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Accident - "Accident" means a sudden, unforeseen and unexpected physical event beyond the control of the Insured/Insured Person resulting in bodily injury, caused by external, visible and violent means.
Accumulation Limit - Accumulation Limit means the amount stated in the Schedule which represents Our maximum liability for all claims under any and all benefits from all Insured Persons arising from the same [accident, event or occurrence or series of related accidents, events or occurrences] AND/OR [location], and if at any time the total value of unpaid claims would, if paid, result in the Accumulation Limit being exceeded (even if the Sum Insured is not) then the individual benefits attributable to those outstanding claims shall be reduced pro rata as necessary to ensure that the Accumulation Limit is not exceeded.
Age or Aged - Age or Aged means completed years as at the Commencement Date.
Aggregate Limit - Aggregate Limit means the amount stated in the Schedule which represents Our maximum liability for any and all claims made by all Insured Persons under any and all benefits, and if at any time the total value of unpaid claims would, if paid, result in the Aggregate Limit being exceeded, the individual benefits attributable to those outstanding claims shall be reduced pro rata as necessary to ensure that the Aggregate Limit is not exceeded.
Ambulance Charges - This benefit provides for reimbursement to the Insured/Insured Person of expenses incurred for his/her transportation by ambulance to and from the Hospital for treatment of disease / illness / injury / critical illness in a Hospital as an in-patient for which a valid claim under this Policy is admissible, subject to the limits as specified in the Schedule to this Policy. This benefit is applicable irrespective of the number of occurrences during the Policy period subject to the overall Sum Insured.
Any One Illness - ANY ONE ILLNESS Any one illness will be deemed to mean continuous period of illness and it includes relapse within 45 days from the date of last consultation with the Hospital/Nursing Home where treatment may have been taken. Occurrence of same illness after a lapse of 45 days as stated above will be considered as fresh illness for the purpose of this policy.
Bodily Injury - "Bodily Injury" means any accidental physical bodily harm solely and directly caused by external, violent and visible means which is verified and certified by a Physician but does not include any sickness or disease.
Bodily Injury/Injury - "Bodily Injury/Injury" means any accidental physical bodily harm solely and directly caused by external, violent and visible and evident means which is verified and certified by a Physician but does not include any sickness or disease.
Break In Policy - Break In Policy - occurs at the end of the existing policy term, when the premium due for renewal on a given policy is not paid on or before the premium renewal date or within 30 days thereof.
Carrier - Carrier means a civilian or commercial land, air or water conveyance operating under a valid license from transportation of goods or passengers by air, sea, road or rail for a fee.
Certificate of Insurance - Certificate of Insurance means the certificate We issue to an Insured Person to confirm his coverage under the Policy. Coverage in respect of an Insured Person shall commence from the date mentioned therein.
Child - Child - means dependent child/children including adopted and step child/children of the Insured Person between Ages two (2) years and eighteen (18) years (twenty-three (23) years if attending as a full time student in an accredited Institution of Higher Learning) who are unmarried, and receive the majority of maintenance and support from the Insured Person
Claim - Claim - means a demand made by You or on Your behalf for payment of Medical Expenses or any other expenses or benefits, as covered under the Policy
Co-payment - Co-payment - is a cost-sharing requirement under a health insurance policy that provides that the policyholder/insured will bear a specified percentage of the admissible claim amount. A co-payment does not reduce the Sum Insured.
Commencement Date - Commencement Date means the commencement date of this Policy as specified in the Schedule.
Condition Precedent - Condition Precedent - shall mean a policy term or condition upon which the Insurer's liability under the policy is conditional upon.
Cover Year - Cover Year - means duration of twelve months beginning from the Cover Period Start Date as specified in the Policy Schedule, and for subsequent Cover Years, it will include any successive durations of twelve months, till the Cover Period End Date, as specified in the Policy Schedule.
Critical Illnesses - Critical Illnesses means diseases/illnesses limited to the following:
- Cancer represented by a malignant tumor characterized by the uncontrolled growth and spread of malignant cells with invasion and destruction of normal tissue.
- First Heart Attack involving death of a portion of the heart muscle arising from inadequate blood supply to the relevant area.
- Coronary Artery Disease involving narrowing of the lumen of at least one coronary artery by a minimum of 75% and of two others by a minimum of 60%, as proven by coronary arteriography, regardless of whether or not any form of coronary artery surgery has been performed. Coronary arteries herein refer to left main stem, left anterior descending circumflex and right coronary artery.
- Coronary Artery bypass surgery involving the actual undergoing of open-chest surgery to correct the narrowing or blockage of one or more coronary arteries with bypass grafts.
- Heart Valve Surgery involving the actual undergoing of open heart surgery to replace or repair heart valve abnormalities.
- Surgery to Aorta involving actual undergoing of major surgery to repair or correct aneurysm, narrowing, obstruction or dissection of the aorta through surgical opening of the chest or abdomen. For the purpose of this definition aorta shall mean the thoracic and abdominal aorta but not its branches.
- Stroke referring to a cerebrovascular incident including infarction of brain tissue, cerebral and subarachnoid hemorrhage, cerebral embolism, and cerebral thrombosis.
- Kidney Failure involving chronic irreversible failure of both kidneys requiring either permanent renal dialysis or kidney transplantation
- Aplastic Anemia involving Chronic persistent bone marrow failure which results in anemia, neutropenia and thrombocytopenia requiring treatment
- End Stage Lung Disease causing chronic respiratory failure
- End Stage Liver Failure evidenced by Permanent jaundice ascites and Hepatic Encephalopathy.
- Coma that persists for at least 30 days.
- Major Burns representing third degree (full thickness of the skin) burns covering at least 30% of the surface of the Insured / Insured person's body.
- xiv) Major Organ/Bone Marrow Transplantation involving human bone marrow using hematopoietic stem cells preceded by total bone marrow ablation; or any one of the human organs limited to heart, lung, liver, kidney or pancreas, that resulted from irreversible end stage failure of the relevant organ.
- Multiple Sclerosis
- Fulminant Hepatitis involving sub-massive to massive necrosis of the liver by the Hepatitis virus, leading precipitously to liver failure
- Motor Neuron Disease characterized by progressive degeneration of corticospinal tracts and anterior horn cells or bulbar efferent neurons which include spinal muscular atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis and primary lateral sclerosis.
- Primary Pulmonary Hypertension with substantial right ventricular enlargement confirmed by investigations including cardiac catheterization, resulting in permanent physical impairment due to cardiac impairment resulting in not being able to engage in any physical activity without discomfort. Symptoms may be present even at rest
- Terminal Illness involving conclusive diagnosis of an illness that is expected to result in the death of the insured person within 12 months.
- Bacterial Meningitis involving bacterial infection causing in severe inflammation of the membranes of the brain or spinal cord resulting in significant, irreversible and permanent neurological deficit. The neurological deficit must persist for at least 6 weeks.
Day Care treatment - "Day Care treatment" means treatment undertaken in a Hospital/ Nursing Home on the recommendation of a Medical Practitioner for the following diseases, illness or injury which requires hospitalisation for less than 24 hours and includes such of those treatments which require hospitalisation for less than 24 hours due to technologically advanced treatment protocol.
- a) Dialysis
- b) Radiotherapy
- d) Eye surgery
- e) Dental surgery
- f) Lithotripsy (kidney stone removal)
- g) Tonsillectomy
- h) Dilatation & Curettage
- i) Cardiac Catheterization
- j) Hydrocele surgery
- k) Hernia repair surgery
- l) Surgeries/procedures that require less than 24 hours’ hospitalization due to medical/ technological advancement and infrastructural facilities.
- m) TURP (Prostate Surgery)
Deductible - Deductible means, in respect of each and every claim, the amount stated in the Schedule which will first be paid by each Insured Person or apply for the period of time stated in the Schedule.
Dependent Child or Dependent Children - Dependent Child or Dependent Children means Your Children Aged between 91 days and 21 years at the commencement of the Policy Period if they are unmarried, still financially dependent on You and have not established their own independent households.
Disease - "Disease" means an alteration in the state of the body or of some of its organs, interrupting or disturbing the performance of the functions, and causing or threatening pain and weakness or physical or mental disorder and certified by a Medical Practitioner.
Doctor - Doctor means a person who holds a qualification in medicine from a recognized institution and is registered by state council, governed by the Medical Council of India in which he operates and is practicing within the scope of such license and will include (but is not limited to) physicians, specialists and surgeons who satisfy the aforementioned criteria.
Domiciliary Hospitalisation Benefit - DOMICILIARY HOSPITALISATION BENEFIT means Medical treatment for a period exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at a hospital/ nursing home but actually taken whilst confined at home in India under any of the following circumstances, namely: i) The condition of the patient is such that he/she cannot be removed to the hospital/nursing home or ii) The patient cannot be removed to the hospital/nursing home for lack of accommodation therein Subject however that domiciliary hospitalisation benefits shall not cover: i) expenses incurred for pre and post hospital treatment, and ii) expenses incurred for the treatment for any of the following diseases: 1. Asthma 2. Bronchitis 3. Chronic Nephritis and Nephritic Syndrome 4. Diarrhea and all types of dysentries including Gastroenteritis 5. Diabetes Mellitus and Insipidus 6. Epilepsy 7. Hypertension 8. Influenza, Cough, and Cold 9. All Psychiatric or Psychosomatic disorders 10. Pyrexia of unknown origin for less than 10 days 11. Tonsillitis and upper respiratory tract infection including Laryngitis and Pharyngitis 12. Arthritis, Gout and Rheumatism Note: When treatment such as Dialysis, Chemotherapy, Radiotherapy is taken in the Hospital/Nursing Home/Clinic and the insured is discharged the same day the treatment will be considered to be taken under Hospitalisation Benefit section.Liability of the Company under this clause is restricted as stated in the Schedule attached hereto.
Domiciliary hospitalization - "Domiciliary hospitalization" means medical treatment for a period exceeding three days for any disease, illness or injury which in the normal course would require care and treatment at a Hospital/Nursing Home but is actually taken whilst confined at home in India under any of the following circumstances, namely: -
- a) The condition of the patient is such that he/she cannot be removed to Hospital/Nursing Home, or
- b) The patient cannot be admitted to Hospital/Nursing Home for lack of accommodation therein.
- a) Pre and post Hospital treatment,
- b) Treatment of any of the following diseases:
- i) Asthma
- ii) Bronchitis
- iv) Diarrhoeaandalltypesofdysenteries including astroenteritis
- v) Diabetes mellitus and insipidus
- vi) Epilepsy
- ix) Allpsychiatricorpsychosomaticdisorders
- x) Pyrexia of unknown origin for less than 10 days
- xi) Tonsillitis and upper respiratory tract infection including aryngitisandpharangitis
Family - "Family" means the Insured, his/her lawful spouse and maximum of two dependent children up to the age of 23 years. xii) Arthritis, goutandrheumatism.
Hospital Cash Allowance - In case the Insured / Insured Person is hospitalized for treatment of any disease / illness / injury / critical illness for which a valid claim is admissible under the Policy and if the hospitalisation exceeds a specified number of days mentioned in the Schedule to this Policy, this benefit provides for payment to the Insured/Insured Person of a daily hospital allowance up to the specified limits as mentioned in the Schedule to this Policy. This benefit is applicable irrespective of the number of occurrences during the Policy period subject to overall Sum Insured
Hospital/Nursing Home - “HOSPITAL/NURSING HOME” means any institution in India established for indoor care and treatment of sickness and injuries and which EITHER (a) has been registered as a hospital or nursing home with the local authorities and is under the supervision of a registered and qualified medical practitioner OR (b) should comply with minimum criteria as under: (i) It should have at least 15 inpatient Beds* (ii) Fully equipped operation theatre of its own wherever surgical operations are carried out (iii) Fully qualified Nursing Staff under its employment round the clock (iv) Fully qualified Doctor(s) should be in charge round the clock (N.B.: *In Class ‘C’ town’s condition of number of beds be reduced to 10)The term “Hospital/ Nursing Home” shall not include an establishment, which is a place of considered to be taken under Hospitalisation Benefit section.
Hospitalisation expenses - "Hospitalisation expenses" mean expenses on hospitalization incurred in India for minimum period of 24 hours incurred in India, which are admissible under this Policy. However, this time limit will not apply for specific treatments defined under Day Care treatment taken in a Hospital / Nursing Home.
Illness - "Illness" means sickness or disease first diagnosed during the period of insurance for which immediate treatment by a Medical Practitioner is necessary.
In-patient - "In-patient" means an Insured / Insured Person who is admitted to Hospital / Nursing Home and stays for at least 24 hours for the sole purpose of receiving treatment.
Insured - "Insured" means the individual who has a permanent place of residence in India and on whose name the Policy is issued.
Insured Person - "Insured Person" means the person named in the Schedule to the Policy, who has a permanent place of residence in India and for whose benefit the insurance is proposed and appropriate premium paid.
Medical charges - "Medical charges" mean reasonable charges unavoidably incurred by the Insured/Insured Person for the medical treatment of disease, illness or injury the subject matter of the claim as an In-patient in a Hospital/ Nursing Home, and includes the costs of a bed; treatment and care by medical staff; medical procedures, Medical Practitioner's/ Consultant's/Specialist's fees, medicines and consumables including cost of pacemaker, cost of organs, artificial limbs etc. as long as these are recommended by the attending Medical Practitioner.
Medical Practitioner - Medical Practitioner means a person who holds a degree/diploma of a recognised institution and is registered by Medical Council of respective sate of India. The term Medical Practitioner would include Physician, Specialist and Surgeon.
Medical Practitioner - "Medical Practitioner" means a person who holds a degree/diploma of a recognized institution and is registered with the Medical Council in respective states of India. The term Medical Practitioner includes a physician, specialist and surgeon, provided that this person is not a member of the Insured/Insured Person's family.
Nominee - Nominee - means the person(s) nominated by You to receive the benefits under this Policy payable on Your death caused by an Accident. For the purpose of avoidance of doubt it is clarified that if You are a minor, Your legal guardian shall appoint the Nominee.
Notification of claim - Notification of claim - is the process of notifying a claim to the insurer or Third party administrator by specifying the timelines as well as the address / telephone number to which it should be notified.
Our Patient - Out-patient is the one in which the Insured who is not hospitalized for more than 24 consecutive hours but who visits a Hospital, clinic, or associated facility for diagnosis or treatment. However, any Insured undergoing any specified "Day care surgeries/Treatment" will not be considered as an Outpatient
Period of insurance - "Period of insurance" means the Policy period defined hereunder
Physical Separation - Physical Separation - means with respect to the hand, severance of limb at or above the wrists, and with respect to the foot, severance of limb at or above the ankle.
Policy - "Policy" means this document of Policy describing the terms and conditions of this contract of insurance, including the company's covering letter to the insured if any, the Schedule attached to and forming part of this Policy, the Insured's Proposer form and any applicable endorsement thereon. The Policy contains details of the scope and extent of cover available to the Insured/Insured Person, the exclusions from the scope of cover and the terms and conditions of the issue of the Policy.
Policy period - "Policy period" means the period between the inception date and the expiry date as specified in the Schedule to this Policy or the cancellation of this insurance, whichever is earlier.
Post Hospitalisation - Relevant medical expenses incurred during period up to 60 days after hospitalization for disease/ illness/injury sustained will be considered as part of claim mentioned under item 1.0 above
Pre Hospitalisation - Relevant medical expenses incurred during period up to 30 days prior to hospitalization on disease/ illness/injury sustained will be considered as part of claim mentioned under item 1.0 above.
Qualified Nurse - Qualified Nurse means a person who holds a certificate of a recoginsed Nursing Council and who is employed as recommendations of the attending Medical Practitioner.
Reasonable and Customary Charges - A charge incurred for medical treatment that are medically necessary to treat Your condition and not exceeding the usual level of charges for similar medical services in the locality where expense is incurred and excludes any charge that would not have been made if there was no insurance
Schedule - Schedule means Schedule attached to and forming part of this Policy mentioning the details of the Insured/ Insured Persons, the Sum Insured, the period and the limits to which benefits under the Policy are subject to.
Subrogation - Subrogation - shall mean the right of the insurer to assume the rights of the insured person to recover expenses paid out under the policy that may be recovered from any other source.
Sum Insured - "Sum Insured" means the sum as specified in the Schedule to this Policy against the name of Insured / each Insured Person, which sum represents the Company's maximum liability for any or all claims under this Policy during the Policy period for the respective benefit(s) against which the sum is mentioned in the Schedule to this Policy.
Surgical Operation - “SURGICAL OPERATION’ means manual and/or operative procedure for correction of deformities and defects, repairs of injuries diagnosis and cure of diseases relief of suffering and prolongation of life.
Surgical Operation - "Surgical operation" means manual and/or operative procedures for correction of deformities and defects, repair of injuries, diagnosis and cure of diseases, relief of suffering and prolongation of life.
Terrorism shall - Terrorism shall mean 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 organisation(s) or Government(s), committed for political, religious or ideological purposes or reasons including the intention to influence any government and/or to put the public, or any section of the public, in fear.
Terrorism/Terrorist Incident - "Terrorism/Terrorist Incident" means any actual or threatened use of force or violence directed at or causing damage, injury, harm or disruption, or the commission of an act dangerous to human life or property or government, with the stated or unstated objective of pursuing economic, ethnic, nationalistic, political, racial or religious interests, whether such interests are declared or not. Robberies or other criminal acts, primarily committed for personal gain and acts arising primarily from prior personal relationships between perpetrator(s) and victim(s) shall not be considered terrorist activity. Terrorism shall also include any act, which is verified or recognized by the relevant Government as an act of terrorism.
Third Party Administrator - Third Party Administrator (TPA) means the services rendered by a TPA to an insurer under an agreement in connection with health insurance business but does not include the business of an insurance company or the soliciting either directly or indirectly, of health insurance business or deciding on the admissibility of a claim or its rejection.
Third Party Administrator (TPA) - "Third Party Administrator (TPA)" means any organization or institution that is licensed by the IRDA as a TPA and is engaged by the Company for a fee or remuneration for providing Policy and claims facilitation services to the Insured/ Insured Person as well as to the Company for an insurable event.