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Date: 18/10/2019

Policy Number: 31036801201900 Customer ID: 1000048361

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

Subject : Max Bupa Health Insurance Policy No. 31036801201900

Dear MR. A MOHAN,

Health Insurance Policy No. 31036801201900 Dear MR. A MOHAN, Thank you for choosing Max Bupa as

Thank you for choosing Max Bupa as your preferred health insurance partner. At Max Bupa, we put your health first and are committed to provide you access to the very best of healthcare, backed by the highest standards of service.

Please find enclosed your Max Bupa Policy Kit which will help you understand your policy in detail and give you more information on how to access our services easily. Your Policy kit includes the following:

Insurance Certificate: Confirming your specific policy details like date of commencement, persons covered and specific conditions related to your plan.

Premium Receipt: Receipt issued for the premium paid by you.

Policy Terms and Conditions: For a clear understanding of policy coverages and exclusions.

Proposal form: This is a copy of the proposal form as per the information provided by you. Do inform us immediately in case there is any change in the details mentioned therein.

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

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

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

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

Yours Sincerely,

you and your loved ones good health always. Yours Sincerely, Ashish Mehrotra Managing Director and Chief

Ashish Mehrotra Managing Director and Chief Executive Officer

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

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

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

POLICY SERVICING

Turnaround time*

(Calendar Days)

Processing of Proposal and Communication of decisions- from the date of receipt of proposal form
Processing of Proposal and Communication of decisions- from the date of receipt of proposal form
Processing of Proposal and Communication of decisions- from the date of receipt of proposal form
Processing of Proposal and Communication of decisions- from the date of receipt of proposal form
Processing of Proposal and Communication of decisions- from the date of receipt of proposal form

Processing of Proposal and Communication of decisions- from the date of receipt of proposal form

Providing copy of the proposal - from the date of acceptance of risk

Post Policy issue service requests - from the date of receipt of service request

Proposal refund in case of cancellation - from the date of decision of the proposal

Request for policy cancellation with free-look period - from the date of receipt of service request

15

Days

30

Days

10

Days

15

Days

15

Days

CLAIM SERVICING

Turnaround time

(Calendar Days)

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

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

30 Days

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

45 Days

GRIEVANCE HANDLING

Turnaround time

(Calendar Days)

Acknowledge a grievance - from the date of receipt of grievance Resolve a grievance -

Acknowledge a grievance - from the date of receipt of grievance

Resolve a grievance - from the date of receipt of grievance

3 days

14 days

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

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

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

Insurance Certificate

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

Policy Holder's Name

MR. A MOHAN

Policy Number

31036801201900

Policy Holder's Address

DOOR NO29 BAR 1 FIRST CROSS SECOND MAIN RAM CHANDRAPURAM, BENGALURU, KARNATAKA - 560021

Date of Commencement

From 18/10/2019 00:00 a.m.

Date of Expiry

To 17/10/2020 23:59 p.m.

Individual/Family Plan

Individual

Details of Electronic Insurance Account (eIA)

Policy Period

1 year

eIA Number

None

Renewal premium due date

17/10/2020

Insurance Repository Name

None

 

Benefits

1. Health Assurance - Accident Care

Relationship

Sum Assured

Renewal Benefit (% of Sum Insured)

Total Sum Insured (Including Renewal Benefit)

Applicant

Level 1 | 500000

0

Level 1 | 500000

Optional Benefit/Feature Details

Particulars

Effective[Y\N]

Sum Insured

Temporary Total Disability

N

0

Accident Hospitalization

N

0

Emergency Ambulance as a part of overall Accident Hospitalization Sum Insured

N

NA

Physiotherapy as a part of overall Accident Hospitalization Sum Insured

N

NA

1.1 Accident Death Sum Insured: 100% of applicable Sum Insured.

1.2 Accident Permanent Total Disability (PTD) Sum Insured: 125 % of applicable Sum Insured.

1.3 Accident Permanent Partial Disability Sum Insured: % of applicable Sum assured as per grid shown in Terms and Conditions.

1.4 Children Education Benefit Sum Insured:

1.5 Funeral Expenses Sum Insured:

Rs. 0

Rs. 5000

2. Health Assurance - CritiCare Benefit *

Relationship

Sum Insured

Applicant

0

Health Assurance-CritiCare Benefit Option

NA

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

3. Health Assurance - Hospi Cash Benefit Daily Limit

Relationship

Daily Hospital Cash Limit

Applicant

0

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

   

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

Intermediary Details

Intermediary Details Intermediary Name Intermediary Code Intermediary Contact No. NA NA NA Insured

Intermediary Name

Intermediary Code

Intermediary Contact No.

NA

NA

NA

Insured Persons' Details

Name of the Insured Person (s)

Age

Insured DOB

Gender

Relationship with the policy holder

Pre - Existing Diseases

Mr. A Mohan

36

23/04/1983

Male

Applicant

None

Nominee Details

 

Nominee name

 

Relationship with the policy holder

Nagaveni Bai

Spouse

Premium Details

Premium (Rs.) - CritiCare

0.00

Premium (Rs.) - Hospi Cash

0.00

Premium (Rs.) - Accident Care

576.00

Loading Premium (Rs.) - Accident Care

0.00

Net Premium/Taxable Value (Rs.)

576.00

Integrated Goods and Service Tax (18.00 %)

103.68

Central Goods and Service Tax (0.00 %)

0.00

State/UT Goods and Service Tax (0.00 %)

0.00

Gross premium (Rs.)

680.00

Gross premium (Rs.) (In words)

Six Hundred Eighty Only

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

Servicing Branch Details

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

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

GSTI No.: 07AAFCM7916H1ZA

SAC Code / Type of Service : 997133 / General Insurance Services

Max Bupa State Code: 7

Customer State Code / Customer GSTI No.: 29 / NA

Location: New Delhi Date: 18/10/2019

GSTI No.: 29 / NA Location: New Delhi Date: 18/10/2019 Chief Operating Officer For and on

Chief Operating Officer For and on behalf of Max Bupa Health Insurance Company Limited

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

Company Contact Details Address: Max Bupa Health Insurance Company Limited. Block B-1/1-2, Mohan Cooperative Industrial

Company Contact Details

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

Customer Helpline Number: 1860-3010-3333

Email Id: customercare@maxbupa.com

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

Premium Receipt

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

SECOND MAIN RAM CHANDRAPURAM BENGALURU KARNATAKA - 560021 We acknowledge the receipt of payment towards the

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

Policy Holder's Name

Mr. A Mohan

Policy Number

31036801201900

Plan Opted for

Health Assurance PA5L 1A

Commencement Date #

18/10/2019

Expiry Date

17/10/2020

Premium Calculation:

 

(A)

Premium (Rs.) - Criti Care

0.00

(B)

Premium (Rs) - Hospi Cash

0.00

(C)

Premium (Rs) - Accident Care

576.00

Net Premium/Taxable Value (Rs.)

 

576.00

Integrated Goods and Service Tax (18.00 %)

103.68

Central Goods and Service Tax (0.00 %)

 

0.00

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

0.00

Gross Premium (Rs.)

 

680.00

Amount Eligible for Income Tax Benefit (A+B+Total GST Tax @18% in Rs.)

0.00

# Issuance of policy is subject to clearance of premium paid

Details of persons Insured:

Name of Person Insured

Age

Gender

Relationship to policy holder

Individual cover(Rs.) (only in case of Family First)

Mr. A

Mohan

36

Male

Applicant

NA

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

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

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

GSTI No.: 07AAFCM7916H1ZA

SAC Code / Type of Service : 997133 / General Insurance Services

Max Bupa State Code: 7

Customer State Code / Customer GSTI No.: 29 /NA

Location: New Delhi Date: 18/10/2019

GSTI No.: 29 /NA Location: New Delhi Date: 18/10/2019 Chief Operating Officer For and on behalf

Chief Operating Officer For and on behalf of Max Bupa Health Insurance Company Limited

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

List of Unrecognized Hospital

Hospital Name Shubham General Hospital Siddhi Clinic & Nursing Home Sparsh MultySpecality Hospital & Trauma
Hospital Name Shubham General Hospital Siddhi Clinic & Nursing Home Sparsh MultySpecality Hospital & Trauma

Hospital Name

Shubham General Hospital

Siddhi Clinic & Nursing Home

Sparsh MultySpecality Hospital & Trauma Care Center

Sree Uday Narayan General Hospital

TripathiChartiable Hospital

Uday Narayan General Hospital TripathiChartiable Hospital S.No. City Hospital Name S.No. City 1
Uday Narayan General Hospital TripathiChartiable Hospital S.No. City Hospital Name S.No. City 1
S.No. City Hospital Name S.No. City 1 Surat Aakansha Hospital 34 Surat 2 Surat

S.No.

City

Hospital Name

S.No.

City

1

Surat

Aakansha Hospital

34

Surat

2

Surat

Abhinav Hospital

35

Surat

3

Surat

Adhar Ortho Hospital

36

Surat

4

Surat

Aris Care Hospital

37

Surat

5

Surat

Arzoo Hospital

38

Surat

37 Surat 5 Surat Arzoo Hospital 38 Surat Umiya Medical & Surgical Hospital Varachha General
Umiya Medical & Surgical Hospital Varachha General Hospital Aastha Multispecialty Hospital Ashwini Nursing Home

Umiya Medical & Surgical Hospital

Varachha General Hospital

Aastha Multispecialty Hospital

Ashwini Nursing Home

Asmita Nursing Home

Balaji Nursing Home

Channan Devi Memorial Hospital

Goodlife Hospitals

Jagannath Clinic & Nursing Home

Jeevan Jyoti Hospital

Krishna Hospital

Mumtaz Nursing Home

Colony Padmaja Hospital

Pragya Nurshing Home

Ram Hospitals

Ramanarayan Hospital

Royal Nursing Home

Sabarmati General Hospital

Sahara Hospital

Sb Nursing Home

Shagun Hospital

Shri Balaji Hospital & Trauma Center

Sri Sai Thirumala Hospitals

Venus Hospital And Medical Research Centre

Vijaya Nursing Home

Virendra Hospital

Yog Nursing Home

6 Auc Hospital

Surat

39 Ahmedabad

7 Dharamjivan General Hospital & Trauma Centre

Surat

40 Surat

8 Dr. Santosh Basotia Hospital

Surat

41 Kushi Nagar

9 Surat

Ghevariya Dental Clinic

42 Thane

10 Surat

God Father Hospital

43 Thane

11 Govind-PrabhaArogyaSankool

Surat

44 Thane

12 Hari Milan Hospital

Surat

45 Rohtak

13 JaldhiAno-Rectal Hospital

Surat

46 Hyderabad

14 Jeevan Path Gen. Hospital

Surat

47 Dhenkanal

15 Kalrav Children Hospital

Surat

48 Allahabad

16 Kanchan General Surgical Hospital

Surat

49 Mayiladuthurai

17 Krishnavati General Hospital

Surat

50 Mumbai

18 Mantra Orthopaedic Hospital Gandhidham (Kutch)

Surat

51 Kesava Nagar

19 Metas Adventist Hospital

Surat

52 Harnaut

20 NiramayamHosptial&Prasutigruah

Surat

53 Jeedimetla

21 Surat

Patna Hospital

54 Gurgaon

22 Surat

Poshia Children Hospital

55 Mumbai

23 Surat

Prayosha Hospital

56 Cuttak

24 Surat

R.D Janseva Hospital

57 Meerut

25 Radha Hospital & Maternity Home

Surat

58 Mumbai

26 Surat

Santosh Hospital

59 Meerut

27 Surat

Shaurya Hospital

60 Gurgaon

28 Shikha General Hospital Changed Name To Sai Hospital

Surat

61 Hyderabad

29 Shishumangal Children Hospital

Surat

62 Bhopal

30 Shree Ramdev General & Surgical Hospital

31 Shree Sai Hospital & PrasutiGruh

32 ShreyansAnorectal & Daycare Hospital

33 Shri Panchratna Hospital & Prasutugruah

Surat

Surat

Surat

Surat

63 Vanasthali Puram

64 Allahabad

65 Meerut

ANNEXURE – A (Part of Policy Pack) Format to be filled up by the proposer for change in occupation of the Insured

Policy Name of Date of Number the Insured birth/Age

Policy

Name of

Date of

Number

the Insured

birth/Age

Policy Name of Date of Number the Insured birth/Age Relationship withPrimary Insured
Policy Name of Date of Number the Insured birth/Age Relationship withPrimary Insured

Relationship

withPrimary

Insured

City of Previous Occupation New Occupation residence or Nature of Work or Nature of Work
City of Previous Occupation New Occupation residence or Nature of Work or Nature of Work

City of

Previous Occupation

New Occupation

residence

or Nature of Work

or Nature of Work

City of Previous Occupation New Occupation residence or Nature of Work or Nature of Work

Place:

Proposer’s Signature

Date:

(DD/MM/YYYY)

Name:

Designation

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

Policy Number

Previous sum insured / Plan

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

New proposed sum insured / Plan

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

Place:

Proposer’s Signature

Date:

(DD/MM/YYYY)

Name:

Designation

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

Health Assurance –Customer Information Sheet

What am I covered for

TITLE

AccidentCare

CritiCare

HospiCash

Permanent

Exclusions

CritiCare HospiCash Permanent Exclusions DESCRIPTION REFER TO POLICY SECTION NUMBER

DESCRIPTION

REFER

TO

POLICY

SECTION

NUMBER

Coverage extended to individual and families. Under family option, AccidentCare coverage is defined as:

For self is 100% of Sum Insured,

For spouse is 50% of Sum Insured or Rs 10 lacs (whichever is lower) and For each child is 20% of Sum Insured or Rs 5 lacs (whichever is lower) upto maximum of 2 dependent children.

a. Accident Death: 100% of applicable Sum Insured would be paid if during the Policy Period Insured Person meets with an Accidental bodily injury that causes death within 365 days from the date of occurrence of such accidental injury and results in direct cause of the death.

b. Accident Permanent Total Disability (PTD): Insured Person would be paid this benefit upon the establishment of Permanent Total Disability caused due to an Accident (in Policy Period) within 365 days from the occurrence of such accident subject to conditions for Permanent Total Disability being met and acceptance of claims by the company Accident Permanent Total Disability: 125% of Sum Insured

We will not make payment under Permanent Total Disability in respect of an Insured Person and for any or all Policy Period more than once in the Insured Person’s lifetime.

c. Accident Permanent Partial Disability (PPD): If an Insured Person suffers an Accident during policy period and within 365days from the date of occurrence of such accident and is the sole and direct cause of loss, Insured Person will be paid the percentage of applicabl e Sum Insured (as opted by Insured Person) as mentioned in the Policy Document

Additional Benefits

a. Child Education Benefit (available only in family option): In case of proposer’s Accident Death or Permanent Total Disability, We will make a onetime payment as specified in the schedule of insurance certificate, per child towards the cost of education of up to 2 dependent children. This benefit would be payable to only the dependent children insured under the policy.

b. Funeral Expenses: In case of death of an Insured Person an amount as specified in the schedule of insurance certificate would be paid towards the funeral expenses of the deceased. Optional Benefits

a. Temporary Total Disability (TTD): If the Policyholder (Proposer) suffers an Injury solely and directly due to an Accident occurring during the policy period which solely and directly results in the Policyholder’s Temporary Total Disability within 365 days from the date of accident, We will pay an amount equal to 1% of TTD sum insured per week for each week that the Temporary Total Disability continues subject always to the availability of the TTD sum insured.

b. Accident Hospitalization: If the Insured Person is hospitalised during the Policy Period solely and directly due to an Injury sustained arising from an Accident occurring during the Policy Period, We will reimburse the hospitalization expenses up to the maximum limit of 2% of AccidentCare sum

insured.

a. Insured Person would be paid as per the benefit option chosen on the first diagnosis of any of the below mentioned 20 Critical Illnesses provided the insured person survives for a minimum of 30 days from the date of diagnosis of such Critical Illness.

b. Under family option, coverage:

For self is 100% of Sum Insured and For spouse is 100% of Sum Insured

c. Critical illnesses covered as mentioned in the Policy Document

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

i. The Illness has occurred after 30 days from date of commencement of the Policy

ii. The Insured Person should have been Hospitalised for a minimum period of atleast 48 hours with continuous and completed peri ods of 24 hours

iii. We will not make any payment in respect of an Insured Person for more than 45 days of Hospitalisation in total under any Poli cy Year (including

7 days of ICU hospitalization)

b. ICU (intensive Care Unit) cash benefit which is equivalent to double the Daily Cash benefit will be payable towards Hospitalisation in ICU up to

maximum of 7 days

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

A. Permanent Exclusions for AccidentCare Cover

1. Suicide or self inflicted Injury, whether the Insured Person is medically sane or insane.

2. Treatment for any injury or illness resulting directly or indirectly from nuclear, radiological emissions, war or war like situations (whether war is declared or not), rebellion (act of armed resistance to an established government or leader), acts of terrorism.

3. Service in the armed forces, or any police organization, of any country at war or at peace or service in any fo rce of an international body or participation in any of the naval, military or air force operation during peace time.

4. Any change of profession after inception of the Policy which results in the enhancement of Our risk, if not accepted and endo rsed by Us on the Schedule of Insurance Certificate.

5. Committing an assault, a criminal offence or any breach of law with criminal intent.

6. Taking or absorbing, accidentally or otherwise, any intoxicating liquor, drug, narcotic, medicine, sedative or poison, except as prescribed by a

2.1

2.1.1

2.1.3

2.1.5

2.1.4

2.1.2

2.1.6

2.1.7

2.2

2.3

3(d)(1)

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

 

Medicial Practitioner other than the Policyholder or an Insured Person.

 

7.

Participation in aviation/marine including crew other than as a passenger in an aircraft/water craft that is authorized by th e relevant regulations to carry such passengers between established airports or ports.

8.

Including but not limited to engaging in or taking part in professional/adventure sports or any hazardous pursuits, such as speed contest or racing of any kind (other than on foot), bungee jumping, parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding, mountain or rock climbing necessitating the use of guides or ropes, potholing, abseiling, deep sea diving using hard helmet and breathing apparatus, polo, snow and ice sports, hunting etc;

9.

Body or mental infirmity or any disease except where such condition arises directly as a correspondence of an Accident during t he policy period. However this exclusion is not applicable to claims made under the PPD benefit.

10.

Any costs or expenses specified in the List of Expenses Generally Excluded at Annexure II of policy document. This is applicable only for Accident Hospitalization benefit.

B.

Permanent Exclusions for CritiCare

1.

Acquired Immune Deficiency Syndrome (AIDS), AIDS-related complex or infection by Human Immunodeficiency Virus (HIV); or

3(d)(2)

2.

The Insured Person’s attempted suicide or self-inflicted injuries while sane or insane; or

3.

Narcotics used by the Insured Person unless taken as prescribed by a Medical Practitioner, or the Insured Person’s abuse of drugs and/or consumption of alcohol; or

4.

The directions, advice and guidance of the treating Medical Practitioner shall be strictly followed. We shall not be obliged to make any payment that arises out of willful failure to comply with such directions, advice or guidance

5.

Treatment for any injury or illness resulting directly or indirectly from nuclear, radiological emissions, war or war like si tuations (whether war is declared or not), rebellion (act of armed resistance to an established government or leader), acts of terrorism.

6.

Taking part in any naval, military or air force operation during peace time; or

7.

Participation in aviation/marine including crew other than as a passenger in an aircraft/water craft that is authorized by the relevant regulations to carry such passengers between established airport or ports .

8.

Including but not limited to engaging in or taking part in professional/adventure sports or any hazardous pursuits, such as speed contest or racing of any kind (other than on foot), bungee jumping, parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding, mountain or rock climbing necessitating the use of guides or ropes, potholing, abseiling, deep sea diving using hard helmet and breathing apparatus, polo, snow and ice sports, hunting etc; or

9.

Participation by the Insured Person in a criminal or a breach of law with criminal intent; or

C.

Permanent Exclusions for HospiCash Benefit

3(d)(3)

1.

Hospitalisation not in accordance with the diagnosis and treatment of the condition for which the Hospital confinement was required;

2.

Hospitalization solely for diagnostic or observation purpose;

3.

Treatment for weight reduction or weight improvement regardless of whether the same is caused (directly or indirectly) by a medical condition;

4.

Any dental care or Surgery of cosmetic nature, extraction of impacted tooth/teeth, orthodontics or orthognathic Surgery, or t empero-mandibular joint disorder except as necessitated by an Accidental Injury;

5.

Treatment for infertility or impotency, sex change or any treatment related to it, abortion, sterilization and contraception including any complications relating thereto;

6.

Treatment arising from pregnancy and it’s complications which shall include childbirth or abortion or threatened abortion excluding ectopic pregnancy;

7.

Hereditary and Genetic Disorders: Screening, counseling or treatment related to Hereditary and Genetic Disorders;

8.

Hospitalisation primarily for diagnosis, X-ray examinations, general physical or medical check-up not followed by active treatment during the Hospitalisation period or Hospitalisation where no active treatment is given by the Medical Practitioner;

9.

Unproven/Experimental treatments/off-label treatment;

10.

Alternative treatment;

11.

Treatment of any mental or psychiatric condition including but not limited to insanity, mental or nervous breakdown / disorder, depression, dementia, Alzheimer’s disease or rest cures;

12.

Admission to a nursing home or home for the care of the aged for rehabilitation, or convalescence;

13.

Treatment directly or indirectly arising from alcohol, drug or substance abuse and any Illness or Accidental Injury which may be suffered after consumption of intoxicating substances, liquors or drugs;

14.

Treatment directly or indirectly arising from or consequent upon war (whether war be declared or not), invasion, acts of forei gn enemies, hostilities, civil war, rebellion, active participation in strikes, riots or civil commotion, revolution, insurrection or military or usurped power, and full- time service in any of the armed forces;

15.

Acquired Immune Deficiency Syndrome (AIDS) and all Illnesses or diseases caused by or related to the Human Immuno-deficiency Virus;

16.

Sexually transmitted diseases;

17.

Cosmetic or plastic Surgery except to the extent that such Surgery is necessary for the repair of damage caused solely by Accidental Inju ries; treatment of xanthelesema, syringoma, and ance alopecia

18.

Nuclear disaster, radioactive contamination and/or release of nuclear or atomic energy;

19.

Treatment for Accidental Injury or Illness caused by intentionally self-inflicted Injuries; or any attempts of suicide while sane or insane;

20.

Treatment for Accidental Injury or Illness caused by violation or attempted violation of the law, or resistance to arrest;

21.

Including but not limited to engaging in or taking part in professional/adventure sports or any hazardous pursuits, such as speed contest or racing of any kind (other than on foot), bungee jumping, parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding, mountain or rock

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

Waiting Period climbing necessitating the use of guides or ropes, potholing, abseiling, deep sea diving

Waiting Period

climbing necessitating the use of guides or ropes, potholing, abseiling, deep sea diving using hard helmet and breathing apparatus, polo, snow and ice sports, hunting etc;

22. Circumcision unless necessary for treatment of a disease or necessitated due to an Accident;

23. Hospitalisation where the Insured Person is a donor for any organ transplant;

24. Any treatment outside of Republic of India;

25. Treatment to assist reproduction, including IVF treatment;

26. Hormone Replacement Therapy;

27. Puberty and Menopause related Disorders: Treatment for any symptoms, Illness, complications arising due to physiological conditions associated with Puberty, Menopause such as menopausal bleeding or flushing;

28. Artificial Life Maintenance: Artificial life maintenance, including life support machine used to sustain a person, who has been declared brain dead, as demonstrated by:

(a)

Deep coma and unresponsiveness to all forms of stimulation;

(b)

Absent pupillary light reaction;

(c)

Absent oculovestibular and corneal reflexes; or

(d)

Complete apnea

29. Sleep disorders: Treatment for sleep apnea, snoring or any other sleep-related breathing problem;

30. Treatment for developmental problems: Treatment for, or related to developmental problems, including – learning difficulties (such as dyslexia), behavioral problems, including attention deficit hyperactivity disorder (ADHD);

a. Initial Waiting Period Criticare: Benefits will not become payable if the signs or symptoms of any of the listed critical illnesses commence within 90 days from the date of commencement of CritiCare coverage of the first policy. HospiCash: Benefits will not become payable if the signs or symptoms and/or Treatment fall within 30 days from the date of commencement of HospiCash coverage except accidents.

b. Pre-Existing Diseases (Applicable for CritiCare and HospiCash)

Benefits will not be available for Pre-existing Diseases until 48 months of continuous coverage have elapsed since the inception of the first Policy with Us or other insurer in case of portability, for the respective benefit.

c. Specific Waiting Period for the HospiCash Benefit For the payment of the HospiCash Benefit, the disease conditions / treatments listed below will be subject to a waiting period of 24 months and will be covered from the commencement of the third Policy Year as long as the Insured Person has been insured continuously under the Policy without any break

1. Stones in biliary and urinary systems

2. Lumps/ cysts/ nodules/ polyps/ internal tumours excluding malignancies

3. Gastric and duodenal ulcers

4. Surgery on tonsils / adenoids

5. Osteoarthrosis / arthritis / gout / rheumatism / spondylosis / spondylitis / intervertebral disc prolapse

6. Cataract and its complications

7. Fissure / Fistula / Haemorrhoids of anal and rectal region

8. Hernia / hydrocele / varicocoele / spermatocoele

9. Chronic renal failure or end stage renal failure

10. Sinusitis / deviated nasal septum / tympanoplasty / chronic suppurative otitis media

11. Benign prostatic hypertrophy

12. Joint replacements surgery except in case of accidents

13. Dilatation and curettage except in case of surgical abortion

14. Varicose veins of legs

15. Dysfunctional uterine bleeding / fibroids / prolapse uterus / endometriosis

16. Diabetes and related complications including but not limited to:

a) Hyperglycaemia with or without coma

b) Hypoglycaemia with or without coma

c) Diabetic Ketoacidosis

d) Diabetic Nephropathy

e) Diabetic Retinopathy

f) Diabetic Neuropathy

17. Hysterectomy for any benign disorder

18. Thyroid and parathyroid gland disorders excluding malignancy

19. Any Congenital Anomaly or inherited disorder or developmental conditions

excluding malignancy 19. Any Congenital Anomaly or inherited disorder or developmental conditions 3(a) 3(b) 3(c)

3(a)

3(b)

3(c)

Payout basis

Renewal

Conditions

Lump sum payout for all the three benefits – CritiCare, AccidentCare and HospiCash;

AccidentCare cover also has an optional Accident Hospitalization benefit which is payable only as reimbursement and optional Temporary Total Disability benefit.

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

wording will get reduced by 1 year with every continuous renewal for the respective benefit under

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

Renewal Benefits  All the three benefits under Health Assurance can be renewed for lifetime

Renewal

Benefits

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

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

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

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

If the AccidentCare cover is renewed, the Sum Insured will be increased by 5% of the Sum Insured (shown in the Schedule of Insurance Certificate during the first Policy Year) for every claim free Policy Period up to a cumulative maximum of 25% of the Sum Insured for all the applicable benefits other than Accident Temporary Total Disability (TTD) and Accident Hospitalization mentioned under the AccidentCare cover only.

At the time of renewal in case of an insured person attaining 70 years of age, for Policyholder’s Sum Insured of more than 100 lacs, the Renewal Benefit will also be reduced in the same proportion of reduction in Sum Insured.

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

Cancellation

1 year

Policy in-force up to

 

2 years

Refund %

Policy in-force up to

Refund %

2 years Refund % Policy in-force up to Refund % 3 years Policy in-force up to

3 years

Policy in-force up to

Refund %

Up to 30 days

75%

Up to 30 days

87.5%

Up to 30 days

90%

       

31

to 90 days

50%

to 90 days

 

31

75%

31

to 90 days

87.5%

91

to 180 days

25%

91

to 180 days

62.5%

91

to 180 days

75%

exceeding 180 days

0%

181

to 365 days

50%

             

366

to 455days

 

25%

366

to 455days

50%

456

to 545 days

 

12%

456

to 545 days

 
       

545

to 720 days

 

Exceeding

545

     

12%

days

 

0%

Exceeding 720 days

0%

60%

181

to 365 days

25%

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

claims under the Policy or has made any mis-representation in the documents submitted in support of

4(j)

4(g)

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

Policy Document

1.

Terms & Conditions

The insurance cover provided under this Policy to the Insured Person/s up to the Sum Insured is and shall be subject to (a) the terms, conditions and exclusions to this Policy and (b) the receipt of premium, and (c) Disclosure to information norm (including by way of the Proposal form or Information Summary Sheet) for Yourself and on behalf of each of the Insured Persons

2.

Benefit

This Policy provides benefits as specified in the Schedule of Insurance Certificate for the specified events occurring during the Policy Period and while the policy is in force for an illness and/or, Accident and/or Hospitalisation or the conditions described below subject to any specific limits specified in the Product Benefits Table, the terms, conditions, limitations and specific and general exclusions mentioned in the Policy and as shown in the Schedule of Insurance Certificate and eligibility for the insurance plan opted for as specified in the Product Benefits Table.

2.1.

AccidentCare (Individual or Family option)

If any of the Insured Persons dies or sustains any Injury resulting solely and directly from an Accident occurring during the Policy Period at any location worldwide, and while the Policy is in force, We will provide the benefits described below.

If a claim gets triggered under Accident Death or Accident Permanent Total Disability for any Insured Person, the coverage shall terminate for the respective Insured Person post payment of the benefit but for the other Insured Person, the coverage shall continue till the end of the policy period and shall be renewable.

2.1.1 Accident Death

If an Insured Person dies solely and directly due to an Accidental Injury within 365 days from occurrence of the Accident we will pay the Sum Insured.

2.1.2 Funeral Expenses

If We have accepted a claim for the Accidental death of an Insured Person under 2.1.1 above, then in addition to any amount payable under 2.1.1, We will make an one time payment as specified in the Schedule of Insurance Certificate towards the funeral expenses of that Insured Person.

2.1.3 Accident Permanent Total Disability (PTD)

If an Insured Person suffers Permanent Total Disability solely and directly due to an Accident and within 365 days from occurrence of such accident, We will pay the sum insured provided that:

2.1.3.1 the Permanent Total Disability is proved to Our satisfaction; and a

disability certificate is presented to Us, and such disability certificate shall

be issued by a Medical Board duly constituted by the Central and/or the State Government; and

2.1.3.2 We will admit a claim under 2.1.3 only if the Permanent Total

Disability continues for a period of at least 6 continuous calendar months

from the commencement of the Permanent Total Disability unless there are no chances of variation over time, in the degree of disability as in amputation/Loss of limbs etc; and

2.1.3.3 If the Insured Person dies before a claim has been admitted under

2.1.3, no amount will be payable under 2.1.3, however We will consider

the claim under 2.1.1; and

2.1.3.4 We will not make payment under 2.1.3 in respect of an insured

person and for any and all policy periods more than once in the insured person’s lifetime.

2.1.4 Child Education Benefit (available only in Family option with children)

If We have accepted a claim for the Accidental Death or Permanent Total Disability of the Policyholder under 2.1.1 or 2.1.3 respectively, then in addition to any amount payable under 2.1.1 or 2.1.3, We will make a one time payment as specified in the Schedule of Insurance Certificate as an education benefit for each of the Policyholder’s dependent children, provided that the child is an insured person under the Policy. Such benefit shall be payable for a maximum of up to 2 Dependent Children.

2.1.5 Accident Permanent Partial Disability (PPD)

If an Insured Person suffers Permanent Partial Disability solely and directly due to an Accident and within 365 days from occurrence of such Accident, We will pay the amount specified in the grid below which is a percentage

of the Sum Insured, provided that:

2.1.5.1 The Permanent Partial Disability is proved to Our satisfaction; and

a disability certificate is presented to Us, and such disability certificate

shall be issued by a Medical Board duly constituted by the Central and/or the State Government: and

2.1.5.2 We will admit a claim under 2.1.5 only if the Permanent Partial

Disability continues for a period of at least 6 continuous calendar months

from the commencement of the Permanent Partial Disability, unless it is irreversible; and

2.1.5.3 If the Insured Person dies before a claim has been admitted under 2.1.5, no amount will be payable under 2.1.5, however We will consider the claim under 2.1.1.

2.1.5.4 If a claim has been admitted under 2.1.3, then no further claim in

respect of the same condition will be admitted under 2.1.5.

2.1.5.5 If this benefit is triggered and the entire Sum Insured does not get

utilized, then the balance Sum Insured shall be available for other Permanent Partial Disability until the entire Sum Insured is consumed. This Sum Insured limit shall be a lifetime limit and once this limit is exhausted whether due to any or more than one of the Permanent Partial Disabilities,

the Policy and all benefits there under shall cease thereafter.

The table below shows the amount payable basis the nature of disability.

Permanent Partial Disability Grid

Sno

Nature of Disability

% of Sum Insured

1.

Loss or total and permanent loss of use of both the hands from the wrist joint

100%

2.

Loss or total and permanent loss of use of both feet from the ankle joint

100%

3. Loss or total and permanent loss of use of one hand from the wrist
3. Loss or total and permanent loss of use of one hand from the wrist
3. Loss or total and permanent loss of use of one hand from the wrist

3.

Loss or total and permanent loss of use of one hand from the wrist joint and of one foot from the ankle joint

100%

4.

Loss or total and permanent loss of use of one hand from the wrist joint and total and permanent loss of sight in one eye

100%

5.

Loss or total and permanent loss of use of one foot from the ankle joint and total and permanent loss of sight in one eye

100%

6.

Total and permanent loss of speech and hearing in both ears

100%

7.

Total and permanent loss of hearing in both ears

50%

8.

Loss or total and permanent loss of use of one hand from wrist joint

50%

9.

Loss or total and permanent loss of use of one foot from ankle joint

50%

10.

Total and permanent loss of sight in one eye

50%

11.

Total and permanent loss of speech

50%

12.

Permanent total loss of use of four fingers and thumb of either hand

40%

13.

Permanent total loss of use of four fingers of either hand

35%

14.

Uniplegia

25%

15.

Permanent total loss of use of one thumb of either hand

a. Both joints

25%

b. One joint

10%

16

Permanent total loss of use of fingers of either hand

a. Three joints

10%

b. Two joints

8%

c. One joint

5%

17

Permanent total loss of use of toes of either foot

a. All toes- one foot

20%

b. Great toe- both joints

5%

c. Great toe- one joint

2%

d. Other than great toe, one toe

1%

2.1.6 Temporary Total Disability (TTD) (Op onal Benefit)

If the Policyholder suffers an Injury solely and directly due to an Accident

occurring during the Policy Period which solely and directly results in the

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

Policyholder’s Temporary Total Disability within 365 days from date of occurrence of such Accident, We will pay an amount equal to 1% of the TTD Sum Insured per week for each week that the Temporary Total Disability con nues subject always to the availability of the TTD Sum Insured.

It is agreed and understood that for the purpose of 2.1.6,

2.1.6.1 We shall not be liable to make any payment under 2.1.6 in respect

of more than 100 weeks in a life me (life me limit) and once this life me

limit is a ained, the TTD benefit cannot be renewed any further. However, the Policy can be renewed with all other benefits including the op onal Accident Hospitaliza on Benefit. The Policyholder shall have an op on to renew the benefit un l the life me limit is exhausted.

2.1.6.2 The amount payable under 2.1.6 is calculated on a per day basis

and shall be payable from the first day of onset of the Temporary Total Disability provided that the Temporary Total Disability con nues for at least 3 con nuous days.

2.1.7 Accident Hospitaliza on (Op onal Benefit)

The Accident Hospitaliza on benefit shall be available only for hospitaliza on in India following an Accident. If the Insured Person is hospitalised during the Policy Period solely and directly due to an Injury sustained arising from an Accident occurring during the Policy Period, We will pay the Medical Expenses incurred subject to the maximum amount specified in the Schedule of Insurance Cer ficate.

2.2. Cri Care Cover (Individual or Family Floater op on)

If an Insured Person suffers a Cri cal Illness during the Policy Period and while the Policy is in force, We will pay the Sum Insured provided that:

2.2.1 Such Cri cal Illness first occurs or manifests itself during the Policy

Period; and

2.2.2 The signs and symptoms of such Cri cal Illness commence a er 90

days from the date of commencement of the Policy i.e. the benefit would not be payable if the signs or symptoms occurred during the first 90 days or earlier from the date of commencement of coverage, as specified in the

Schedule of Insurance Cer ficate; and

2.2.3 The Insured Person survives for a minimum period of at least 30 days

from the date of diagnosis of such Cri cal Illness for the claim to be

admissible under 2.2.

2.2.4 If this Cri cal Illness cover is in force on a Family Floater basis, then:

2.2.4.1 We will not be liable to make payment under this cover in respect

of any and all Insured Persons more than once in a Policy Year;

2.2.4.2 If We have admi ed a claim under this cover for an Insured Person

in any Policy Year, this cover shall not be renewed in respect of that Insured Person for any subsequent Policy Year, but the cover will be renewable for the other Insured Persons.

2.2.5 The benefit shall be paid as per the benefit op on chosen at

incep on:

2.2.5.1 Benefit Op on 1: Sum Insured as lump sum

2.2.5.2 Benefit Op on 2: Sum Insured as lump sum along with 10% of the

Sum Insured payable annually at the beginning of each year from the date of payment of lump sum benefit, for subsequent 5 years. The coverage under the Policy shall cease for that Insured Person. This cover shall not be renewed in respect of that Insured Person for any subsequent policy year, but the cover will be renewed for the other Insured Persons. Once the benefit gets triggered, the annual benefits shall be paid at respec ve intervals irrespec ve of the survival status of the insured.

For Ex: If the Sum Insured chosen at incep on is Rs.50,00,000 then as per chosen op on:

- Op on 1, Rs.50,00,000 shall be paid as lump sum

- Op on 2, Rs.50,00,000 is paid as lump sum on 1st June 2016. In

addi on, from next year onwards at the beginning of each year for subsequent 5 years i.e on 1st June of every year from 2017 to 2021, payout equal to Rs.5,00,000 shall be made to the beneficiary.

For the purpose of this Cri Care Cover, ‘Cri cal Illness’ means the following illnesses:

1. Cancer of Specified Severity

A malignant tumor characterized by the uncontrolled growth and spread

of malignant cells with invasion and destruc on of normal ssues. This

diagnosis must be supported by histological evidence of malignancy and confirmed by a pathologist. The term cancer includes leukemia, lymphoma and sarcoma.

The following are excluded:

Tumours showing the malignant changes of carcinoma in situ and tumours which are histologically described as premalignant or non invasive, including but not limited to: Carcinoma in situ of breasts, Cervical dysplasia CIN-1, CIN-2 & CIN-3.

• Any skin cancer other than invasive malignant melanoma.

• All tumours of the prostate unless histologically classified as having a Gleason score greater than 6 or having progressed to at least clinical TNM classifica on T2N0M0.

• Papillary micro - carcinoma of the thyroid less than 1 cm in diameter.

• Chronic lymphocyc c leukaemia less than RAI stage 3.

• Microcarcinoma of the bladder.

• All tumours in the presence of HIV infec on.

What does it mean?

Cancer (also known as a malignant tumour) is a disease where cells change and grow in an abnormal way. If le untreated, they can destroy surrounding healthy cells and eventually destroy healthy cells in other parts of the body. There are about 200 different types of cancer, varying widely in outlook and treatment.

2. Myocardial Infarc on

(First Heart A ack of specific severity)

I. The first occurrence of heart a ack or myocardial infarc on, which means the death of a por on of the heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis for Myocardial Infarc on should be evidenced by all of the following criteria:

i. A history of typical clinical symptoms consistent with the diagnosis of acute myocardial infarc on (For e.g. typical chest pain)

ii. New characteris c electrocardiogram changes

iii. Eleva on of infarc on specific enzymes, Troponins or other specific biochemical markers.

II. The following are excluded:

i. Other acute Coronary Syndromes

ii. Any type of angina pectoris

iii. A rise in cardiac biomarkers or Troponin T or I in absence of overt ischemic heart disease OR following an intra-arterial cardiac procedure.

What Does It Mean?

A

heart a ack, also known as a myocardial infarc on, happens when part

of

the heart muscle dies because it has been starved of oxygen. This causes

severe pain and an increase in cardiac enzymes and troponins, which are

released into the blood stream from the damaged heart muscle.

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

3.

Open Chest CABG

What Does It Mean?

I.

The actual undergoing of heart surgery to correct blockage or narrowing in one or more coronary artery(s), by coronary artery bypass gra ing done via a sternotomy (cu ng through the breast bone) or minimally invasive keyhole coronary artery bypass procedures. The diagnosis must be supported by a coronary angiography and the realiza on of surgery has to

be

confirmed by a cardiologist.

II.

The following are excluded:

i.

Angioplasty and/or any other intra-arterial procedures

What does it mean?

Coronary arteries can become narrowed or blocked by the build-up of fa y deposits caused by poor lifestyle such as high fat diet, smoking and high blood pressure. This may cause symptoms including chest pain and can some mes cause a heart a ack. Coronary artery by-pass surgery is used to treat blocked arteries in the heart by diver ng the blood supply around the blocked artery using a vein, usually taken from the leg, arm or

chest. This defini on covers surgery if it requires the heart to be reached

by

a surgical incision through the chest wall or sternum (breastbone), to

replace the blocked arteries with a vein.

4.

Open Heart Replacement or Repair of Heart Valves

The actual undergoing of open-heart valve surgery is to replace or repair one or more heart valves, as a consequence of defects in, abnormali es of, or disease-affected cardiac valve(s). The diagnosis of the valve abnormality must be supported by an echocardiography and the realiza on of Surgery has to be confirmed by a specialist medical prac oner.

Catheter based techniques including but not limited to, balloon valvotomy/valvuloplasty are excluded.

What does it mean?

Heart valve repair or replacement surgery is done when valves are damaged or diseased and do not work the way they should. When one (or more) valve(s) becomes steno c (s ff), narrowed or diseased due to any

reasons, the heart must work harder to pump the blood through the valve.

your heart valve(s) becomes damaged, you may have the following symptoms:

If

• Dizziness

• Chest pain

• Breathing difficul es

• Palpita ons

• Edema (swelling) of the feet, ankles, or abdomen (belly)

• Rapid weight gain due to fluid reten on

This defini on implies a large surgical incision made in the chest and the heart stopped for a me so that the surgeon can repair or replace the valve(s).

5.

Coma of Specified Severity

A state of unconsciousness with no reac on or response to external

s muli or internal needs. This diagnosis must be supported by evidence of all of the following:

a) no response to external s muli con nuously for at least 96 hours;

b) life support measures are necessary to sustain life; and

c) permanent neurological deficit which must be assessed at least 30

days a er the onset of the coma.

The condi on has to be confirmed by a specialist medical prac oner. Coma resul ng directly from alcohol or drug abuse is excluded.

A coma is a state of unconsciousness from which the pa ent cannot be

aroused and has no control over bodily func ons. It may be caused by illness, stroke, infec on, very low blood sugar or serious accident. Recovery rates vary, depending upon the depth and dura on of the coma.

6. Kidney Failure Requiring Regular Dialysis

End stage renal disease presen ng as chronic irreversible failure of both kidneys to func on, as a result of which either regular renal dialysis

(hemodialysis or peritoneal dialysis) is ins tuted or renal transplanta on

is carried out. Diagnosis has to be confirmed by a specialist medical

prac oner.

What Does It Mean?

The kidneys perform an important role filtering the body’s waste to pass

as urine. If the kidneys fail, there is a harmful build up of the body’s waste

products. In severe cases it may be necessary for the filtering to be done by a dialysis machine or, in some cases, a transplant may be needed.

7. Stroke Resul ng in Permanent Symptoms

Any cerebrovascular incident producing permanent neurological sequelae. This includes infarc on of brain ssue, thrombosis in an

intracranial vessel, haemorrhage and embolisa on from an extracranial

source.

Diagnosis has to be confirmed by a specialist medical prac oner and evidenced by typical clinical symptoms as well as typical findings in CT Scan

or MRI of the brain.

Evidence of permanent neurological deficit las ng for atleast 3 months has to be produced.

The following are excluded:

i. Transient ischemic a acks (TIA)

ii. Trauma c Injury of the brain

iii. Vascular disease affec ng only the eye or op c nerve or ves bular func ons

What Does It Mean?

Strokes are caused by a sudden loss of blood supply or haemorrhage to a par cular part of the brain. The symptoms and how well a person recovers will depend on which part of the brain is affected and the extent of the damage. A transient ischaemic a ack, some mes referred to as a ‘mini- stroke’, does not result in any permanent neurological deficit. These are not covered by this defini on, because symptoms aren’t permanent and will disappear within 24 hours.

8. Major Organ/Bone Marrow Transplant

The actual undergoing of a transplant of:

• One of the following human organs: heart, lung, liver, kidney, pancreas, that resulted from irreversible end-stage failure of the relevant organ, or

• Human bone marrow using haematopoie c stem cells.

The undergoing of a transplant has to be confirmed by a specialist medical prac oner.

The following are excluded:

• Other stem-cell transplants

• Where only islets of langerhans are transplanted

What Does It Mean?

An organ may become so diseased that it needs to be replaced.

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

9.

Permanent Paralysis of Limbs

shortness of breath, excessive bleeding and an increased chance of catching infec ons.

Total and irreversible loss of use of two or more limbs as a result of Injury or disease of the brain or spinal cord. A specialist medical prac oner must be of the opinion that the paralysis will be permanent with no hope of recovery and must be present for more than 3 months.

What Does It Mean?

Paralysis is the complete loss of use. It may be caused by injury or illness. A limb is an arm or leg.

10. Motor Neurone Disease with Permanent Symptoms

Motor neurone disease diagnosed by a specialist medical prac oner as spinal muscular atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis or primary lateral sclerosis. There must be progressive

degenera on of cor cospinal tracts and anterior horn cells or bulbar efferent neurons. There must be current significant and permanent func onal neurological impairment with objec ve evidence of motor dysfunc on that has persisted for a con nuous period of at least 3

months.

What Does It Mean?

Motor neurone disease (MND) is a gradual weakening and was ng of the muscles, usually beginning in the arms and legs. This may cause difficulty walking or holding objects. As the disease develops, other muscle groups may be affected, such as those involving speech, swallowing and breathing. Eventually, 24 hour care may be needed.

11. Mul ple Sclerosis with Persis ng Symptoms

I. The unequivocal diagnosis of Definite Mul ple Sclerosis confirmed and evidenced by all of the following:

i. inves ga ons including typical MRI findings which unequivocally confirm the diagnosis to be mul ple sclerosis and

ii. there must be current clinical impairment of motor or sensory func on, which must have persisted for a con nuous period of at least 6 months.

II. Other causes of neurological damage such as SLE and HIV are excluded.

What Does It Mean?

Mul ple sclerosis (MS) is the most common disabling neurological disease among young adults and is usually diagnosed between the ages of 20 and

 

40.

12.

Aplas c Anaemia

Aplas c Anemia is chronic persistent bone marrow failure. A cer fied hematologist must make the diagnosis of severe irreversible aplas c anemia. There must be permanent bone marrow failure resul ng in bone marrow cellularity of less than 25% and there must be two of the following:

a) Absolute neutrophil count of less than 500/mm³

b) Platelets count less than 20,000/mm³

c) Re culocyte count of less than 20,000/mm³

The Insured Person must be receiving treatment for more than 3 consecu ve months with frequent blood product transfusions, bone marrow s mula ng agents, or immunosuppressive agents or the Insured Person has received a bone marrow or cord blood stem cell transplant. Temporary or reversible Aplas c Anemia is excluded and not covered under this Policy.

What Does It Mean?

Aplas c anaemia is a serious condi on where bone marrow fails to produce sufficient blood cells or clo ng agents. Symptoms include

13.

Bacterial Meningi s Bacterial meningi s is a bacterial infec on of the meninges of the brain causing brain dysfunc on. There must be an unequivocal diagnosis by a consultant physician of bacterial meningi s that must be proven on analysis and culture of the cerebrospinal fluid. There must also be permanent objec ve neurological deficit that is present on physical examina on at least 3 months a er the diagnosis of the meningi s infec on.

What Does It Mean?

Bacterial meningi s causes inflamma on to the meninges, which is the protec ve layer around the brain and spinal cord. It’s caused by a bacterial infec on and needs prompt medical treatment. Ini al symptoms include headache, fever and vomi ng.

14.

Loss of Speech

I.

Total and irrecoverable loss of the ability to speak as a result of injury or disease to the vocal cords. The inability to speak must be established for a con nuous period of 12 months. This diagnosis must be supported by medical evidence furnished by an Ear, Nose, Throat (ENT) specialist.

II.

All psychiatric related causes are excluded

What Does It Mean?

The total loss of the ability to speak. It’s o en caused when the vocal cords need to be removed because of a tumour or a serious injury.

15.

End Stage Liver Disease

Permanent and irreversible failure of liver func on that has resulted in all three of the following:

a) Permanent jaundice; and

b) Ascites; and

c) Hepa c Encephalopathy.

Liver failure secondary to drug or alcohol abuse is excluded.

What Does It Mean?

The liver is an important organ, which carries out several of the body’s vital func ons such as helping with diges on and clearing toxins. This defini on covers liver failure at an advanced stage. This type of liverfailure leads to permanent jaundice (yellow discoloura on of the skin), ascites (build up of fluid in the abdomen), and encephalopathy (brain disease or damage).

16.

Deafness

Total and irreversible loss of hearing in both ears as a result of illness or accident. This diagnosis must be supported by pure tone audiogram test and cer fied by an Ear, Nose and Throat (ENT) specialist. Total means “the loss of hearing to the extent that the loss is greater than 90decibels across all frequencies of hearing” in both ears.

What Does It Mean?

This means permanent loss of hearing in both ears, measured by using an audiogram across different frequencies, which vary from low to high pitch.

17.

End-stage Lung Disease

End stage lung disease, causing chronic respiratory failure, as evidenced by all of the following:

a) FEV1 test results consistently less than 1 litre measured on 3 occasions 3 months apart; and

b) Requiring con nuous permanent supplementary oxygen therapy for hypoxemia; and

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

c) Arterial blood gas analyses with par al oxygen pressures of 55mmHg or less (PaO2< 55mmHg); and

d) Dyspnea at rest.

This diagnosis must be confirmed by a respiratory physician.

What Does It Mean?

The lungs allow us to breathe in oxygen and get rid of harmful carbon dioxide. The defini on of End Stage Lung Disease covers advanced lung

failure when breathing is severely affected and regular oxygen therapy is

required.

18. Fulminant Viral Hepa s

A sub-massive to massive necrosis of the liver by any virus, leading precipitously to liver failure.

This diagnosis must be supported by all of the following:

a) rapid decreasing of liver size; and

b) necrosis involving en re lobules, leaving only a collapsed re cular framework; and

c) rapid deteriora on of liver func on tests; and

d) deepening jaundice; and

e) hepa c encephalopathy.

Acute Hepa s infec on or carrier status alone does not meet the diagnos c criteria.

What does it mean?

Appearance of severe systemic complica ons like sepsis, gastro-intes nal bleeding, cerebral oedema, renal and cardiac failure, rapidly a er the first signs of liver disease (such as jaundice), and indicates that the liver has sustained severe damage.

19. Third Degree Burns

There must be third-degree burns with scarring that cover at least 20% of the body’s surface area. The diagnosis must confirm the total area involved using standardized, clinically accepted, body surface area charts covering 20% of the body surface area.

20. Muscular Dystrophy

Muscular Dystrophy is a disease of the muscle causing progressive and permanent weakening of certain muscle groups. The diagnosis of Muscular Dystrophy must be made by a consultant neurologist, and confirmed with the appropriate laboratory, biochemical, histological, and electromyographic evidence. The disease must result in the permanent inability of the Insured Person to perform (whether aided or unaided) at least three (3) of the six (6)“Ac vi es of Daily Living”.

Ac vi es of Daily Living are defined as:

i. Washing : the ability to maintain an adequate level of cleanliness and personal hygiene

ii. Dressing : the ability to put on and take off all necessary garments, ar ficial limbs or other surgical appliances that are Medically Necessary

iii. Feeding : the ability to transfer food from a plate or bowl to the mouth once food has been prepared and made available

iv. Toile ng : the ability to manage bowel and bladder func on, maintaining an adequate and socially acceptable level of hygiene

v. Mobility : the ability to move indoors from room to room on level surfaces at the normal place of residence

vi. Transferring: the ability to move from a lying posi on in a bed to a si ng posi on in an upright chair or wheel chair and vice versa.

2.3 HospiCash Benefit

2.3.1. If an Insured Person is Hospitalized solely and directly due to an injury arising from an Accident or due to an Illness for a minimum period of 48 hours, then We will pay the daily allowance as specified in the Cer ficate of Insurance for each con nuous and completed period of 24 hours of Hospitalisa on from the first day of Hospitaliza on provided that:

2.3.2. We shall not be liable to make any payment for Hospitalisa on and/or treatment and/or treatment following diagnosis which occurs within 30 days from the date of commencement of the Policy specified in the Schedule of Insurance Cer ficate, unless such Hospitalisa on is required solely and directly due to an Accident;

2.3.3. We shall not be liable to make payment of the Daily Allowance under this benefit for more than 45 days for an Insured Person in a Policy Year, including all days of admission to the Intensive Care Unit. This is applicable for both individual and family op on.

2.3.4. If an Insured Person is required to be admi ed to the Intensive Care Unit of a Hospital solely and directly due to an injury arising from an Accident or due to an Illness, then We will pay twice the Daily Allowance specified in the Cer ficate of Insurance for each con nuous and completed period of 24 hours of admission in the Intensive Care Unit for a maximum of 7 days for an Insured Person in a policy year.

3.

Exclusions

 

In addi on to exclusions/wai ng periods specified elsewhere in the Policy Document, We shall not be liable under this Policy for any claim in connec on with or in respect of the following:

a.

Ini al Wai ng Period

Cri care: Benefits will not become payable if the signs or symptoms of any of the listed cri cal illnesses commence within 90 days from the date of commencement of Cri Care coverage of the first policy.

HospiCash: Benefits will not become payable if the signs or symptoms and/or Treatment fall within 30 days from the date of commencement of HospiCash coverage except accidents.

b.

Pre-Exis ng Diseases

For Cri Care and HospiCash, Benefits will not be available for Pre-exis ng Diseases un l 48 months of con nuous coverage have elapsed since the incep on of the first Policy with Us or other insurer in case of portability, for the respec ve benefit.

c.

Specific Wai ng Period for the HospiCash Benefit under 2.3

For the payment of the HospiCash Benefit, the disease condi ons / treatments listed below will be subject to a wai ng period of 24 months and will be covered from the commencement of the third Policy Year as long as the Insured Person has been insured con nuously under the Policy without any break

1. Stones in biliary and urinary systems

2. Lumps/ cysts/ nodules/ polyps/ internal tumours excluding malignancies

3. Gastric and duodenal ulcers

4. Surgery on tonsils / adenoids

5. Osteoarthrosis / arthri s / gout / rheuma sm / spondylosis / spondyli s /intervertebral disc prolapse

6. Cataract and its complica ons

7. Fissure / Fistula / Haemorrhoids of anal and rectal region

8. Hernia / hydrocele / varicocoele / spermatocoele

9. Chronic renal failure or end stage renal failure

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

10. Sinusi s / deviated nasal septum / tympanoplasty / chronic suppura ve o s media

11. Benign prosta c hypertrophy

12. Joint replacements surgery except in case of accidents

13. Dilata on and cure age except in case of surgical abor on

14. Varicose veins of legs

15. Dysfunc onal uterine bleeding / fibroids / prolapse uterus / endometriosis

16. Diabetes and related complica ons including but not limited to:

a) Hyperglycaemia with or without coma

b) Hypoglycaemia with or without coma

c) Diabe c Ketoacidosis

d) Diabe c Nephropathy

e) Diabe c Re nopathy

f) Diabe c Neuropathy

17. Hysterectomy for any benign disorder

18. Thyroid and parathyroid gland disorders excluding malignancy

19. Any Congenital Anomaly or inherited disorder or developmental condi ons

d. Permanent Exclusions

1. Specific Exclusions for AccidentCare Cover under 2.1

We shall not be liable to make any payment under any benefits under the AccidentCare Cover under 2.1 if the claim is a ributable to, or based on, or arise out of, or are directly or indirectly connected to any of the following:

i. Suicide or self inflicted Injury, whether the Insured Person is medically sane or insane.

ii. Treatment for any injury or illness resul ng directly or indirectly from nuclear, radiological emissions, war or war like situa ons (whether war is declared or not), rebellion (act of armed resistance to an established government or leader), acts of terrorism.

iii. Service in the armed forces, or any police organiza on, of any country at war or at peace or service in any force of an interna onal body or par cipa on in any of the naval, military or air force opera on during peace me.

iv. Any change of profession a er incep on of the Policy which results in the enhancement of Our risk, if not accepted and endorsed by Us on the Schedule of Insurance Cer ficate.

v. Commi ng an assault, a criminal offence or any breach of law with criminal intent.

vi. Taking or absorbing, accidentally or otherwise, any intoxica ng liquor, drug, narco c, medicine, seda ve or poison, except as prescribed by a Medical Prac oner other than the Policyholder or an Insured Person.

vii. Par cipa on in avia on/marine including crew other than as a passenger in an aircra /water cra that is authorized by the relevant regula ons to carry such passengers between established airports or ports.

viii. Including but not limited to engaging in or taking part in professional/adventure sports or any hazardous pursuits, such as speed contest or racing of any kind (other than on foot), bungee jumping, parasailing, ballooning, parachu ng, skydiving, paragliding, hang gliding, mountain or rock climbing necessita ng the use of guides or ropes, potholing, abseiling, deep sea diving using hard helmet and breathing apparatus, polo, snow and ice sports, hun ng etc;

ix. Body or mental infirmity or any disease except where such condi on arises directly as a correspondence of an Accident during the Policy Period. However this exclusion is not applicable to claims made under the PPD benefit.

x. Any costs or expenses specified in the List of Expenses Generally Excluded at Annexure II. This is applicable only for Accident Hospitaliza on benefit.

2. Specific Exclusions for Cri Care under 2.2

In addi on to any condi ons and exclusions listed under each Cri cal Illness, We shall not be liable to make any payment of the Cri Care Benefit under 2.2 if the claim is a ributable to, or based on, or arise out of, or are directly or indirectly connected to any of the following:

a. Acquired Immune Deficiency Syndrome (AIDS), AIDS-related complex or infec on by Human Immunodeficiency Virus (HIV); or

b. the Insured Person’s a empted suicide or self-inflicted injuries while sane or insane; or

c. narco cs used by the Insured Person unless taken as prescribed by a Medical Prac oner, or the Insured Person’s abuse of drugs and/or consump on of alcohol; or

d. The direc ons, advice and guidance of the trea ng Medical Prac oner shall be strictly followed. We shall not be obliged to make any payment that arises out of willful failure to comply with such direc ons, advice or guidance.

e. Treatment for any injury or illness resul ng directly or indirectly from nuclear, radiological emissions, war or war like situa ons (whether war is declared or not), rebellion (act of armed resistance to an established government or leader), acts of terrorism

f. taking part in any naval, military or air force opera on during peace me; or

g. Par cipa on in avia on/marine including crew other than as a passenger in an aircra /water cra that is authorized by the relevant regula ons to carry such passengers between established airport or ports.

h. Including but not limited to engaging in or taking part in professional/adventure sports or any hazardous pursuits, such as speed contest or racing of any kind (other than on foot), bungee jumping, parasailing, ballooning, parachu ng, skydiving, paragliding, hang gliding, mountain or rock climbing necessita ng the use of guides or ropes, potholing, abseiling, deep sea diving using hard helmet and breathing apparatus, polo, snow and ice sports, hun ng etc; or

i. par cipa on by the Insured Person in a criminal or a breach of law with criminal intent; or

3. Specific Exclusions for HospiCash Benefit under 2.3

We shall not be liable to make any payment if Hospitalisa on or any claim under this benefit are a ributable to, or based on, or arise out of, or are directly or indirectly connected to any of the following:

I. Hospitalisa on not in accordance with the diagnosis and treatment of the condi on for which the Hospital confinement was required;

ii. Hospitaliza on solely for diagnos c or observa on purpose;

iii. Treatment for weight reduc on or weight improvement regardless of whether the same is caused (directly or indirectly) by a medical condi on;

iv. Any dental care or Surgery of cosme c nature, extrac on of impacted tooth/teeth, orthodon cs or orthognathic Surgery, or tempero-mandibular joint disorder except as necessitated by an Accidental Injury;

v. Treatment for infer lity or impotency, sex change or any treatment related to it, abor on, steriliza on and contracep on including any complica ons rela ng thereto;

vi. Treatment arising from pregnancy and it’s complica ons which shall include childbirth or abor on or threatened abor on excluding ectopic pregnancy;

vii. Hereditary and Gene c Disorders: Screening, counseling or treatment related to Hereditary and Gene c Disorders;

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

viii. Hospitalisa on primarily for diagnosis, X-ray examina ons, general physical or medical check-up not followed by ac ve treatment during the Hospitalisa on period or Hospitalisa on where no ac ve treatment is given by the Medical Prac oner;

ix. Unproven/Experimental treatments/off-label treatment;

x. Alterna ve treatment;

xi. Treatment of any mental or psychiatric condi on including but not limited to insanity, mental or nervous breakdown / disorder, depression, demen a, Alzheimer’s disease or rest cures;

xii. Admission to a nursing home or home for the care of the aged for rehabilita on, or convalescence;

xiii. Treatment directly or indirectly arising from alcohol, drug or substance abuse and any Illness or Accidental Injury which may be suffered a er consump on of intoxica ng substances, liquors or drugs;

xiv. Treatment directly or indirectly arising from or consequent upon war (whether war be declared or not), invasion, acts of foreign enemies, hos li es, civil war, rebellion, ac ve par cipa on in strikes, riots or civil commo on, revolu on, insurrec on or military or usurped power, and full- me service in any of the armed forces;

xv. Acquired Immune Deficiency Syndrome (AIDS) and all Illnesses or diseases caused by or related to the Human Immuno-deficiency Virus;

xvi. Sexually transmi ed diseases;

xvii. Cosme c or plas c Surgery except to the extent that such Surgery is necessary for the repair of damage caused solely by Accidental Injuries; treatment of xanthelesema, syringoma, acne and alopecia;

xviii. Nuclear disaster, radioac ve contamina on and/or release of nuclear or atomic energy;

xix. Treatment for Accidental Injury or Illness caused by inten onally self- inflicted Injuries; or any a empts of suicide while sane or insane;

xx. Treatment for Accidental Injury or Illness caused by viola on or a empted viola on of the law, or resistance to arrest;

xxi. Including but not limited to engaging in or taking part in professional/adventure sports or any hazardous pursuits, such as speed contest or racing of any kind (other than on foot), bungee jumping, parasailing, ballooning, parachu ng, skydiving, paragliding, hang gliding, mountain or rock climbing necessita ng the use of guides or ropes, potholing, abseiling, deep sea diving using hard helmet and breathing apparatus, polo, snow and ice sports, hun ng etc.;

xxii. Circumcision unless necessary for treatment of a disease or necessitated due to an Accident;

xxiii. Hospitalisa on where the Insured Person is a donor for any organ transplant;

xxiv. Any treatment outside of Republic of India;

xxv. Treatment to assist reproduc on, including IVF treatment;

xxvi. Hormone Replacement Therapy;

xxvii.Puberty and Menopause related Disorders: Treatment for any symptoms, Illness, complica ons arising due to physiological condi ons associated with Puberty, Menopause such as menopausal bleeding or flushing;

xxviii. Ar ficial Life Maintenance: Ar ficial life maintenance, including life support machine used to sustain a person, who has been declared brain dead, as demonstrated by:

a. Deep coma and unresponsiveness to all forms of s mula on;

b. Absent pupillary light reac on;

c. Absent oculoves bular and corneal reflexes; or

d. Complete apnea

xxix. Sleep disorders: Treatment for sleep apnea, snoring or any other sleep-related breathing problem;

xxx. Treatment for developmental problems: Treatment for, or related to developmental problems, including – learning difficul es (such as dyslexia), behavioral problems, including a en on deficit hyperac vity disorder (ADHD);

4. Standard Terms and Condi ons

a. Observance of terms and condi ons.

The due observance and fulfillment of the terms, condi ons and endorsements of this Policy in so far as they relate to anything to be done or complied with by the Insured Person, shall be a condi on precedent to any liability to make payment under this Policy .

b. Subroga on and Contribu on

Subroga on and Contribu on provisions are not applicable to the Policy.

c. Fraudulent claims

If a claim is in any way found to be fraudulent, or if any false statement, or declara on is made or used in support of such a claim, or if any fraudulent means or devices are used by the Insured Person or any false or incorrect disclosure to informa on norms or anyone ac ng on behalf of the Insured Person to obtain any benefit under this Policy, then this Policy shall be void and all claims being processed shall be forfeited for all Insured Persons and all sums paid under this Policy shall be repaid to Us by all Insured Persons who shall be jointly liable for such repayment.

d. Free Look Provision

You have a period of 15 days from the date of receipt of the Policy document to review the terms and condi ons of this Policy. The Free Look period will be 30 days if the Policy is purchased through distance marke ng mode and Policy Period is 3 years. If You have any objec ons to any of the terms and condi ons, You may cancel the Policy sta ng the reasons for cancella on and provided that no claims have been made under the Policy, We will refund the premium paid by You a er deduc ng the amounts spent on stamp duty charges, pre policy medical checkup and propor onate risk premium for the period on cover. All rights and benefits under this Policy shall immediately stand ex nguished on the free look cancella on of the Policy. The free look provision is not applicable and available at the me of Renewal of the Policy.

e. Portability :

All health insurance policies are portable. You should ini ate ac on to approach another insurer to take advantage of portability well before the renewal date to avoid any break in the policy coverage due to delay in acceptance of the proposal by the other insurer.

If You/the Insured Person has exercised the Portability Op on at the me of Renewal of Your previous health insurance policy by submi ng Your applica on and the completed Portability form with complete documenta on at least 45 days before, but not earlier than 60 days from the expiry of Your previous Policy Period, then the Insured Person will be provided with credit gained for Pre-exis ng Diseases in terms of Wai ng Periods and me bound exclusions up to the exis ng Sum Insured and cover in accordance with the exis ng guidelines of the IRDAI provided that:

a. The ported Insured Person was insured con nuously and without a break under another Indian retail health insurance policy with any other Indian general insurance company or stand-alone health insurance company or any group/retail indemnity health insurance policy from Us.

b. The Wai ng Period with respect to change in Sum Insured or plan shall be taken into account as follows:

i. If the ported Sum Insured is higher than the Sum Insured under the expiring policy, Wai ng Periods would be applied on the amount of proposed increase in Sum Insured only, in accordance with the exis ng guidelines of the IRDAI.

ii. If the proposed Plan is to be changed and not the Sum Insured then the applicable Wai ng Periods would be applied as per the proposed plan.

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

c.

In case of different policies and plan in previous years, the Portability Op on would be provided for the expiring policy or Plan which is to be ported to Us.

d.

The Portability Op on has been accepted by Us within 15 days of receiving Your Proposal and Portability Form subject to the following:

i. You shall have paid Us the applicable premium in full;

ii. We might have, subject to Our medical underwri ng as per Our Board approved underwri ng policy, restricted the terms upon which We have offered cover, the decision as to which shall be in Our sole and absolute discre on;

iii. There was no obliga on on Us to insure all Insured Persons or to insure all Insured Persons on the proposed terms, even if You have given Us all documenta on;

iv. We have received necessary details of medical history and claim history from the previous insurance company for the Insured Person’s previous health insurance policy through the IRDAI’s web portal.

v. No addi onal loading or charges have been applied by Us exclusively for por ng the Policy.

e.

In case You have opted to switch to any other insurer under Portability provisions(Por ng Out) and the outcome of acceptance of the Portability request is awaited from the new insurer on the date of Renewal,

i. We may upon Your request extend this Policy for a period of not less than one month at an addi onal premium to be paid on a pro rata basis.

ii. If during this extension period a claim has been reported, You shall be required to first pay the balance of the full annual Policy premium. Our liability for the payment of such claim shall commence only once such premium is received. Alternately We may deduct the premium for the balance period and pay the balance claim amount if any and issue the Policy for the remaining period.

iii. We reserve the right to modify or amend the terms and the applicability of the Portability op on in accordance with the provisions of the regula ons and guidance issued by the IRDAI as amended from me to me.

f.

No fica on :

You will inform Us immediately of any change in the address, nature of job, state of health, or of any other changes affec ng You or any Insured Person through the format Annexure III.

We shall allow the enhancement in Sum Insured or scope of cover only at the me of Renewal, provided You in mate Us at the me of Renewal. The decision of acceptance of enhancement of the sum insured or the scope of cover will be based on our underwri ng policy and shall be subject to payment of applicable premium for such enhanced cover.

g.

Cancella on/ Termina on (other than free look cancella on)

1.

Cancella on by Insured Person:

You may terminate this Policy during the Policy Period by giving Us at least 30 days prior wri en no ce. We shall cancel the Policy and refund the premium for the balance of the Policy Period in accordance with the table below provided that no claim has been made under the Policy by or on behalf of any Insured Person.

3 years Policy in-force Refund up to Premium (%) Up to 30 days 90% 31
3 years
Policy in-force
Refund
up to
Premium
(%)
Up to 30 days
90%
31 to 90 days
87.5%
1 year 2 years Policy in-force Refund Policy in-force Refund up to Premium up to
1 year
2 years
Policy in-force
Refund
Policy in-force
Refund
up to
Premium
up to
Premium
(%)
(%)
Up to 30 days
75%
Up to 30 days
87.5%
31
to 90 days
50%
31
to 90 days
75%
91
to 180 days
25%
91
to 180 days
62.5%
exceeding 180 days
0%
181
to 365 days
50%
366
to 455 days
25%
456
to 545 days
12%
Exceeding 545 days
0%
91 to 180 days 75% 181 to 365 days 60% 366 to 455 days 50%

91

to 180 days

75%

181

to 365 days

60%

366

to 455 days

50%

456

to 545 days

25%

545

to 720 days

12%

Exceeding 720

0%

days

60% 366 to 455 days 50% 456 to 545 days 25% 545 to 720 days 12%
60% 366 to 455 days 50% 456 to 545 days 25% 545 to 720 days 12%
60% 366 to 455 days 50% 456 to 545 days 25% 545 to 720 days 12%
60% 366 to 455 days 50% 456 to 545 days 25% 545 to 720 days 12%
60% 366 to 455 days 50% 456 to 545 days 25% 545 to 720 days 12%
366 to 455 days 50% 456 to 545 days 25% 545 to 720 days 12% Exceeding
366 to 455 days 50% 456 to 545 days 25% 545 to 720 days 12% Exceeding
366 to 455 days 50% 456 to 545 days 25% 545 to 720 days 12% Exceeding
366 to 455 days 50% 456 to 545 days 25% 545 to 720 days 12% Exceeding

2.

Automa c Cancella on:

 

a.

Individual Policy:

The Policy shall automa cally terminate on death of the Insured Person.

b.

For Policy issued to Family:

The Policy shall automa cally terminate in the event of the death of all the Insured Persons.

c. Refund:

 

A refund in accordance with the table in Sec on 4(h)(1) above shall be payable if there is an automa c cancella on of the Policy provided that no claim has been filed under the Policy by or on behalf of any Insured Person.

3.

Cancella on by Us:

 

Without prejudice to the above, We may terminate this Policy during the Policy Period by sending 30 days prior wri en no ce to Your address shown in the Schedule of Insurance Cer ficate without refund of premium (for cases other than non coopera on) if in Our opinion:

i.

You or any Insured Person or any person ac ng on behalf of either has acted in a dishonest or fraudulent manner under or in rela on to this Policy; and/or

ii.

You or any Insured Person has not disclosed the material misrepresented in rela on to the Policy; and/or

facts or

iii.

You or any Insured Person has not co operated with Us. In such cases, premium will be refunded on pro-rata basis provided that no claim has been filed under the Policy by or on behalf of any Insured Person.

For avoidance of doubt, it is clarified that no claims shall be admi ed and/or paid by Us during the no ce period.

The policy shall terminate for AccidentCare cover in case of change in occupa on of the Policyholder resul ng in change in the Risk Class to Category 3. In case of family op on, the cover of all insured persons shall terminate. However, in case of change in occupa on of any insured person other than Policyholder resul ng in change in the Risk Class to Category 3, the cover of that par cular insured person only shall terminate. In all such cases of termina on, pro-rata premium will be refunded provided that no claim has been filed under the Policy by or on behalf of any Insured Person.

4.

Withdrawal of Product: This product may be withdrawn at Our op on subject to prior approval of the Insurance Regulatory and Development Authority of India (IRDAI) or due to a change in regula ons. In such a case We shall provide an op on to migrate to our other suitable retail products as available with Us. We shall no fy You of any such change at least 3 months prior to the date from which such withdrawal shall come into effect.

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

5.

Revision or Modifica on: The product and/or premium rates may be revised or modified subject to prior approval of the Insurance Regulatory and Development Authority of India(IRDAI). In such case We shall no fy You of any such change at least 3 months prior to the date from which such revision or modifica on shall come into effect, provided it is not otherwise provided by the authority.

h.

Territorial Jurisdic on

a) AccidentCare including Temporary Total Disability coverage is available worldwide.

b) Accident Hospitalisa on, Cri Care and HospiCash are available in India only.

c) All claims shall be payable in India in Indian Rupees only.

i.

Policy Disputes

Any dispute concerning the interpreta on of the terms, condi ons, limita ons and/or exclusions contained herein shall be governed by Indian law and shall be subject to the jurisdic on of the Indian Courts at New Delhi.

j.

Renewal of Policy

The Renewal premium is payable on or before the due date in the amount shown in the Schedule of Insurance Cer ficate or at such altered rate as may be reviewed and no fied by Us before comple on of the Policy Period. We are under no obliga on to no fy You of the Renewal date of Your Policy. We will allow a Grace Period of 30 days from the due date of the Renewal premium for payment to Us. No benefits or coverage under the Policy will be available for the period for which no premium is received.

If the Policy is not Renewed within the Grace Period then We may agree to issue a fresh policy subject to Our underwri ng criteria and no con nuing benefits shall be available from the expired Policy.

If any Dependent Child has completed 21 years at the me of Renewal, then such insured person will have to take a separate policy as he/she will no longer be eligible as Dependent Child, however the con nuity benefits will be passed on to the separate policy taken by such Insured Person.

There will not be any loading at the me of Renewal on individual claims experience of the Insured Person. Renewal of the Policy will not ordinarily be denied other than on grounds of moral hazard, misrepresenta on or fraud or non-coopera on by You.

Please note:

1.

Under Accident Care, specifically for the Policyholder’s Sum Insured of 100 lacs and above, on the insured person a aining age 70 years, the coverage would get reduced to a flat sum insured of Rs100 lacs from the date of next renewal of the Policy, irrespec ve of the original sum insured

2.

Accidental Temporary Total Disability benefit is available provided that life me limit of 100 weeks is not exhausted.

k.

Renewal Benefits (For AccidentCare Cover only):

If the AccidentCare cover is renewed, the Sum Insured will be increased by 5% of the Sum Insured (shown in the Schedule of Insurance Cer ficate during the first Policy Year) for every claim free Policy Period up to a cumula ve maximum of 25% of the Sum Insured for all the applicable benefits other than Accident Temporary Total Disability (TTD) and Accident Hospitaliza on men oned under the AccidentCare cover only.

At the <