrite only to the extent of increased sum insured
5.1.4 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/Certificate of Insurance/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. The insurer shall obtain nomination at
the time of new business and at the time of renewal for existing policies.
5.1.5 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.
5.1.6 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.
5.1.7 Withdrawal of Policy
a. 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.
b. lnsured Person will have the option to either renew (up to 90 days from renewal date) same product or 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.
5.1.8 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: Email us through our service platform https://rules.nivabupa.com/customer-service/ (Senior citizens may write to
us at: seniorcitizensupport@nivabupa.com)
Fax: 011-4174-3397
Courier: Customer Services Department
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. If
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

Contact No: 1860-500-8888

Fax No: 011-4174-3397
Email ID: Email our Grievance officer through our Grievance Redressal platform
https://transactions.nivabupa.com/pages/grievance-redressal.aspx
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 III).
Grievance may also be lodged at IRDAI integrated Grievance Management System – www.bimabharosa.irdai.gov.in
5.1.9 Claim settlement (Provision for Penal interest)
a. The Company shall settle or reject a claim, as the case may be, within 15 days from the claim submission date.
b. 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 claim document till the date of payment of claim at a rate of 2% above the bank rate.

5.1.10 Multiple Policies
a. Indemnity Based Policies:
a. In 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. In all such cases the insurer chosen by the Policyholder shall
be considered as the Primary Insurer and will 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.
b. If the amount to be claimed exceeds the available coverage of the said policy, then the primary insurer
shall seek the details of other available policies of the policyholder and shall coordinate with other
insurers to ensure settlement pf the balance amount as per the policy conditions, without causing any
hassles to the policy holder.
b. Benefit Based Policies:

a. On occurrence of the insured event, the policy holder can claim from all Insurers under all policies.
5.1.11 Disclosure to 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)
5.1.12 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.
5.1.13 Complete Discharge
Any payment to the policyholder, Insured Person or his/ her nominees or his/ her legal representative or assignee or to the
Hospital, as the case may be, for any benefit under the policy shall be a valid discharge towards payment of claim by the
Company to the extent of that amount for the particular claim.
5.2 Specific Terms and Conditions
5.2.1 Additional premium (Risk Loading)
a. We may ask for additional premium after due risk evaluation (it’s what referred to as Underwriting) based on all information
provided by you. We will issue policy to you only after you pay us the additional premium and provide us consent.
b. We will never ask for more than 100% for any particular health condition and never more than 150% for any individual.
c. Once applied, Risk loading continues even for all renewals
5.2.2 Other Renewal Conditions:
a. Renewal Premium:
Renewal premium can alter based on Age.
b. Addition of Insured Persons on Renewal:

If a new member is added in the 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 afresh for that member.

c. Changes to Sum Insured on Renewal:
You may opt for enhancement of Sum Insured at the time of Renewal, subject to underwriting.
5.2.3 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.
5.2.4 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:
Niva Bupa Health Insurance Company Limited

Fax No: 011-4174-3397
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.
5.2.5 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.
5.2.6 Assignment
The Policy can be assigned subject to applicable laws.
5.2.7 Premium Payment in Installments
lf the Insured Person has opted for Payment of Premium on an instalment basis i.e. Half Yearly, Quarterly or Monthly, as
mentioned in the policy Schedule/Certificate of Insurance, the following Conditions shall apply (notwithstanding any terms
contrary elsewhere in the policy)
a. Grace Period of 30 days in all types of policies, and a period of 15 days in case of monthly installments
b. For policies where premium is paid in instalments only, the coverage will be given during grace period.
c. The Insured Person will get the accrued continuity benefit in respect of the "Waiting Periods", "Specific Waiting Periods" in
the event of payment of premium within the stipulated grace Period.
d. No interest will be charged lf the instalment premium is not paid on due date
e. ln case of instalment premium due not received within the grace period, the policy will get cancelled.
f. ln the event of a claim, all subsequent premium instalments shall immediately become due and payable.
g. The company has the right to recover and deduct all the pending installments from the claim amount due under the policy.

5.2.8 Per Kilometer based Coverage
 Per Kilometer based coverage will be provided through our app/website or through a 3rd party app or website. It will be
basis maps and location services the app has access to (like Google maps).
Premium for Mountainous terrain will be higher, because of higher risk of travel in these areas. Regions under
Mountainous terrain: Jammu & Kashmir, Himachal Pradesh, Uttarakhand, Sikkim, Arunachal Pradesh, Nagaland,
Mizoram, Manipur, Meghalaya and Tripura.
 Premium will be collected in advance
 RBI approved channels will be used to collect the premium - credit cards, net banking, debit cards, mobile wallets, UPI etc.
Customer can avail per km basis coverage by making a premium payment by either of below mentioned processes -
i. Point to point: Customer will choose start point and destination point for his/her trip on the app. App will calculate the
distance between the two points and compute the premium accordingly. An additional 25% premium will be collected to
ensure continuity of coverage should the distance between the points vary for reasons like change in route. Multiple
notifications/ messages will be sent to customers much before his/her premium gets exhausted. This will allow customer
to make an informed decision on whether to extend his/her coverage or not. He/she can extend coverage by paying
additional premium for fixed number of km’s (in multiples of 10 km).
ii. Fixed number of kms: Customer can buy coverage for fixed number of km’s (in multiples of 10km) and pay the premium
accordingly. Multiple notifications/ messages will be sent to customers much before their premium gets exhausted. This
will allow customer to make an informed decision on whether to extend his/her coverage or not. He/she can extend
coverage by paying additional premium for fixed number of km’s (in multiples of 10 km).
Termination of cover
 Customer can voluntarily terminate the coverage.

 Automatic termination of coverage on complete utilization of premium or km’s bought.
 Automatic termination at the end of 30 days from coverage inception.
Return of Excess Premium: Unused balance or extra premium paid at the start of the coverage, will be returned to the
customer at the time of coverage termination.
5.2.9 The Plan can be offered for accident linked to a Specific Geography, Mode of Transport, Type of Vehicle or/and extending
only to the liability of the Proposer (w.r.t duration, duty hours, place of work and/or membership). Details will be
mentioned in the Certificate of Insurance.
5.2.10 Claims
a. Cashless claim facility is available at our network hospitals ONLY. As list of network hospitals is dynamic, for the latest list,
refer to our website www.nivabupa.com.
b. Once the final authorization request is received for discharge, the same will be processed within three hours from the
final documents received. In case of delay from our end, any additional amount charged by the hospital will be borne by
us. This amount will be paid over and above the policy limits.
Note: We offer Cashless Everywhere, even in hospitals which are not part of our network. For More details and process
please visit our website: https://transactions.nivabupa.com/cashlessclaims/pages/intimation-claim.aspx
c. We shall be provided with the following necessary information and documentation in respect of all claims at Your/Insured
Person’s expense at the earliest possible time.
d. Documents required
• Our duly filled and signed Claim Form or Online claim submission
Documents Required
• Scanned copy of COI

• Treating Doctor’s prescription advising the need, as mentioned under the benefit terms and
conditions of the policy (wherever applicable)
• Copy of settlement letter from other insurance company
• Medical Records, Case histories, investigation reports and Laboratory investigation reports with
supporting prescriptions
• Death Certificate and/or Post-mortem report (wherever applicable)
• Disability Certificate, issued by a Medical Board duly constituted by the Central and/or the State
Government (wherever applicable)
• FIR (First Information Report), MLC (Medico-Legal Case) report Copy (if MLC is done), Spot
Panchnama, Inquest Panchnama attested by issuing / appropriate authorities
• Original Discharge summary with first and subsequent consultation/treatment papers
• Original Final Hospital bill with detailed break-up and payment receipt (including pharmacy bills)
• Legal heir certificate (wherever applicable)
• Marriage Certificate (wherever applicable)
• Legal documents as Age proofs (wherever applicable)
• Original legal heir certificate (if nomination has not been filed by deceased)
• Loan Account statement and last EMI proof (if loan linked policy)
Policyholder documents (Nominee in case of death of Policyholder):

• KYC documents
• Cancelled cheque
Note - The list of Documents is indicative more documents may be asked for as per claim
servicing requirement
S. No. Benefits Claim Documents
• Death Certificate attested by issuing / appropriate authority
Accidental Death
1 • Post Mortem Report attested by issuing authorities wherever applicable
Benefit
• Original legal heir certificate (in case nomination has not been filed by deceased)
• Photograph of the injured as a proof of disablement
• Disability Certificate from appropriate Government Authority Medical Certificate from treating
Permanent Total
2 Doctor
Disability Benefit
• Medical reports, case histories, investigation reports, treatment papers as applicable
• Leave certificate from the employer (as per requirement)
• Disability Certificate from appropriate Government Authority Medical Certificate from treating
Permanent Partial
3 Doctor
Disability Benefit
• Leave certificate from the employer (as per requirement)
• Treating doctor certificate mentioning the nature of injury and duration of rest advised
Temporary Total
4 • Medical reports, case histories, investigation reports, treatment papers as applicable
Disability Benefit
• Leave certificate from the employer
• Original X ray films (where applicable)
Accidental • Discharge summary
5
Hospitalization • Original invoice and payment receipt for hospitalization expenses
• Details of any other related document such as medical bills with prescription
• Final Hospital bill and/or Discharge Summary mentioning the date and time of admission and
Serious Illness
8 discharge.
Benefit
• Documents related to Accidental Hospitalization as mentioned in the policy wording

Out-patient Expense
10 • Original invoice and payment receipt for OPD expenses
Cover
• Original X ray films (where applicable)
11 Physiotherapy Cover • Physiotherapy schedule / Chart
• Original invoice and payment receipt for Physiotherapy expenses
• Prescription of the treating doctor with confirmation that the medicine is not available in India
Transportation of
• Original invoice and payment receipt for the freight incurred for import of the medicine
12 Imported Medicine
• Original invoice and payment receipt for the imported medicine
Cover
Purchase of Blood • Original invoice and payment receipt for blood expenses
13
Cover • Documents related to Accidental Hospitalization as mentioned in the policy wording
• Original invoice and payment receipt for expenses incurred on the Prosthetics
Prosthesis Device
14 • Documents related to Accidental Hospitalization, PTD, PPD, TTD, Burns, Broken Bones or Coma
Cover
as mentioned in the policy wording
• Final Hospital bill and/or Discharge Summary mentioning the date and time of admission and
Hospital Daily Cash
15 discharge
Benefit
Road Ambulance • Original invoice and payment receipt for ambulance charges
16
Cover • Documents related to Accidental Hospitalization as mentioned in the policy wording
• Original invoice and payment receipt for air ambulance charges (In case of non-network)
17 Air Ambulance Cover
• FIR / Medico Legal Report or related police records
19 Burns Benefit • Copies of all the medical records including discharge summary, follow up medical records,
Laboratory reports & Diagnostic reports like X-ray, CT scan, MRI report, etc.
• FIR / Medico Legal Report or related police records
Broken Bones • Copies of all the medical records including discharge summary, follow up medical records,
20
Benefit Laboratory reports & Diagnostic reports like X-ray, CT scan, MRI report, etc.
• Original X ray films
• Copies of all the medical records including discharge summary, follow up medical records,
Laboratory reports & Diagnostic reports like X-ray, CT scan, MRI report, etc.
21 Coma Benefit • Medical certificate from treating doctor giving the details of neurological status & prognosis,
proving the conditions as per defined in the policy wordings
• Original invoice and payment receipt for the expenses incurred on the treatment
22 Animal Attack Cover • Final Hospital bill and/or Discharge Summary
• Customer declaration regarding narration of incidence
• Copy of consultation / reference letter from treating doctor
23 Rehabilitation Cover
• Original invoice and payment receipt with consultation notes
• Documents related to Accidental Hospitalization, PTD, PPD or Burns as mentioned in the policy
wording
Reconstructive • Copy of medical records showing the details of medical condition (facial scarring / dental
24
surgery Cover reconstruction)
• Original invoice and payment receipt towards the medical treatment
• Final Hospital bill and/or Discharge Summary
• Treating Doctor’s letter / certificate / medical report indicating the cause of miscarriage and the
Accidental status of pregnancy at the time of accident event
25
Miscarriage Benefit • Final Hospital bill and/or Discharge Summary
• Copy of Investigation reports, diagnostic test reports, etc.

Domestic Travel for
26 Medical Treatment
• Original invoice and payment receipt towards the travel expenses incurred
Cover
27 Repatriation Cover • Documents related to Accidental Death as mentioned in the policy wording
28 Funeral Benefit • Documents related to Accidental Death as mentioned in the policy wording
• Recommendation letter from treating doctor for wheelchair or any other support required for
Home and Vehicle
29 treatment that require the modification of home and/or vehicle
Modification Benefit
• Documents related to PTD or PPD as mentioned in the policy wording
• All related legal documents of the accident and insured involvement and liability
30 Personal liability
• Proof of payment made or to be made as a liability of the insured
• Recommendation letter to validate the condition of the insured indicating the travel related
Emergency Hotel disability of the insured
31
Requirement Cover • Original invoice and payment receipt towards accommodation booking and confirmation
• Final Hospital bill and / or Discharge Summary
• Recommendation by the treating doctor for appointing an attendant at home for continuation
Home of treatment
32
Convalescence Cover • Original invoice and payment receipt towards expenses on the attendant
• Treating doctor recommendation indicating the criteria for loss of daily living
Loss of Activities of
33 • Documents related to PTD, PPD, Burns, Broken Bones or Coma as mentioned in the policy
Daily Living Benefit
wording
Monthly Needs
34 • Documents related to Accidental Death or PTD as mentioned in the policy wording
Benefit
• Documents related to Accidental Death or PTD as mentioned in the policy wording
Education for
• Copy identity card of dependent child of an educational institute at the time of date of loss and
35 Dependent Children
last fee payment receipt
Benefit
• Copy of Birth Certificate or any other valid document establishing age
Marriage Fund for • Copy of Birth Certificate or any other valid document establishing age
36
Children Benefit • Original declaration from the benefactor indicating that the child is unmarried and eligible as
per conditions of the policy wordings
37 Orphan Benefit • Documents related to Accidental Death as mentioned in the policy wording for both the parents
38 Spouse Care Benefit • Documents related to Accidental Death as mentioned in the policy wording
• Proof of the immediate family member such as Ration Card to establish the age and relation
Compassionate Visit
39 with the insured
Benefit
• Copy of medical insurance policy showing the premium details for spouse and dependent
Medical Insurance
40 children of the insured
Premium Cover
• Legal Document such as Aadhar card, Pan card, Marriage certificate to specify the relation of
Parental Care
41 the insured with the parents
Benefit
• Consultation / reference letter from treating doctor validating the conditions as mentioned in
Family Counselling the policy wordings
42
Benefit • Proof of relation with the insured such as Aadhar card
• Documents related to Accidental Death, PTD or Coma as mentioned in the policy wording
• FIR (First Information Report) copy mentioning about the loss details & lost items
Loss of Personal
43 • Original invoice and payment receipt (bills) towards the actual cost of the material lost under
Material Cover
consideration

• Official declaration from the employer that the insured was on duty while the accidental event
44 On Duty Cover
occurred
• Copy of valid ticket showing that insured was riding as a bonafide passenger in the public carrier
Common Carrier
45 under consideration
Benefit
• Valid document from the necessary authority to validate the "Terrorism, War & War like
situations" in the region under consideration
46 Terrorism Cover
• Proof of injury/death caused due to accident due to act of terrorism
• Declaration from the insured on the narration of incident
• Copy of valid tickets of the insured and his / her spouse validating that the couple was travelling
Common Accident
47 together during the accident event as a bonafide passenger
Benefit
• Documents related to Accidental Death as mentioned in the policy wording
Adventure Sport
48 • Original declaration from Insured Person that he was not involved in Professional Sport
Cover
• Head or Spinal Injury has to be confirmed by a confirmed by a Doctor and imaging investigations
Head & Spinal Injury
49 like an X-ray, CT-Scan, MRI, Ultrasound.
Benefit
• Documents related to PTD, PPD or Coma as mentioned in the policy wording
• Copy of Loan sanction letter and regular EMI paid details with Principal loan outstanding details
50 Loan Protect Benefit as on date of loss
IMPORTANT:
• For any delay in submission, You MUST provide the reasons in writing. We will condone such delay on merits (i.e. reasons
beyond your control).
• We reserve the right to ask for additional documents/reports from case to case basis.
• We reserve the right to check and investigate the hospital / medical records from any doctor, Hospital, clinic, individual
or institution.
e. For any hospitalization, We will pay for items included in the bill by the Hospital during the duration of hospitalization.
Items not included in the bill will not be paid.

Annexure 1 - The expenses that are not covered or subsumed into room charges / procedure charges / costs of
treatment
List I – Expenses not covered
S. No. Item S. No. Item S. No. Item
1 BABY FOOD 24 ATTENDANT CHARGES 47 LUMBO SACRAL BELT
2 BABY UTILITIES CHARGES 25 EXTRA DIET OF PATIENT (OTHER 48 NIMBUS BED OR WATER OR AIR BED
THAN THAT WHICH FORMS PART OF CHARGES
BED CHARGE)
3 BEAUTY SERVICES 26 BIRTH CERTIFICATE 49 AMBULANCE COLLAR
4 BELTS/ BRACES 27 CERTIFICATE CHARGES 50 AMBULANCE EQUIPMENT
5 BUDS 28 COURIER CHARGES 51 ABDOMINAL BINDER
6 COLD PACK/HOT PACK 29 CONVEYANCE CHARGES 52 PRIVATE NURSES CHARGES- SPECIAL

NURSING CHARGES
7 CARRY BAGS 30 MEDICAL CERTIFICATE 53 SUGAR FREE Tablets
8 EMAIL / INTERNET 31 MEDICAL RECORDS 54 CREAMS POWDERS LOTIONS (Toiletries

CHARGES are not payable, only prescribed
medical pharmaceuticals payable)
9 FOOD CHARGES (OTHER 32 PHOTOCOPIES CHARGES 55 ECG ELECTRODES

THAN PATIENT's DIET
PROVIDED BY HOSPITAL)
10 LEGGINGS 33 MORTUARY CHARGES 56 GLOVES
11 LAUNDRY CHARGES 34 WALKING AIDS CHARGES 57 NEBULISATION KIT
12 MINERAL WATER 35 OXYGEN CYLINDER (FOR USAGE 58 ANY KIT WITH NO DETAILS
OUTSIDE THE HOSPITAL) MENTIONED [DELIVERY KIT, ORTHOKIT,
RECOVERY KIT, ETC]
13 SANITARY PAD 36 SPACER 59 KIDNEY TRAY
14 TELEPHONE CHARGES 37 SPIROMETRE 60 MASK
15 GUEST SERVICES 38 NEBULIZER KIT 61 OUNCE GLASS
16 CREPE BANDAGE 39 STEAM INHALER 62 OXYGEN MASK
17 DIAPER OF ANY TYPE 40 ARMSLING 63 PELVIC TRACTION BELT
18 EYELET COLLAR 41 THERMOMETER 64 PAN CAN
19 SLINGS 42 CERVICAL COLLAR 65 TROLLY COVER

20 BLOOD GROUPING AND 43 SPLINT 66 UROMETER, URINE JUG
CROSS MATCHING OF
DONORS SAMPLES
21 SERVICE CHARGES WHERE 44 DIABETIC FOOT WEAR 67 AMBULANCE

NURSING CHARGE ALSO
CHARGED
22 TELEVISION CHARGES 45 KNEE BRACES (LONG/ SHORT/ 68 VASOFIX SAFETY

HINGED)
23 SURCHARGES 46 KNEE IMMOBILIZER/SHOULDER

IMMOBILIZER
List II – Items that are to be subsumed into Room Charges
1 BABY CHARGES (UNLESS 14 BED PAN 27 ADMISSION KIT

SPECIFIED/INDICATED)
2 HAND WASH 15 FACE MASK 28 DIABETIC CHART CHARGES
3 SHOE COVER 16 FLEXI MASK 29 DOCUMENTATION CHARGES /

ADMINISTRATIVE EXPENSES
4 CAPS 17 HAND HOLDER 30 DISCHARGE PROCEDURE CHARGES
5 CRADLE CHARGES 18 SPUTUM CUP 31 DAILY CHART CHARGES
6 COMB 19 DISINFECTANT LOTIONS 32 ENTRANCE PASS / VISITORS PASS CHARGES
7 EAU-DE-COLOGNE / 20 LUXURY TAX 33 EXPENSES RELATED TO PRESCRIPTION ON

ROOM FRESHNERS DISCHARGE
8 FOOT COVER 21 HVAC 34 FILE OPENING CHARGES
9 GOWN 22 HOUSE KEEPING CHARGES 35 INCIDENTAL EXPENSES / MISC. CHARGES

(NOT EXPLAINED)
10 SLIPPERS 23 AIR CONDITIONER CHARGES 36 PATIENT IDENTIFICATION BAND / NAME TAG
11 TISSUE PAPER 24 IM IV INJECTION CHARGES 37 PULSEOXYMETER CHARGES
12 TOOTH PASTE 25 CLEAN SHEET
13 TOOTH BRUSH 26 BLANKET/WARMER BLANKET
List III – Items that are to be subsumed into Procedure Charges

1 HAIR REMOVAL CREAM 9 WARD AND THEATRE BOOKING 17 BOYLES APPARATUS

CHARGES CHARGES
2 DISPOSABLES RAZORS CHARGES (for 10 ARTHROSCOPY AND ENDOSCOPY 18 COTTON

site preparations) INSTRUMENTS
3 EYE PAD 11 MICROSCOPE COVER 19 COTTON BANDAGE
4 EYE SHEILD 12 SURGICAL BLADES, 20 SURGICAL TAPE

HARMONICSCALPEL, SHAVER
5 CAMERA COVER 13 SURGICAL DRILL 21 APRON
6 DVD, CD CHARGES 14 EYE KIT 22 TORNIQUET
7 GAUSE SOFT 15 EYE DRAPE 23 ORTHOBUNDLE, GYNAEC

BUNDLE
8 GAUZE 16 X-RAY FILM
List IV – Items that are to be subsumed into costs of treatment
1 ADMISSION/REGISTRATION CHARGES 7 INFUSION PUMP– COST 13 MOUTH PAINT
HOSPITALISATION FOR EVALUATION/ HYDROGEN PEROXIDE\SPIRIT\

2 8 14 VACCINATION CHARGES
DIAGNOSTIC PURPOSE DISINFECTANTS ETC
NUTRITION PLANNING
3 URINE CONTAINER 9 CHARGES - DIETICIAN CHARGES- 15 ALCOHOL SWABES
DIET CHARGES
BLOOD RESERVATION CHARGES AND

4 10 HIV KIT 16 SCRUB SOLUTION/STERILLIUM
ANTE NATAL BOOKING CHARGES
5 BIPAP MACHINE 11 ANTISEPTIC MOUTHWASH 17 GLUCOMETER & STRIPS
6 CPAP/ CAPD EQUIPMENTS 12 LOZENGES 18 URINE BAG

Annexure 2 - List of Insurance Ombudsmen
Jurisdiction of Office
Office Details
Union Territory,District)
AHMEDABAD - Shri Kuldip Singh

Office of the Insurance Ombudsman,
Jeevan Prakash Building, 6th floor, Gujarat,
Tilak Marg, Relief Road, UT of Dadra & Nagar Haveli,
Ahmedabad – 380 001. Daman and Diu.
Tel.: 079 - 25501201/02/05/06
Email: bimalokpal.ahmedabad@ecoi.co.in
BENGALURU - Smt. Neerja Shah

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@ecoi.co.in
BHOPAL - Shri Guru Saran Shrivastava

Janak Vihar Complex, 2nd Floor,
6, Malviya Nagar, Opp. Airtel Office,
Madhya Pradesh
Near New Market,
Chhattisgarh.
Bhopal – 462 003.
Tel.: 0755 - 2769201 / 2769202
Fax: 0755 - 2769203
Email: bimalokpal.bhopal@ecoi.co.in
BHUBANESHWAR - Shri Suresh Chandra Panda

62, Forest park,
Bhubneshwar – 751 009. Orissa.
Tel.: 0674 - 2596461 /2596455
Fax: 0674 - 2596429
Email: bimalokpal.bhubaneswar@ecoi.co.in
CHANDIGARH - Dr. Dinesh Kumar Verma

Punjab,
S.C.O. No. 101, 102 & 103, 2nd Floor,
Haryana,
Batra Building, Sector 17 – D,
Himachal Pradesh,
Chandigarh – 160 017.
Jammu & Kashmir,
Tel.: 0172 - 2706196 / 2706468
UT of Chandigarh.
Fax: 0172 - 2708274
Email: bimalokpal.chandigarh@ecoi.co.in

CHENNAI - Shri M. Vasantha Krishna
Fatima Akhtar Court, 4th Floor, 453,
Tamil Nadu,UT-
Anna Salai, Teynampet,
Pondicherry Town and
CHENNAI – 600 018.
Karaikal (which are part of UT of Pondicherry).
Tel.: 044 - 24333668 / 24335284
Fax: 044 - 24333664
Email: bimalokpal.chennai@ecoi.co.in
DELHI - Shri Sudhir Krishna

2/2 A, Universal Insurance Building,
Asaf Ali Road, Delhi.
New Delhi – 110 002.
Tel.: 011 - 23232481/23213504
Email: bimalokpal.delhi@ecoi.co.in
GUWAHATI - Shri Kiriti .B. Saha

Assam,
Meghalaya,
Jeevan Nivesh, 5th Floor,
Manipur,
Nr. Panbazar over bridge, S.S. Road,
Mizoram,
Guwahati – 781001(ASSAM).
Arunachal Pradesh,
Tel.: 0361 - 2632204 / 2602205
Nagaland and Tripura.
Email: bimalokpal.guwahati@ecoi.co.in
HYDERABAD - Shri I. Suresh Babu

6-2-46, 1st floor, "Moin Court",
Andhra Pradesh,
Lane Opp. Saleem Function Palace,
Telangana, UT of
A. C. Guards, Lakdi-Ka-Pool,
Yanam and
Hyderabad - 500 004.
part of UT of Pondicherry.
Tel.: 040 - 67504123 / 23312122
Fax: 040 - 23376599
Email: bimalokpal.hyderabad@ecoi.co.in
JAIPUR - Smt. Sandhya Baliga

Jeevan Nidhi – II Bldg., Gr. Floor,
Bhawani Singh Marg,
Rajasthan.
Jaipur - 302 005.
Tel.: 0141 - 2740363
Email: Bimalokpal.jaipur@ecoi.co.in
ERNAKULAM - Ms. Poonam Bodra

Office of the Insurance Ombudsman, Kerala, UT of (a)Lakshadweep,(b) Mahe-a part
2nd Floor, Pulinat Bldg., of UT of Pondicherry.
Opp. Cochin Shipyard, M. G. Road,
Ernakulam - 682 015.
Tel.: 0484 - 2358759 / 2359338

Fax: 0484 - 2359336
Email: bimalokpal.ernakulam@ecoi.co.in
KOLKATA - Shri P. K. Rath

Hindustan Bldg. Annexe, 4th Floor,
West Bengal,
4, C.R. Avenue,
Sikkim, UT of
KOLKATA - 700 072.
Andaman & Nicobar Islands.
Tel.: 033 - 22124339 / 22124340
Fax : 033 - 22124341
Email: bimalokpal.kolkata@ecoi.co.in
LUCKNOW -Shri Justice Anil Kumar Srivastava Districts of Uttar Pradesh :

Office of the Insurance Ombudsman, Laitpur, Jhansi, Mahoba, Hamirpur, Banda,
6th Floor, Jeevan Bhawan, Phase-II, Chitrakoot, Allahabad, Mirzapur, Sonbhabdra,
Nawal Kishore Road, Hazratganj, Fatehpur, Pratapgarh, Jaunpur,Varanasi, Gazipur,
Lucknow - 226 001. Jalaun, Kanpur, Lucknow, Unnao, Sitapur,
Tel.: 0522 - 2231330 / 2231331 Lakhimpur, Bahraich, Barabanki, Raebareli, Sravasti,
Fax: 0522 - 2231310 Gonda, Faizabad, Amethi, Kaushambi, Balrampur,
Email: bimalokpal.lucknow@ecoi.co.in Basti, Ambedkarnagar, Sultanpur, Maharajgang,
Santkabirnagar, Azamgarh, Kushinagar, Gorkhpur,
Deoria, Mau, Ghazipur, Chandauli, Ballia,
Sidharathnagar.
MUMBAI - Shri Milind A. Kharat

3rd Floor, Jeevan Seva Annexe,
Goa,
S. V. Road, Santacruz (W),
Mumbai Metropolitan Region
Mumbai - 400 054.
excluding Navi Mumbai & Thane.
Tel.: 022 - 26106552 / 26106960
Fax: 022 - 26106052
Email: bimalokpal.mumbai@ecoi.co.in
NOIDA - Shri Chandra Shekhar Prasad State of Uttaranchal and the following Districts
Office of the Insurance Ombudsman, of Uttar Pradesh:
Bhagwan Sahai Palace Agra, Aligarh, Bagpat, Bareilly, Bijnor, Budaun,
4th Floor, Main Road, Bulandshehar, Etah, Kanooj, Mainpuri, Mathura,
Naya Bans, Sector 15, Meerut, Moradabad, Muzaffarnagar, Oraiyya,
Distt: Gautam Buddh Nagar, Pilibhit, Etawah, Farrukhabad, Firozbad,
U.P-201301. Gautambodhanagar, Ghaziabad, Hardoi,
Tel.: 0120-2514250 / 2514252 / 2514253 Shahjahanpur, Hapur, Shamli, Rampur, Kashganj,
Email: bimalokpal.noida@ecoi.co.in Sambhal, Amroha, Hathras, Kanshiramnagar,
Saharanpur.
PATNA - Shri N. K. Singh

Office of the Insurance Ombudsman, Bihar,
1st Floor,Kalpana Arcade Building,, Jharkhand.
Bazar Samiti Road,
Bahadurpur,
Patna 800 006.

Tel.: 0612-2680952
Email: bimalokpal.patna@ecoi.co.in
PUNE - Shri Vinay Sah

Jeevan Darshan Bldg., 3rd Floor,
Maharashtra,
C.T.S. No.s. 195 to 198,
Area of Navi Mumbai and Thane
N.C. Kelkar Road, Narayan Peth,
excluding Mumbai Metropolitan Region.
Pune – 411 030.
Tel.: 020-41312555
Email: bimalokpal.pune@ecoi.co.in
EXECUTIVE COUNCIL OF INSURERS,

3rd Floor, Jeevan SevaAnnexe,
S. V. Road, Santacruz (W),
Mumbai - 400 054.
Tel.: 022 - 26106889 / 671 / 980

Fax: 022 - 26106949
Email:inscoun@ecoi.co.in
Shri. M.M.L. Verma, Secretary General
Smt. Moushumi Mukherji, Secretary
Ombudsmen details are subject to change. Please refer this link for the updated details: CIO (cioins.co.in)”
Annexure 3 – Risk Class Grid
The below list is indicative of the type of professions that fall under different risk classification.
Risk Class Occupation/s
Persons engaged in white collar jobs and non-hazardous occupations in office such as Administrative,
Clerical, Financial, Marketing professions (desk jobs), teacher, doctor, Laboratory technical staff /
Supportive staff under health and healthcare services, Creative and performing artists of drama and
1 cinema, Authors, Journalists, linguists, Arts & media related designers, Home maker, Student and
Research scholars, Architects, Town planners and Interior designers, Employed in Hotel and
Hospitality industry, Gardeners & those involved in horticulture, Personal service workers ( Hair
dressing & other jobs in saloons or beauty parlors ), self-employed and businessmen involved in
non-hazardous businesses, IT / Software Engineers, Non-earning members or members earning
passive income (Rental /investment income).
2 Persons engaged in semi-hazardous occupations, engaged in superintending activities with duties in

a supervisory capacity and not an operator of light / heavy machinery or doing manual work. Such
professions include Supervisors involved in manufacturing or construction with no heavy machinery,

Culinary and Food preparation occupation with machinery, Drivers of light commercial vehicles ( Car,
Motorbike, scooter ), Onsite Engineers (mechanical, electrical, civil, aeronautical, textile), Veterinary
Doctors.
Persons engaged in professions such as Technicians working in low electrical voltage and related
occupation, Workers involved in agriculture, livestock, wildlife, forestry & fisheries, Drivers of
3 commercial vehicles, heavy trucks, vehicles (e.g. JCB), Drivers of noncommercial vehicles (domestic
drivers), workers related to strenuous transportation related work, professions such as Ground
staff of airlines, railways or shipping, Private Security Personnel, Politician.
Persons engaged in hazardous occupations such as Supervisors involved in work in underground

mining, tunneling, manufacturing, construction and/or dealing with heavy machines, workers
involved in mining, construction, mineral processing and/or any manufacturing work, workers
involved in plant operation work in chemical, rubber and textile plants, Technicians working in High
4
electrical voltage and related occupation, Professions related to adventure sports (Instructors or
related occupation), Acrobats, professional sportsmen, Jockey, Racing Drivers, circus professionals,
workers in Aviation, Railways and Shipping crew, professions such as Armed forces, Police, State &
Central reserve police and Home guards, Self-employed and/or businessmen involved in hazardous
businesses.
Annexure 4 – Product Benefit table
Product Benefit Table

Policy Hourly, KM wise, Daily, Weekly, Monthly, Quarterly, Yearly
Tenure Up to 5 years for loan linked
Adult- 18 yrs. to 100 yrs.
Entry Age Child: 0 Days onwards
Dependent Child Classification - less than or equal to 25 years of age
Plans Individual or to a Family on Individual Basis
Dependent Adult - Up to 100% of base sum Insured

Coverage
Dependent Child - Up to 50% of base sum insured
Self, Spouse, Children, Daughter-in-law, Father, Mother, Father-in-law, Mother-in-law,
Grandfather, Grandmother, Grandson, Granddaughter, Son-in-law, Brother, Sister, Sister-in-
Relationships law, Brother-in-law, Nephew, Niece and any relationship where there is insurable interest
Borrower(s) & Co-Borrower(s)

Benefit
Main Benefit Main benefit Options
S. No. Coverage Options Type
Name and Validations
Options
Option 1: Lump sum benefit up to
Rs. 10 Cr.
Option 2: Payout Options
a: Staggered - weekly, monthly,
quarterly, annually
b: Lump sum
Option 3: Benefit up to 100X of
the amount linked to salary
(monthly, quarterly or annually),
income, bank account, credit card
limit, credit card bill, wallet, Utility
bills, Systematic Investment Plans,
Termination Condition -
outstanding loan, Average
The policy will terminate
Accidental Death Quarterly balance (AQB), Rent,
1 for the member for Benefit
Benefit Any Fees paid for child for
whom we have paid the
education, any EMI.
claim under this benefit.
Option 4: Benefit up to 150% of
limit, credit card bill, wallet,
Utility bills, Systematic Investment
Plans, outstanding loan, Average
Quarterly balance (AQB), Rent,
Any Fees paid for child for
education, any EMI.
Option 5: Any possible reasonable
combination of above options.
Rs. 10 Cr.
quarterly, annually
b: Lump sum
Termination Condition - the amount linked to salary
The policy will terminate (monthly, quarterly or annually),
for the member for income, bank account, credit card
Permanent Total
2 whom we have paid a limit, credit card bill, wallet, Utility Benefit
Disability Benefit
total of 100% PTD Sum bills, Systematic Investment Plans,
Insured claim in a outstanding loan, Average
lifetime of the Insured. Quarterly balance (AQB), Rent,
education, any EMI.

education, any EMI.

Rs. 10 Cr.
quarterly, annually
b: Lump sum
limit, credit card bill, wallet, Utility
bills, Systematic Investment Plans,
Permanent
3 Partial Disability Benefit
Benefit
education, any EMI.
education, any EMI.

Option 1:
Earning Members -
Option a: Up to 5% of Base SI per
week. Max up to 5 L per week.
Max up to 100 Weeks
Option b: Up to 5% of Weekly
salary/income received, Max up to
5 L per week. Max up to 100
Weeks.
Non-earning members - Up to 5%
of Base SI per week. Max up to 1 L
per week. Max up to 50 Weeks

Option a: Staggered - weekly,
Options Available - monthly, quarterly, annually
TTD Sum Insured can be Option b: Lump sum
utilized as per the Option 3: Benefit up to 100X of
following options - the amount linked to salary
Temporary Total • TTD benefit to use (monthly, quarterly or annually),
4 Benefit
Disability Benefit Accidental Death Sum income, bank account, credit card
Insured limit, credit card bill, wallet ,
• TTD benefit to have Utility bills, Systematic Investment
Independent Sum Plans, outstanding loan, Average
Insured Quarterly balance (AQB), Rent,
education, any EMI.
education, any EMI.
Option 5: Up to 3 Days Deductible
Option 6: Up to 3 Days Franchise

Options Available -
Accidental
Hospitalization is
available as per the
following options -
• Coverage under this
benefit NOT linked to
fulfillment of conditions
of Accidental Death,
Permanent Total
Disability, Permanent
Partial Disability or
Temporary Total Up to INR 1Cr, if hospitalization
Disability. due to Accident.
Accidental
5 benefit linked to Indemnity
Hospitalization
fulfillment of conditions (Only Cashless, Only
of Accidental Death, Reimbursement or Combination
Permanent Total can be offered)
Temporary Total
Disability.
Offering Conditions -
Either Accidental
Hospitalization or
Animal Attack cover can
be offered. Both the
benefits cannot be
offered together.
Option 1: Up to Unlimited times
reinstatement of up to 150%
Offering Conditions - Accidental Hospitalization Sum
The benefit can be Insured in a policy year, up to
offered ONLY if 150% of Accidental Hospitalization
6 Refill Indemnity
Accidental Sum Insured on each
Hospitalization Benefit is reinstatement
offered. Option 2: Can be either given to
same person for same illness
and/or different illness.
The benefit can be
offered ONLY if Up to 50% for each claim free
7 No Claim Bonus Indemnity
Accidental year. Max Up to 200%
Hospitalization Benefit is
offered.

Option 1: Overall Sum Insured up
to INR 5 Crore
quarterly, annually
Option b: Lump sum
Fixed Deposit (FD) Amount,
Savings account, credit card limit,
credit card bill, wallet, Utility bills,
Options Available -
Systematic Investment Plans,
Coverage in a policy year
Serious Illness can be given for any
8 Quarterly balance (AQB), Rent, Benefit
Benefit number of days,
maximum up to 365
education, any EMI.
days.
education, any EMI.
The benefit can be
offered ONLY if
9 Safeguard+ Indemnity
Accidental
Hospitalization Benefit is
offered.
Options Available -
Geographical coverage
options available are -
• Only in India
Option 1: Up to 50% of Base Sum
• India and Outside India
Insured
Option 2: Up to INR 50L as lump
Options Available -
sum
OPD is available as per
Out-patient Option 3: Any possible reasonable Indemnity
10 the following options -
Expense Cover combination of above options. OR Benefit
benefit NOT linked to
(Only Cashless, Only
Reimbursement or Combination
can be offered)
Permanent Total
Temporary Total

Disability.
benefit linked to
Permanent Total
Temporary Total
Disability.
Either Out-patient
Expense Cover or Animal
Attack cover can be
offered. Both the
benefits cannot be
offered together.
Insured, Maximum limit of 10L per
policy year
sum
Either Rehabilitation
Physiotherapy Cover or Physiotherapy Indemnity
11 combination of above options,
Cover Cover can be offered. OR Benefit
Maximum limit of 10L per policy
Both the benefits cannot
year.
be offered together.
can be offered)
Insured
Transportation
Option 2: Up to INR 5L as lump Indemnity
12 of Imported
sum OR Benefit
Medicine Cover
combination of above options
Insured
Purchase of Option 2: Up to INR 5L as lump Indemnity
13
Blood Cover sum OR Benefit
Insured
Prosthesis Option 2: Up to INR 5L as lump Indemnity
14
Device Cover sum OR Benefit

Option 1: Up to Rs. 10,000 per day
Option 2: Lump sum of up to Rs.
2L
Option 3: Up to 7 days of
Franchise
Hospital Daily
15 Option 4: Up to 7 days of Benefit
Cash Benefit
Deductible
combination of above options,
Maximum coverage of up to 90
days of Hospitalisation
Option 1: Covered up to 100% of
Base Sum Insured
Option 2: Lump sum amount up to
Rs. 50,000
Road Ambulance Option 3: Any possible reasonable Indemnity
16
Cover combination of above options OR Benefit

can be offered)
Option 1: Covered up to 100% of
Base Sum Insured
Option 2: Lump sum amount up to
Rs. 2L
Air Ambulance Option 3: Any possible reasonable Indemnity
17
Cover combination of above options OR Benefit

can be offered)
Up to Unlimited times of Second
medical opinion
Second Medical Benefit
18
Opinion Benefit (Only Cashless, Only (Service)
can be offered)
Termination Condition - Option 1: Up to 100% of Base Sum
The coverage under this Insured, Maximum limit of 1 Cr
Benefit would terminate per policy year
for lifetime for the Option 2: Up to INR 1 Cr as lump
19 Burns Benefit Insured Member for sum Benefit
whom we have paid a Option 3: Any possible reasonable
total of 100% Burns Sum combination of above options,
Insured claim in the Maximum limit of 1 Cr per policy
lifetime of the Insured. year
Insured, Maximum limit of 1 Cr
Broken Bones per policy year
20 Benefit
Benefit Option 2: Up to INR 1 Cr as lump
sum

Maximum limit of 1 Cr per policy
year
Termination Condition - Option 1: Up to 100% of Base Sum

The coverage under this Insured, Maximum limit of 1 Cr
Benefit would terminate per policy year
for lifetime for the Option 2: Up to INR 1 Cr as lump
21 Coma Benefit Insured Member for sum Benefit
whom we have paid a Option 3: Any possible reasonable
total of 100% Coma Sum combination of above options,
Insured claim in the Maximum limit of 1 Cr per policy
lifetime of the Insured. year
policy year
If Out-patient Expense
Animal Attack Cover or Accidental Indemnity
22 sum
Cover Hospitalization offered, OR Benefit
then this benefit cannot
be offered.
year
policy year
Either Rehabilitation
Rehabilitation Cover or Physiotherapy Indemnity
23 sum
Cover Cover can be offered. OR Benefit
Both the benefits cannot
be offered together.
year
Insured
Reconstructive Option 2: Up to INR 50L as lump Indemnity
24
surgery Cover sum OR Benefit
policy year
Accidental Option 2: Up to INR 1L as lump
25 Miscarriage sum Benefit
Benefit Option 3: Any possible reasonable
year
Insured
Domestic Travel
Option 2: Up to INR 50L as lump Indemnity
26 for Medical
sum OR Benefit
Treatment Cover

policy year
Repatriation Indemnity
27 sum
Cover OR Benefit
year
policy year
28 Funeral Benefit sum Benefit
year
policy year
Home and
Vehicle
29 sum Benefit
Modification
Benefit
year
Insured
30 Personal liability Indemnity
sum
Hotel stay days covered up to 10
Emergency Hotel
days and per day hotel cost of Rs. Indemnity
31 Requirement
1000 to 20,000 In the multiples of OR Benefit
Cover
1000
policy year
Home Option 2: Up to INR 5L as lump
Indemnity
32 Convalescence sum
OR Benefit
Cover Option 3: Any possible reasonable
year
Termination Condition - Insured
Loss of Activities
This coverage of this Option 2: Up to INR 50L as lump
33 of Daily Living Benefit
benefit will cease after sum
Benefit
Age of seventy-five. Option 3: Any possible reasonable

Insured
Monthly Needs
34 Option 2: Up to 12 months Benefit
Benefit
Insured
Education for The claim under this
Option 2: Up to INR 1Cr as lump
35 Dependent benefit would payable Benefit
sum
Children Benefit only once in the lifetime
for the Insured Member.
Insured
Marriage Fund The claim under this
36 for Children benefit would payable Benefit
sum
Benefit only once in the lifetime
Insured
37 Orphan Benefit Benefit
sum
Insured
Spouse Care Option 2: Up to INR 50L as lump
38 Benefit
Benefit sum
Compassionate Up to 2% of the Base Sum Insured
39 Benefit
Visit Benefit (Max INR 1,00,000)
Termination Condition - Option 1: As per Actuals
Medical The claim under this Option 2: Up to INR 50K as lump
Indemnity
40 Insurance benefit would payable sum
OR Benefit
Premium Cover only once in the lifetime Option 3: Any possible reasonable
for the Insured Member. combination of above options
The claim under this
Parental Care
41 benefit would payable Up to INR 10L as lump sum Benefit
Benefit
only once in the lifetime
Family
42 Counselling Up to INR 1 L as lump sum Benefit
Benefit
Options Available -
Option 1: As per Actuals,
• Coverage for
Electronic Equipment,
year
Loss of Personal like Cellphone, laptop, Indemnity
43 Option 2: Up to INR 5L as lump
Material Cover headphones OR Benefit
sum
• Coverage for Books,
Bag, Course Material,
Study Material

• Coverage for Uniform Maximum limit of 5L per policy
(outfit provided by an year
employer to a
professional)
• Any one or
Combination of the
above option can be
offered
exclusion
44 On Duty Cover Payouts as per the base benefit
removal
Insured
Common Carrier Option 2: Up to INR 1Cr as lump
45 Benefit
Benefit sum
exclusion
46 Terrorism Cover Payouts as per the base benefit
removal
Insured
Common Option 2: Up to INR 1Cr as lump
47 Benefit
Accident Benefit sum
Adventure Sport exclusion
48 Payouts as per the base benefit
Cover removal
policy year
Head & Spinal
49 sum Benefit
Injury Benefit
year
Option 1: Up to 100% of balance
outstanding principal for any loan,
Maximum up to Base Sum Insured
Option 2: Up to 100% of balance
outstanding for any loan,
Loan Protect
50 Maximum up to Base Sum Insured Benefit
Benefit
Option 3: Up to 100 times of EMI,

Accident Armour Policy Wording

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ACCIDENT ARMOUR - POLICY TERMS AND CONDITIONS

2.1 Standard definitions

Product Name: Accident Armour | Product UIN: NBHPAGP24166V012324

Product Name: Accident Armour | Product UIN: NBHPAGP24166V012324

2.2 Specific definitions

Product Name: Accident Armour | Product UIN: NBHPAGP24166V012324

arm at the shoulder joint

arm to a point above elbow joint

arm below elbow joint

hand at the wrist

leg above center of the femur

leg up to a point below the femur

leg to a point below the knee

foot at the ankle

Product Name: Accident Armour | Product UIN: NBHPAGP24166V012324

i. Base Sum Insured followed by;

Product Name: Accident Armour | Product UIN: NBHPAGP24166V012324

3.1 Accidental Death Benefit

3.2 Permanent Total Disability Benefit

Condition for Permanent Total Disability % of Sum Insured

Complete & Irrecoverable loss of:

Product Name: Accident Armour | Product UIN: NBHPAGP24166V012324

3.3 Permanent Partial Disability Benefit

Condition for Permanent Partial Disability % of Sum Insured

Each arm at the shoulder joint 70%

Each arm to a point above elbow joint 65%

Each arm below elbow joint 50%

Each hand at the wrist 50%

Each Thumb 20%

Each Index Finger 10%

Each other Finger 5%

Each leg above center of the femur 70%

Each leg up to a point below the femur 65%

Each leg to a point below the knee 50%

Each foot at the ankle 40%

Each big toe 5%

Each other toe 2%

Each eye 50%

Hearing in each ear 30%

Sense of smell 10%

Product Name: Accident Armour | Product UIN: NBHPAGP24166V012324

3.4 Temporary Total Disablement Benefit

3.5 Accidental Hospitalization

Product Name: Accident Armour | Product UIN: NBHPAGP24166V012324

The benefit can be offered ONLY if Accidental Hospitalization Benefit is offered.

3.7 No Claim Bonus

3.8 Serious Illness Benefit

The benefit can be offered ONLY if Accidental Hospitalization Benefit is offered.

3.10 Out-patient Expenses Cover

Outpatient Expenses includes ONLY:

Product Name: Accident Armour | Product UIN: NBHPAGP24166V012324

3.11 Physiotherapy Cover

3.12 Transportation of Imported Medicine Cover

3.13 Purchase of Blood Cover

3.14 Prosthesis Device Cover

Product Name: Accident Armour | Product UIN: NBHPAGP24166V012324

3.15 Hospital Daily Cash Benefit

3.16 Road Ambulance Cover

NOTE: Must use a registered ambulance provider Only.

3.17 Air Ambulance Cover