Form No.

GH 2022-MAR

THE NEW INDIA ASSURANCE CO. LTD.

REGISTERED & HEAD OFFICE: 87, MAHATMA GANDHI ROAD, MUMBAI 400001

DIVISIONAL OFICE: 712500, ALLIED’S MOUNT CASA BLANCA,

2nd FLOOR, NO.260, ANNA SALAI, CHENNAI-600 006.
PHONE :-044- 23456824,23456826,23456827 FAX : 044-23456825
E-MAIL: nia.712500@newindia.co.in website: www.newindia.co.in/citibank

GOODHEALTH GROUP MEDICLAIM POLICY CLAUSE

UIN : NIAHLGP21236V022021

1. PREAMBLE
This is your GOOD HEALTH GROUP MEDICLAIM POLICY issued to you being a Card Member or Account
Holder of CITIBANK, relying on the information provided by you in the proposal and declaration for
this policy or its preceding Policy/Policies of which this is a renewal.

The terms and conditions set out in this Policy and its Schedule will be the basis for any claim and/or
benefit under this Policy.

Please read this Policy carefully and point out discrepancy, if any, in Policy Schedule. Otherwise, it
will be presumed that the Policy and the Schedule correctly represent the cover agreed upon.

If during the Period of Insurance, You or any Insured Person incurs Hospitalisation Expenses which are
Reasonable and Customary and Medically Necessary for treatment of any Illness or Injury sustained in Accident,
we will reimburse such expense incurred by You, through the Third Party Administrator, in the manner stated
herein.

Please note that the above coverage is subject to Limits, Terms and Conditions contained in this Policy and no
Exclusion being found applicable.

In this Policy, the members will be covered for the Sum Insured as stated in the Policy Certificate.

2. DEFINITIONS
STANDARD DEFINITIONS

2.1 ACCIDENT means a sudden, unforeseen and involuntary event caused by external, visible and violent
means.

2.2 ANY ONE ILLNESS means continuous period of Illness and includes relapse within forty-five days from
the date of last consultation with the Hospital where treatment has been taken.
2.3 AYUSH HOSPITAL is a Healthcare facility wherein medical / surgical / para-surgical treatment procedures
and interventions are carried out by AYUSH Medical Practitioner(s) comprising of any of the following:
a. Central or State Government AYUSH Hospital or
b. Teaching hospital attached to AYUSH College recognized by the Central Government / Central
Council of Indian Medicine / Central Council for Homeopathy; or
c. AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any recognized
system of medicine, registered with the local authorities, wherever applicable, and is under the
supervision of a qualified registered AYUSH Medical Practitioner and must comply with all the
following criterion:
i. Having at least 5 in-patient beds;
ii. Having qualified AYUSH Medical Practitioner in charge round the clock;
iii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre
where surgical procedures are to be carried out;
iv. Maintaining daily records of the patients and making them accessible to the insurance
company’s authorized representative.

2.4 AYUSH DAY CARE CENTRE means and includes Community Health Centre (CHC), Primary Health Centre
(PHC), Dispensary, Clinic, Polyclinic or any such health centre which is registered with the local
authorities, wherever applicable and having facilities for carrying out treatment procedures and medical
or surgical/para-surgical interventions or both under the supervision of registered AYUSH Medical
Practitioner(s) on day care basis without in-patient services and must comply with all the following
criterion:
i. Having qualified registered AYUSH Medical Practitioner(s) in charge;
ii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre
where surgical procedures are to be carried out;
iii. Maintaining daily records of the patients and making them accessible to the insurance company’s
authorized representative.

2.5 CASHLESS FACILITY means a facility extended by Us to You where the payments, of the costs of
treatment undergone by You in accordance with the policy terms and conditions, are directly made to
the Network provider by Us to the extent of pre-authorization approved.

2.6 CONDITION PRECEDENT means a Policy term or condition upon which Our liability under the Policy is
conditional upon.

2.7 CONGENITAL ANOMALY refers to a condition(s) which is present since birth, and which is abnormal with
reference to form, structure or position
i. CONGENITAL INTERNAL ANOMALY means a Congenital Anomaly which is not in the visible and
accessible parts of the body.
ii. CONGENITAL EXTERNAL ANOMALY means a Congenital Anomaly which is in the visible and
accessible parts of the body.

2.8 CO-PAYMENT is a cost-sharing requirement under a health insurance policy that provides that the
Insured Person will bear a specified percentage of the admissible claim amount. A co-payment does not
reduce the Sum Insured.
2.9 CUMULATIVE BONUS means any increase or addition in the Sum Insured granted by the Insurer without
an associated increase in premium.

2.10 DAY CARE DAY CARE CENTRE means any institution established for Day Care Treatment of Illness or
Injury, or a medical set-up within a Hospital and which has been registered with the local authorities,
wherever applicable, and is under the supervision of a registered and qualified Medical Practitioner AND
must comply with all minimum criteria as under:

- Has qualified nursing staff under its employment

- Has qualified Medical Practitioner(s) in charge
- Has a fully equipped operation theatre of its own where Surgical Procedures are carried out
- Maintains daily records of patients and will make these accessible to the Insurance Company’s
authorized personnel.

2.11 DAY CARE TREATMENT refers to medical treatment or Surgery which is:
- Undertaken under General or Local Anesthesia in a Hospital/ Day Care Centre in less than 24 hours
because of technological advancement, and
- Which would have otherwise required a Hospitalization of more than 24 hours.

Treatment normally taken on an out-patient basis is not included in the scope of this definition.

2.12 DEDUCTIBLE is a cost-sharing requirement under a health insurance policy that provides that the Insurer
will not be liable for a specified rupee amount in case of indemnity policies and for a specified number
of days/hours in case of hospital cash policies, which will apply before any benefits are payable by the
insurer. A deductible does not reduce the sum insured.

2.13 DENTAL TREATMENT means a treatment related to teeth or structures supporting teeth including
examinations, fillings (where appropriate), crowns, extractions and Surgery.

2.14 DISCLOSURE TO INFORMATION NORM: The policy shall be void and all premium paid thereon shall be
forfeited to the Company in the event of misrepresentation, mis-description or non-disclosure of any
material fact.

2.15 DOMICILIARY HOSPITALISATION means medical treatment for an Illness/Injury which in the normal
course would require care and treatment at a Hospital but is actually taken while confined at home
under any of the following circumstances:

- The condition of the patient is such that he/she is not in a condition to be removed to a Hospital, or

- The patient takes treatment at home on account of non-availability of room in a Hospital.

2.16 EMERGENCY CARE means management for an Illness or Injury which results in symptoms which occur
suddenly and unexpectedly, and requires immediate care by a medical practitioner to prevent death or
serious long-term impairment of the Insured Person’s health.

2.17 GRACE PERIOD means specified period of time immediately following the premium due date during
which a payment can be made to renew or continue the Policy in force without loss of continuity benefits
 such as waiting period and coverage of pre-existing diseases. Coverage is not available for the period for
which no premium is received.

2.18 HOSPITAL means any institution established for Inpatient Care and Day Care Treatment of Illness or
Injury and which has been registered as a Hospital with the local authorities under the Clinical
Establishment (Registration and Regulation) Act, 2010 or under the enactments specified under the
schedule of Section 56(1) of the said act OR complies with all minimum criteria as under:
- Has qualified nursing staff under its employment round the clock;
- Has at least 10 Inpatient beds in towns having a population of less than 10,00,000 and at least 15
inpatient beds in all other places;
- Has qualified Medical Practitioner(s) in charge round the clock;
- Has a fully equipped operation theatre of its own where surgical procedures are carried out;
- Maintains daily records of patients and makes these accessible to the insurance company’s authorized
personnel.

2.19 HOSPITALISATION means admission in a Hospital for a minimum period of 24 consecutive hours of
Inpatient Care except for the specified procedures/ treatments as mentioned in in Annexure-I, where
such admission could be for a period of less than 24 consecutive hours.

Note : Procedures / treatments usually done in outpatient department are not payable under the Policy
even if converted as an in-patient in the Hospital for more than twenty four consecutive hours.

2.20 INTENSIVE CARE UNIT (ICU) means an identified section, ward or wing of a Hospital which is under the
constant supervision of a dedicated medical practitioner(s), and which is specially equipped for the
continuous monitoring and treatment of patients who are in a critical condition, or require life support
facilities and where the level of care and supervision is considerably more sophisticated and intensive
than in the ordinary and other wards.

2.21 ICU CHARGES means the amount charged by a Hospital towards ICU expenses which shall include the
expenses for ICU bed, general medical support services provided to any ICU patient including monitoring
devices, critical care nursing and intensivist charges.

2.22 ILLNESS means a sickness or a disease or pathological condition leading to the impairment of normal
physiological function and requires medical treatment.

i. Acute Condition means a disease, illness or injury that is likely to respond quickly to treatment which
aims to return the person to his or her state of health immediately before suffering the disease/ illness/
injury which leads to full recovery.
ii. Chronic Condition means a disease, illness, or injury that has one or more of the following
characteristics
a. it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and
/ or tests
b. it needs ongoing or long-term control or relief of symptoms
c. it requires rehabilitation for the patient or for the patient to be special trained to cope with it
d. it continues indefinitely
e. it recurs or is likely to recur
2.23 INJURY means accidental physical bodily harm excluding Illness solely and directly caused by external,
violent and visible and evident means which is verified and certified by a Medical Practitioner.

2.24 INPATIENT CARE means treatment for which the Insured Person has to stay in a Hospital for more than
24 hours for a covered event.

2.25 MEDICAL ADVICE means any consultation or advice from a Medical Practitioner including the issue of
any prescription or follow up prescription.

2.26 MEDICAL EXPENSES means those expenses that an Insured Person has necessarily and actually incurred
for medical treatment on account of Illness or Accident on the advice of a Medical Practitioner, as long
as these are no more than would have been payable, if the Insured Person had not been Insured and no
more than other Hospitals or Medical Practitioner in the same locality would have charged for the same
medical treatment.

2.27 MEDICAL PRACTITIONER means a person who holds a valid registration from the Medical Council of any
state or Medical Council of India or Council for Indian Medicine or for Homeopathy set up by the
Government of India or a State Government and is thereby entitled to practice medicine within its
jurisdiction; and is acting within the scope and jurisdiction of his licence.

Note : The Medical Practitioner should not be the insured or close family members.

2.28 MEDICALY NECESSARY TREATMENT means any treatment, tests, medication or stay in Hospital or part
of a stay in Hospital which

- Is required for the medical management of the illness or Injury suffered by the insured;
- Must not exceed the level of care necessary to provide safe, adequate and appropriate medical care
in scope, duration, or intensity;
- Must have been prescribed by a Medical Practitioner;
- Must conform to the professional standards widely accepted in international medical practice or by
the medical community in India.

2.29 MIGRATION means, the right accorded to health insurance policyholders (including all members under
family cover and members of group Health insurance policy), to transfer the credit gained for pre-existing
conditions and time bound exclusions, with the same insurer.

2.30 NETWORK PROVIDER means Hospitals or health care providers enlisted by an insurer, TPA or jointly by
an Insurer and TPA to provide medical services to an insured by a cashless facility. The list is available
with the insurer/TPA and subject to amendment from time to time.

2.31 NON-NETWORK PROVIDER means any Hospital, Day Care Centre or other provider that is not part of
the network.

2.32 NEW BORN BABY means a baby born during the Period of Insurance to a female Insured Person, who
has twenty-four months of Continuous Coverage.

2.33 NOTIFICATION OF CLAIM means the process of intimating a claim to Us or TPA through any of the
recognized modes of communication.
2.34 PRE-EXISTING CONDITION/DISEASE (PED) means any condition, ailment, Injury or Illness
a. That is/are diagnosed by a physician within 48 months prior to the effective date of the Policy issued
by Us and its reinstatement or
b. For which medical advice or treatment was recommended by, or received from, a physician within 48
months prior to the effective date of the Policy or its reinstatement.

2.35 PRE-HOSPITALISATION MEDICAL EXPENSES means Medical Expenses incurred during the period of 30
days preceding the Hospitalisation of the Insured Person, provided that:
a. Such Medical Expenses are incurred for the same condition for which the Insured Person’s
Hospitalisation was required, and
b. The Inpatient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.

2.36 POST-HOSPITALISATION MEDICAL EXPENSES means Medical Expenses incurred during the period of 60
days immediately after the Insured Person is discharged from the Hospital provided that:
a. Such Medical Expenses are for the same condition for which the Insured Person’s Hospitalisation
was required, and
b. The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance
Company.

2.37 PORTABILITY means the right accorded to an individual health insurance policy holder (including family
cover), to transfer the credit gained for pre-existing conditions and time bound exclusions, from one
insurer to another or from one plan to another of the same insurer.

2.38 QUALIFIED NURSE means a person who holds a valid registration from the Nursing Council of India or
the Nursing Council of any state in India.

2.39 REASONABLE AND CUSTOMARY CHARGES mean the charges for services or supplies, which are the
standard charges for the specific provider and consistent with the prevailing charges in the geographical
area for identical or similar services, taking into account the nature of the Illness / Injury involved.

2.40 RENEWAL means the terms on which the contract of insurance can be renewed on mutual consent with
a provision of grace period for treating the renewal continuous for the purpose of gaining credit for pre-
existing diseases, time-bound exclusions and for all waiting periods.

2.41 ROOM RENT means the amount charged by a Hospital towards Room and Boarding expenses and shall
include the associated medical expenses.

2.42 SURGERY means manual and / or operative procedure (s) required for treatment of an illness or injury,
correction of deformities and defects, diagnosis and cure of diseases, relief from suffering and
prolongation of life, performed in a hospital or Day Care Centre by a Medical Practitioner.

2.43 UNPROVEN/EXPERIMENTAL TREATMENT means treatment including drug experimental therapy, which
is not based on established medical practice in India, is treatment experimental or unproven.
 SPECIFIC DEFINITIONS

2.44 AGE means age of the Insured person on last birthday as on date of commencement of the Policy.

2.45 ASSOCIATE MEDICAL EXPENSES means medical expenses such as Professional fees of Surgeon,
Anaesthetist, Consultant, Specialist; Anaesthesia, Blood, Oxygen, Operating Theatre Charges and
Procedure Charges such as Dialysis, Chemotherapy, Radiotherapy & similar medical expenses
related to the treatment.

2.46 AYUSH TREATMENT refers to hospitalisation treatments given under Ayurveda, Yoga and
Naturopathy, Unani, Siddha and Homeopathy systems.

2.47 BREAK IN POLICY means the period of gap that occurs at the end of the existing policy term, when
the premium due for renewal on a given policy is not paid on or before the premium renewal date
or within 30 days thereof

2.48 CLAIM FREE YEAR means coverage under the New India Mediclaim Policy for a period of one year
during which no claim is paid or payable under the terms and conditions of the Policy in respect of
Insured Person.

2.49 INSURED PERSON means You and each of the others who are covered under this Policy as shown in
the Schedule.

2.50 LEGAL GUARDIAN OR CUSTODIAN is a person who has taken the responsibility of taking care of or
protecting the children of deceased parents. This definition is to be used for the sole purpose of
taking a Health Insurance Policy. This person shall not be eligible for claiming tax rebate under
section 80D of the IT act.

2.51 PREFERRED PROVIDER NETWORK (PPN) means network providers in specific cities which have
agreed to a cashless packaged pricing for specified planned procedures for the policyholders of the
Company. The list of planned procedures is available with the Company/TPA and subject to
amendment from time to time. Reimbursement of expenses incurred in PPN for the procedures (as
listed under PPN package) shall be subject to the rates applicable to PPN package pricing.

2.52 POLICY means these Policy wordings, the Policy Schedule and any applicable endorsements or
extensions attaching to or forming part thereof. The Policy contains details of the extent of cover
available to the Insured person, what is excluded from the cover and the terms & conditions on
which the Policy is issued to The Insured person.
2.53 POLICY PERIOD means period of one policy year as mentioned in the schedule for which the Policy is
issued

2.54 POLICY SCHEDULE means the Policy Schedule attached to and forming part of Policy

2.55 POLICY YEAR means a period of twelve months beginning from the date of commencement of the
policy period and ending on the last day of such twelve-month period. For the purpose of
subsequent years, policy year shall mean a period of twelve months commencing from the end of
the previous policy year and lapsing on the last day of such twelve-month period, till the policy
period, as mentioned in the schedule.

2.56 RENAL FAILURE is a condition in which the kidneys lose the ability to remove waste and balance fluids

- ACUTE RENAL FAILURE (ARF) is the abrupt loss of kidney function, resulting in the retention of metabolic
waste products and dysregulation of volume and electrolytes of body fluids. The medical term Acute
Kidney Injury (AKI) has now largely replaced ARF in the medical communities (Injury not necessarily
related to Accidents), reflecting the recognition that smaller decrements in kidney function that do
not result in overt organ failure are of substantial clinical relevance and are associated with
increased morbidity and mortality.

- CHRONIC RENAL FAILURE: End stage kidney disease characterized by irreversible failure of both kidneys
to function normally, as a result of which either regular dialysis (hemodialysis or peritoneal dialysis)
is instituted or a renal transplantation becomes necessary. The diagnosis has to be confirmed by a
specialist medical practitioner.

- RENAL TRANSPLANTATION: Kidney transplantation is a surgical procedure to remove a healthy and

functioning kidney from a living or brain-dead donor and implant it into a patient with non-
functioning kidneys.

2.57 SUB-LIMIT means a cost sharing requirement under a health insurance policy in which We would not
be liable to pay any amount in excess of the pre-defined limit

2.58 SUM INSURED is the maximum amount of coverage opted for each Insured Person and as shown in
the Schedule.

Note: Sum Insured means pre-defined limit as shown in the schedule excluding Cumulative
Bonus/Buffer.

2.59 TPA (THIRD PARTY ADMINISTRATORS) means any person who is registered under the IRDAI (Third
Party Administrators – Health Services) Regulation, 2016 notified by the Authority, and is engaged,
for a fee or remuneration by Us, for the purposes of providing Health Services defined in those
Regulations.

2.60 WAITING PERIOD means a period from the inception of this Policy during which specified
diseases/treatments are not covered. On completion of the period, diseases/treatments shall be
covered provided the Policy has been continuously renewed without any break.
2.61 WARD who are under the care or protection of the Legal Guardian or Custodian. The definition of
Children shall be applicable for Ward.

2.62 WE/OUR/US/COMPANY means The New India Assurance Co. Ltd.

2.63 YOU/YOUR means the person who has taken this Policy and is shown as Insured or the first insured
(if more than one) in the Schedule.

3. BENEFITS COVERED UNDER THE POLICY

3.1 Our liability for all claims admitted during the Period of Insurance will be only up to Sum Insured for which
the Insured Person is covered as mentioned in the Schedule. In respect of those Insured Persons with
Cumulative Bonus, our liability for claims admitted under this Policy shall not exceed the aggregate of the
Sum Insured and the Cumulative Bonus. Subject to this, we will reimburse the following Reasonable and
Customary and Medically Necessary Expenses admissible as per the terms and conditions of the Policy:

Room Rent, boarding DMO/RMO/CMO/RMP Charges, Nursing expenses (including Injection /

3.1 (a) Drugs and Intravenous fluid administration expenses) as provided by the Hospital not exceeding
1 % of the Sum Insured (including Cumulative Bonus) per day
Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU), Intensivist charges, Monitor and
3.1 (b) Pulse Oxymeter expenses not exceeding 2 % of the Sum Insured (including Cumulative Bonus) per
day
Associate Medical Expenses such as Professional fees of Surgeon, Anesthetist, Consultant,
3.1 (c) Specialist; Anaesthesia, Blood, Oxygen, Operating Theatre Charges and Procedure Charges such as
Dialysis, Chemotherapy, Radiotherapy & similar medical expenses related to the treatment.
Cost of Pharmacy and Consumables, Cost of Implants and Medical Devices and
3.1 (d)
Cost of Diagnostics.
3.1 (e) Pre-Hospitalization Medical Expenses, not exceeding thirty days
3.1 (f) Post-Hospitalization Medical Expenses, not exceeding sixty days

3.2 LIMIT ON PAYMENT FOR CATARACT

Our liability for payment of any claim relating to Cataract, for each eye, shall not exceed 20% of the Sum
Insured subject to a maximum of Rs.40,000.

The limit mentioned above shall be applicable per event for all the Policies of Our Company including
Group Policies. Even if two or more Policies of New India are invoked, sublimit of the Policy chosen by
Insured shall prevail and our liability is restricted to stated sublimit.

3.3 TREATMENTS UNDER AYURVEDIC/HOMEOPATHIC/UNANI SYSTEMS

Expenses incurred for Ayurvedic/Homeopathic/Unani/Siddha treatments are admissible up to 25% of

the Sum Insured provided the treatment for illness or injury, is taken in a Government Hospital or in any
institute recognized by Government and/or accredited by Quality Council of India / National
Accreditation Board on Health, excluding centres for spas, massage and health rejuvenation procedures.
3.4 HOSPITAL CASH

HOSPITAL CASH BENEFIT IS APPLICABLE FOR TABLE 2, TABLE 3 & TABLE 5 OF GH PREMIUM CHART

This benefit is extended to an insured person under Good Health Mediclaim Policy towards
incidental expenses during hospitalization upon exercising the option for such a coverage and
appropriate premium for such cover having been received by the Company, subject to the limits
specified against the insured person’s names in the policy certificate.

If this Benefit is opted by payment of additional premium and confirmed in the Policy Certificate,
the Company will pay Cash Benefit towards incidental expenses during Hospitalization at the rate
and for the period stated below:

Option for No. of Days

Table Table 2 Table -3 Table – 5 & Plan No.31-35
No. of 15 Days 30 Days 200 Days
Days Age More than 70 Yrs
Age Upto Age Upto Upto 70 Yrs at the commencement of and upto 100 Yrs on
100 yrs 100 Yrs Insurance renewal if not opted
otherwise
1) @ Rs.1000 Per Day for Non-
Accident Hospitalization

2) However, if the insured person

@ 0.2% of @ 0.2% of
is in ICU, during such period @ 500/- Per Day for
Basic Sum Basic Sum
benefit shall be paid @ maximum of 30 days
Insured Per Insured Per
Rs.2000 Per Day maximum of during the Period of
Cash Day for Plan Day for plan
15 days during the policy year.
Benefit 15-22, 23-30, Insurance
Payable Rs.1250/- for Rs.1250/- for irrespective of nature
3) @ 2000 Per Day maximum of
plan 93 and plan 95 and of Hospitalizations
15 days during the policy year
Rs.1500/- for Rs.1500/- for
for Hospitalisation due to
plan 94 plan 96.
Accident.

4) Convalescene Benefit –
Rs.15000 if confinement in
hospital exceeds 21
consecutive days, payable
once during the policy year

The Benefit shall be payable

a) In addition to the Hospitalization Expenses covered by the Policy

b) Only in the event of claim for Hospitalization being admissible

c) In all, only for maximum number of days opted, in respect of any number of
Hospitalizations/ claims that may occur during the Period of Insurance.

d) Under 200 days for age upto 70 yrs the benefits 2 & 3 starts on completion of first
 24 hrs and only one benefit either 1,2 or 3 shall be payable at a time and not
collectively.

e) Hospital Cash will be payable for completion of every twenty four hours and not part
thereof.

f) Hospital Cash Benefit is not applicable for Day Care Procedures.

3.5 PAYMENT OF AMBULANCE CHARGES

We will pay You the charges for Emergency Ambulance services up to 1% of the Sum Insured subject to
a maximum of Rs.5,000, Reasonably and Medically Necessarily incurred for shifting any Insured Person
to Hospital for admission in Emergency Ward or ICU, or from one Hospital to another Hospital for better
medical facilities.

3.6 PAYMENTS ONLY IF INCLUDED IN HOSPITAL BILL

No payment shall be made for any Hospitalisation expenses incurred, unless they form part of the
Hospital Bill. However, the bills raised by Surgeon, Anaesthetist directly and not included in the Hospital
Bill shall be paid provided a numbered Bill is produced in support thereof, for an amount not exceeding
Rs. Ten thousand, where such payment is made in cash and for an amount not exceeding Rs. Twenty
thousand, where such payment is made by cheque.

3.7 MEDICAL EXPENSES FOR ORGAN TRANSPLANT :

If treatment involves Organ Transplant to Insured Person, then we will also pay Hospitalisation Expenses
(excluding cost of organ) incurred on the donor, provided our liability towards expenses incurred on the
donor and the insured recipient shall not exceed the aggregate of the Sum Insured and Cumulative
Bonus, if any, of the Insured Person receiving the organ.

3.8 MEDICAL EXPENSES INCURRED UNDER TWO POLICY PERIODS :

If the claim event falls within two policy periods, the claims shall be paid taking into consideration the
available Sum Insured of the expiring Policy only. Sum Insured of the Renewed Policy will not be
available for the Hospitalisation (including Pre & Post Hospitalisation Expenses), which has commenced
in the expiring Policy. Claim shall be settled on per event basis.

3.9 CUMULATIVE BONUS

Cumulative Bonus will be available under this policy subject to the following conditions:
3.9.1 Sum Insured under the Policy shall be progressively increased by 5%, by way of cumulative
bonus, in respect of each claim free year of insurance, subject to a maximum accumulation of
50%.
3.9.2 In case of any claim under this policy in respect of the insured person who has earned the
cumulative bonus, the increased percentage will be reduced by 5% at the next renewal. However
basic sum insured will be maintained and will not be reduced.
3.9.3 Cumulative bonus will be lost if policy is not renewed on the date of expiry.
3.9.4 The cumulative Bonus shown in the Policy is Provisional. It is subject to revision in the event of
any claim under the earlier Policy being made after issuance of this policy.
3.9.5 Cumulative Bonus will start from zero for increased Sum Insured.
3.9.6 In case Sum Insured under the policy is reduced at the time of renewal, the applicable Cumulative
Bonus percentage shall be applied on the reduced Sum Insured

3.10 SPECIFIC COVERAGES:

a) Impairment of Persons’ intellectual faculties by usage of drugs, stimulants or

depressants as prescribed by a medical practitioner is covered up to 5% of Sum
Insured, maximum up to Rs. 25,000 per policy period subject to it arising during
treatment of covered illness.
b) Artificial life maintenance, including life support machine use, where such treatment
will not result in recovery or restoration of the previous state of Health under any
circumstances unless in a vegetative state as certified by the treating medical
practitioner, is covered up to 10% of Sum Insured and for a maximum of 15 days per
policy period with a per day limit of 10% of Sum Insured following admission for a
covered illness. (Explanation: Expenses up to the date of confirmation by the treating
doctor that the patient is in vegetative state shall be covered as per the terms and
conditions of the policy contract).
c) 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 is covered only as Inpatient
procedure after 24 months of continuous coverage. This cover will have a sub-limit
of up to 25% of Sum Insured per policy period.
d) Age Related Macular Degeneration (ARMD) is covered after 48 months of
continuous coverage only for Intravitreal Injections and anti – VEGF medication. This
cover will have a sub-limit of 10% of Sum Insured, maximum upto Rs. 75,000 per
policy period.
e) Behavioural and Neuro developmental Disorders: Disorders of adult personality and
Disorders of speech and language including stammering, dyslexia; are covered as
Inpatient procedure after 24 months of continuous coverage. This cover will have a
sub-limit of 25% of Sum Insured per policy period.
f) Genetic diseases or disorders are covered with a sub-limit of 25% of Sum Insured per
policy period with 48 months waiting periods.
Note: For the coverages defined in 3.10 (a) to (f), waiting period's, if any, shall be
applicable afresh i.e. for both New and Existing Policyholders w.e.f 1st October 2020 or
date of inception of first policy, whichever is later. Coverage for such illness or
procedures shall only be available after completion of the said waiting periods.

g) Treatment of mental illness, stress or psychological disorders and

neurodegenerative disorders The Company shall indemnify the Hospital or the
Insured the Medical Expenses (including Pre and Post Hospitalisation Expenses
related to following and they are covered after a waiting period of 48 months with a
sub-limit up to 25% of Sum Insured per policy period.
 The below covers are subject to the patient exhibiting any of the following traits and
requiring Hospitalisation as per the treating Psychiatrist’s advice
1. Major Depressive Disorder- when the patient is aggressive or violent.
2. Acute psychotic conditions- aggressive/violent behavior or hallucinations, incoherent
talking or agitation.
3. Schizophrenia- esp. Psychotic episodes.
4. Bipolar disorder- manic phase.

Treatment of any Injury due to Suicidality shall not be covered.

Condition
Treatment shall be undertaken at a Hospital categorized as Mental Health Establishment or at a
Hospital with a specific department for Mental Illness, under a Medical Practitioner qualified as
Mental Health Professional.

Exclusions
Any kind of Psychological counseling, cognitive/ family/ group/ behavior/ palliative therapy or
other kinds of psychotherapy for which Hospitalization is not necessary shall not be covered.

Note: For the coverages defined in 3.10 (g), waiting period, if any, shall be applicable
afresh i.e. for both New and Existing Policyholders w.e.f 16th August 2018 or date of
inception of first policy, whichever is later. This Coverage shall only be available after
completion of the said waiting period.

3.11 COVERAGE FOR MODERN TREATMENTS or PROCEDURES: The following procedures will be
covered (wherever medically indicated) either as in patient or as part of day care treatment in a
hospital up to the limit specified against each procedure during the policy period.

S No Treatment or Procedure Limit (Per Policy Period)

Uterine Artery Embolization and HIFU (High intensity focused Upto 20% of Sum Insured subject to
3.11.1
ultrasound) a Maximum upto Rs. 2 Lakh
Upto 20% of Sum Insured subject to
3.11.2 Balloon Sinuplasty.
a Maximum upto Rs. 2 Lakh
Upto 50% of Sum Insured subject to
3.11.3 Deep Brain stimulation.
a maximum upto Rs. 5 Lakh
Upto 10% of Sum Insured subject to
3.11.4 Oral chemotherapy.
Maximum upto Rs.1 Lakh.
Immunotherapy- Monoclonal Antibody to be given as Upto 25% of Sum Insured subject to
3.11.5
injection. a Maximum of Rs 2 Lakh.
Upto 10% of Sum Insured subject to
3.11.6 Intravitreal injections.
a Maximum of Rs.75,000.
Upto 50% of Sum Insured subject to
3.11.7 Robotic surgeries.
Maximum of Rs. 5 Lakh.
Upto 50% of Sum Insured subject to
3.11.8 Stereotactic radio surgeries.
Maximum Rs. 3 Lakh.
Upto 50% of Sum Insured subject to
3.11.9 Bronchial Thermoplasty.
Maximum of Rs. 2.5 Lakh.
 Vaporisation of the prostrate (Green laser treatment or Upto 50% of Sum Insured subject to
3.11.10
holmium laser treatment). Maximum of Rs. 2.5 Lakh.
Upto 10% of Sum Insured subject to
3.11.11 IONM - (Intra Operative Neuro Monitoring).
Maximum of Rs. 50,000.
Stem cell therapy: Hematopoietic stem cells for bone marrow Upto 50% of Sum Insured subject to
3.11.12
transplant for haematological conditions to be covered. Maximum of Rs. 2.5 Lakh.

3.12 TREATMENT FOR CONGENITAL DISEASES

Congenital Internal Disease or Defects or anomalies shall be covered after twenty-four months
of Continuous Coverage.

Congenital External Disease or Defects or anomalies shall be covered after thirty-six months of
Continuous Coverage, but such cover for Congenital External Disease or Defects or anomalies
shall be limited to 10% of the average Sum Insured in the preceding four years.

3.13 AGE LIMIT

 This insurance is available to persons between ages of 18 yrs and 65 yrs.

 Children between 3 months and 18 years of age can be covered provided one or both the
Parents are covered simultaneously.
 Persons between the age of 61 to 65 are enrolled only on submission of Medical Reports along
with MEDICAL PRACTITIONERS certificate. In case of acceptance of proposal 50% of reasonable
cost towards the diagnostic tests and doctors’ fees will be reimbursed by the Company (Subject
to maximum of Rs 500 per Insured Person).
 Persons above the age of 65 years can be considered for renewal only (no change in plan is
allowed.
 The right to right to accept or reject coverage for any person proposed for this Mediclaim
insurance on a fresh basis, shall rest solely with the Company.

3.13.1 If the policy is to be renewed for enhanced sum insured, as a continuation of the earlier policy,
the increased benefits are not applicable for those illnesses / diseases / disabilities contracted
/ suffered during the previous policy periods and in such cases, the claim if any arises for
the said illness / disease / disability, if admitted, shall be processed taking into account the
sum insured prior to enhancement However the increased Sum insured shall become eligible
after 48 months of continuous coverage.
4. EXCLUSIONS

No claim will be payable under this policy for the following :

STANDARD EXCLUSIONS

4.1 PRE-EXISTING DISEASES (Code- Excl01)

a. Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications
shall be excluded until the expiry of 48 months of continuous coverage after the date of
inception of the first policy with us.
b. In case of enhancement of Sum Insured the exclusion shall apply afresh to the extent of Sum
Insured increase.
c. If the Insured Person is continuously covered without any break as defined under the
portability norms of the extant IRDAI (Health Insurance) Regulations then waiting period for
the same would be reduced to the extent of prior coverage.
d. Coverage under the policy after the expiry of 48 months for any pre-existing disease is subject
to the same being declared at the time of application and accepted by us.

4.2 SPECIFIC WAITING PERIOD (Code- Excl02)

a. Expenses related to the treatment of the following listed conditions, surgeries / treatments
shall be excluded until the expiry of 24 / 36 / 48 months of continuous coverage, as may be
the case after the date of inception of the first policy with the insurer. This exclusion shall
not be applicable for claims arising due to an accident.
b. In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum
insured increase.
c. If any of the specified disease/procedure falls under the waiting period specified for pre-
existing diseases, then the longer of the two waiting periods shall apply.
d. The waiting period for listed conditions shall apply even if contracted after the policy or
declared and accepted without a specific exclusion.
e. If the Insured Person is continuously covered without any break as defined under the
applicable norms on portability stipulated by IRDAI, then waiting period for the same would
be reduced to the extent of prior coverage.

(i) 24 Months waiting period

1. Benign prostate hypertrophy
2. Hernia of all types
3. Hydrocele
4. Piles, Fistula in anus
5. Sinusitis and related disorders
6. Hysterectomy due to Fibroids or Menorrhagia
7. Puberty and Menopause related Disorders
8. Behavioural and Neuro-Developmental Disorders:
a. Disorders of adult personality
b. Disorders of speech and language including stammering, dyslexia
9. Internal Congenital Diseases

(ii) 36 months waiting period

1. Total Knee/Hip replacement (due to arthritis, rheumatism and other degenerative
 disorders)
2. Cataract
3. External Congenital Diseases

(iii) 48 Months waiting period

1. Treatment of mental illness, stress or psychological disorders and neurodegenerative

disorders.
2. Age Related Macular Degeneration (ARMD)
3. Genetic diseases or disorders

4.3 FIRST THIRTY DAYS WAITING PERIOD (Code- Excl03)

a. Expenses related to the treatment of any illness within 30 days from the first policy
commencement date shall be excluded except claims arising due to an accident, provided
the same are covered.
b. This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for
more than twelve months.
c. The within referred waiting period is made applicable to the enhanced sum insured in the
event of granting higher sum insured subsequently.

4.4 EXCLUSIONS
The Company shall not be liable to make any payment under the policy, in respect of any expenses
incurred in connection with or in respect of:

4.4.1 INVESTIGATION & EVALUATION (Code- Excl04)

a. Expenses related to any admission primarily for diagnostics and evaluation purposes.
b. Any diagnostic expenses which are not related or not incidental to the current diagnosis and
treatment.

However, Treatment for any symptoms, Illness, complications arising due to physiological
conditions for which aetiology is unknown is not excluded. It is covered with a Sub-Limit of upto
10% of Sum Insured per policy period.

4.4.2 REST CURE, REHABILITATION AND RESPITE CARE (Code- Excl05) Expenses related to any admission
primarily for enforced bed rest and not for receiving treatment. This also includes:
a. Custodial care either at home or in a nursing facility for personal care such as help with
activities of daily living such as bathing, dressing, moving around either by skilled nurses or
assistant or non-skilled persons.
b. Any services for people who are terminally ill to address physical, social, emotional and
spiritual needs.

However, Expenses related to any admission primarily for enteral feedings is not excluded, if the
Oral intake is absent for a period of at-least 5 days. It will be covered for a Maximum period of 14
days in a Policy Period.

4.4.3 OBESITY/ WEIGHT CONTROL (Code- Excl06) Expenses related to the surgical treatment of obesity
that does not fulfil all the below conditions:
a. Surgery to be conducted is upon the advice of the Doctor
 b. The surgery/Procedure conducted should be supported by clinical protocols
c. The member has to be 18 years of age or older and
d. Body Mass Index (BMI);
1. greater than or equal to 40 or
2. greater than or equal to 35 in conjunction with any of the following severe co-
morbidities following failure of less invasive methods of weight loss:
i. Obesity-related cardiomyopathy
ii. Coronary heart disease
iii. Severe Sleep Apnea
iv. Uncontrolled Type2 Diabetes

4.4.4 CHANGE-OF-GENDER TREATMENTS (Code- Excl07)

Expenses related to any treatment, including surgical management, to change characteristics of
the body to those of the opposite sex.

4.4.5 COSMETIC OR PLASTIC SURGERY (Code- Excl08)

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

4.4.6 HAZARDOUS OR ADVENTURE SPORTS (Code- Excl09)

Expenses related to any treatment necessitated due to participation as a professional in hazardous
or adventure sports, including but not limited to, para-jumping, rock climbing, mountaineering,
rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.

However, Treatment related to Injury or Illness associated with Hazardous activities related to
particular line of employment or occupation (not for recreational purpose) is not excluded.

4.4.7 BREACH OF LAW (Code- Excl10)

Expenses for treatment directly arising from or consequent upon any Insured Person committing
or attempting to commit a breach of law with criminal intent.

4.4.8 EXCLUDED PROVIDERS (Code-Excl11)

Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other
provider specifically excluded by the Insurer and disclosed in its website / notified to the
policyholders are not admissible. However, in case of life-threatening situations or following an
accident, expenses up to the stage of stabilization are payable but not the complete claim.

4.4.9 Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences
thereof. (Code- Excl12)

4.4.10 Treatments received in health hydros, nature cure clinics, spas or similar establishments or
private beds registered as a nursing home attached to such establishments or where admission
is arranged wholly or partly for domestic reasons. (Code- Excl13)

4.4.11 Dietary supplements and substances that can be purchased without prescription, including but
 not limited to Vitamins, minerals and organic substances unless prescribed by a medical
practitioner as part of hospitalization claim or day care procedure. (Code- Excl14)

4.4.12 REFRACTIVE ERROR (Code- Excl15)

Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5
dioptres.

4.4.13 UNPROVEN TREATMENTS (Code- Excl16)

Expenses related to any unproven treatment, services and supplies for or in connection with any
treatment. Unproven treatments are treatments, procedures or supplies that lack significant
medical documentation to support their effectiveness.

4.4.14 STERILITY AND INFERTILITY (Code- Excl17)

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

4.4.15 MATERNITY EXPENSES (Code - Excl18)

a. Medical treatment expenses traceable to childbirth (including complicated deliveries and
caesarean sections incurred during hospitalization) except ectopic pregnancy;
b. Expenses towards miscarriage (unless due to an accident) and lawful medical termination of
pregnancy during the policy period.

SPECIFIC EXCLUSIONS

4.4.16 Acupressure, acupuncture, magnetic therapies.

4.4.17 Any expenses incurred on Domiciliary Hospitalisation.

4.4.18 Any kind of Service charges, Surcharges, Luxury Tax and similar charges levied by the Hospital.

4.4.19 Bodily Injury or Illness due to willful or deliberate exposure to danger (except in an attempt to
save human life), intentional self-inflicted Injury, attempted suicide.

However, Failure to seek or follow medical advice or failure to follow treatment is not excluded.
It is covered with a sub-limit of 10% of Sum Insured per policy period.

4.4.20 Circumcision unless Medically necessary for treatment of an Illness not excluded here under or
as may be necessitated due to an accident.

4.4.21 All Health Check-up, Convalescence, General debility and Venereal disease.

4.4.22 Cost of braces, equipment or external prosthetic devices, non-durable implants, eyeglasses, Cost
of spectacles and contact lenses, hearing aids including cochlear implants, durable medical
equipment.
4.4.23 Dental treatment or Surgery of any kind unless necessitated by accident and requiring
Hospitalisation.

4.4.24 External and or durable Medical / Non-medical equipment of any kind used for diagnosis and or
treatment including CPAP (Continuous Positive Airway Pressure), CPAD (Continuous Peritoneal
Ambulatory Dialysis), Oxygen Concentrator for Bronchial Asthmatic condition, Infusion pump
etc. Ambulatory devices i.e., walker, crutches, Belts, Collars, Caps, Splints, Slings, Stockings, Elasto
crepe bandages, external orthopaedic pads, sub cutaneous insulin pump, Diabetic foot wear,
Glucometer / Thermometer, alpha / water bed and similar related items etc., and also any
medical equipment, which is subsequently used at home and outlives the use and life of the
Insured Person.

4.4.25 Naturopathy Treatment.

4.4.26 Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from or
from any other cause or event contributing concurrently or in any other sequence to the loss,
claim or expense. For the purpose of this exclusion:
a. Nuclear attack or weapons means the use of any nuclear weapon or device or waste or
combustion of nuclear fuel or the emission, discharge, dispersal, release or escape of fissile/
fusion material emitting a level of radioactivity capable of causing any Illness, incapacitating
disablement or death.
b. Chemical attack or weapons means the emission, discharge, dispersal, release or escape of
any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable
of causing any Illness, incapacitating disablement or death.
c. Biological attack or weapons means the emission, discharge, dispersal, release or escape of
any pathogenic (disease producing) micro-organisms and/or biologically produced toxins
(including genetically modified organisms and chemically synthesized toxins) which are
capable of causing any Illness, incapacitating disablement or death.

4.4.27 Stem cell implantation/Surgery for other than those treatments mentioned in clause 3.11.12

4.4.28 Treatment for Sleep Apnoea Syndrome, treatments such as Rotational Field Quantum Magnetic
Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation
(EECP), Hyperbaric Oxygen Therapy and CPAD (Continuous Peritoneal Ambulatory Dialysis).

4.4.29 Treatment taken outside the geographical limits of India

4.4.30 Vaccination and/or inoculation

4.4.31 War (whether declared or not) and war like occurrence or invasion, acts of foreign enemies,
hostilities, civil war, rebellion, revolutions, insurrections, mutiny, military or usurped power,
seizure, capture, arrest, restraints and detainment of all kinds.
 GOOD HEALTH GROUP PERSONAL ACCIDENT POLICY

IRDA/NL-HLT/NIA/P-H/V.I/353/13-14

1. SCOPE OF COVER:

If an ACCIDENTAL bodily INJURY caused by a sudden, unforeseen and involuntary event caused by
external, violent, and visible means shall within twelve (12) calendar months of its occurrence be
the sole and direct cause of:

a) Death, the Capital Sum Insured (C.S.I.) becomes payable, also any expenses incurred for
transportation of the fatal accident victim to the place of residence; a lump sum of 2% of C.S.I. or
Rs. 2500/- whichever is less is payable.

b) (i) Loss of sight of both eyes or of the actual loss by physical separation of two entire hands or
two entire feet or of one entire hand and one entire foot, the C.S.I. stated in the Schedule hereto
applicable to such insured person becomes payable.

(ii) Loss of two hands or two feet or one hand and one foot or loss of sight of one eye and one
hand or one foot, C.S.I. stated in the Schedule hereto applicable to such insured person
becomes payable.

c) (i) Loss of sight of one eye or one entire hand or one entire foot, fifty percent (50%) of the C.S.I.
becomes payable.

(ii) Loss of use of a hand or a foot without physical separation, fifty percent (50%) of the C.S.I.
becomes payable.

d) Permanent Total Disablement (PTD) from Injuries other than named above, varying percentage
becomes payable, as may be assessed by the Company's panel Medical Practitioner.
e) Permanent Partial Disablement (PPD) involving Total and/or partial irrecoverable loss of use or
of the actual loss by physical separation of parts of limbs then the applicable percentage of C.S.I.
is payable as enumerated below:

Table giving % of CSI payable for Permanent Partial Disablement (PPD) claims:
Loss of toes - all 20% of CSI
Great both phalanges 5% of CSI
I.
Great one phalanx 2% of CSI
Other than great if more than one toe lost (each) 1% of CSI
II. Loss of hearing – both ears 75% of CSI
III. Loss of hearing – one ear 30% of CSI
IV Loss of four fingers and thumb of one hand 40% of CSI
V. Loss of four fingers 35% of CSI
Loss of thumb – both phalanges 25% of CSI
VI.
One phalanx 10% of CSI
VII Loss of index 3 phalanges or 2 phalanges or 1 phalanx 10% of CSI
VIII Loss of middle finger 3 phalanges or 2 phalanges or 1 phalanx 6% of CSI
 IX Loss of ring finger 3 phalanges or 2 phalanges or 1 phalanx 5% of CSI
X Loss of little finger 3 phalanges or 2 phalanges or 1 phalanx 4% of CSI
st nd th th
XI Loss of metacarpal 1 or 2 (additional) or 3rd, 4 or 5 (additional) 3% of CSI
Any other Permanent Partial Disablement as assessed by the Company’s
XII
MEDICAL PRACTITIONER.

This policy also covers medical expenses arising out of accidents resulting in death/permanent
disablement subject to a maximum of 10% of the C.S.I.

2. DEFINITIONS

1. ACCIDENT: An accident is a sudden, unforeseen and involuntary event caused by external, visible
and violent means.

2. INJURY: Injury means accidental physical bodily harm excluding illness or disease solely and directly
caused by external, violent and visible and evident means which is verified and certified by a
MEDICAL PRACTITIONER.

3. MEDICAL PRACTITIONER: A Medical practitioner is a person who holds a valid registration from the
Medical Council of any State or Medical Council of India or Council for Indian Medicine for
Homeopathy set up by the Government of India or a State Government and is thereby entitled to
practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of his license.

4. MEDICAL EXPENSES : Medical Expenses means those expenses that an Insured Person has
necessarily and actually incurred for medical treatment on account of Accident on the advice of a
Medical Practitioner, as long as these are no more than would have been payable if the insured
person had not been insured and no more than other hospitals or doctors in the same locality would
have charged for the same medical treatment.

3. DETAILS OF EXCLUSION

A. The Company shall not be liable for payment of claims arising out of

i. Compensation under more than one of the sub-clauses in scope of cover (1) in respect of the
same period of disablement.

ii. Any other payment after a claim under sub-clauses (a) or (b) or (d) in scope of cover (1) has
been admitted and has become payable.

iii. Any payment during the policy exceeding the C.S.I. plus applicable medical expenses, which is
the Company's maximum liability.

iv. a) Self-injury, suicide or attempted suicide.

b) Whilst under the influence of alcoholic drinks or drugs,
c) Whilst engaging in Aviation or whilst mounting into, dismounting from, or travelling in any
aircraft other than as a passenger (fare paying or otherwise) in a duly licensed standard type
of aircraft as defined in the Master policy issued to Citibank.
d) Venereal disease, insanity, or AIDS
 e) Whilst committing any breach of law with criminal intent.

v. War and allied perils vi. Radiations, Radio activity or any nuclear accidents vii. Pregnancy,
childbirth or in consequence thereof.

B. The Company shall not be liable for payment of claims arising out of participation of the Insured
person in winter sports, mountaineering, skiing, Ice-hockey, ballooning, polo, riding or driving in
races or on horseback or rallies, caving or rot holing, hunting or equestrian, scuba diving or other
under water activity·, rafting, yachting or other similar hazardous activities Further no claim will be
paid in case insured person, trained or otherwise, participates in professional sports or any other
hazardous sports, working in underground mines, explosives, magazines(firearms), electrical
installations with high tension supply, jockeys, circus personnel, big game hunting and occupation of
similar hazards.

“This Policy covers insured person from the age of 5 years to 70 years “

The continuous benefits will not be lost if the Policy is renewed within 30 days grace period after its
expiry. Coverage is not available for the period for which no premium is received

4. CLAIMS PROCEDURE

Preliminary notice of claim should be sent to the Company within 30 days in case of death /
disablement of insured person upon which a claim form will be sent to the claimant's address.
A. In the event of a death claim, the claim form should be returned duly completed by the legal heir
of the insured along with the following:

(i) Postmortem report / Coroner's inquest report

(ii) Police report
(iii) Death Certificate
(iv) Attending MEDICAL PRACTITIONER’S report
(v) Succession Certificate /Legal heir certificate/copy of nomination
(vi) Receipt for carriage owners for carrying the fatal accident victim to the place of residence
(vii) ECS Form of Nominee.

B. In the event of a disablement claim, the claim form should be duly completed by the insured
along with the following:

(i) Attending Medical Practitioner's report and Certificate from the MEDICAL
PRACTITIONER’S giving details of loss and / or percentage of disablement,
(ii) Diagnostic report, X-rays, MEDICAL PRACTITIONER’S prescriptions and bills,
(iii) Police Investigation report
(iv) ECS Form

All payment shall be made in Indian Rupees in India though the cover is valid all over the world.

Good Health Group Personal Accident Policy (One Year) Claim intimation letter and Claim Form can be
downloaded from our website www.newindia.co.in/citibank)

DECLARATION FOR NOMINATION (In respect of each insured person under Good Health Group
Personal Accident Policy (One Year) only).
Nomination is compulsory under Good Health Group Personal Accident Policy (One Year). Each insured
person has to nominate a person who would become eligible to receive the claim amount in the event
of insured person’s death. Nomination form is available at the end of the policy clause. It can also be
downloaded from our website, www.newindia.co.in/citibank. The insured may send the declaration for
nomination to the Insurance Company in the Prescribed Format, in duplicate, (along with a self-
addressed unstamped envelope). The duplicate copy will be returned to insured person duly
acknowledged.

In the event of the death of the Insured Person due to accident, the nominee(s) should submit the
acknowledged copy for settlement of the claim. Otherwise a Succession Certificate / Legal Heir ship
certificate will have to be produced.

5. GENERAL TERMS AND CLAUSES

STANDARD GENERAL TERMS AND CLAUSES

5.1 FRAUD, MISREPRESENTATION, CONCEALMENT:

The policy shall be null and void and no benefits shall be payable in the event of misrepresentation,
misdescription or nondisclosure of any material fact/particular if such claim be in any manner
fraudulent or supported by any fraudulent means or device whether by the Insured Person or by any
other person acting on his/her behalf.

5.2 MULTIPLE POLICIES:

If two or more policies are taken by You during a period from Us or other Insurers to indemnify
treatment costs, You shall have the right to require a settlement of Your claim in terms of any of Your
policies.

1. In all such cases Insurer who has issued the chosen Policy shall be obliged to settle the claim
as long as the claim is within the limits of and according to the terms of chosen policy.
2. Policyholder having multiple policies shall also have the right to prefer claims from other
Policy/policies for the amounts disallowed under the earlier chosen Policy/Policies, even if
the Sum Insured is not exhausted. The Claim shall be settled subject to the terms and
conditions of the other Policy/Policies so chosen.
3. If the amount to be claimed exceeds the Sum Insured under a single policy after considering
the deductibles or co-pay, You shall have the right to choose Insurers from whom You want
to claim the balance amount.
4. You shall only be indemnified the Hospitalisation costs in accordance with the terms and
conditions of the chosen Policy.
Note: The Insured Person must disclose such other Insurance at the time of making a claim under this
Policy.
None of the provisions of this Clause shall apply for payments under Clause 3.4 of the Policy.

5.3 RENEWAL CLAUSE:

 Renewal of this policy is Automatic, only if the premium due is paid by Citibank to the Company
before the due date on behalf of the Card Member or the Account holder as applicable.

If the Proposer opts for non-renewal of this policy or for changes in renewal policy, he/she shall
inform Citibank indicating his/her preference 20 days prior to the date of commencement of the
policy. Once the policy is renewed, no request for alteration of policy choice will be entertained.

The Company shall not be responsible or liable for non-renewal of the policy for any reason
whatsoever arising out of any decision of Citibank in this regard.

The Company may at its discretion revise the premium rates and/or the Terms & Conditions of the
Policy every year upon renewal thereof.

We shall be entitled to decline renewal if:

1. Any fraud, misrepresentation or suppression by You or any one acting on Your behalf is found
either in obtaining insurance or subsequently in relation thereto, or non-cooperation of the
Insured Person; or
2. We have discontinued issue of the Policy, in which event you shall however have the option for
renewal under any similar Policy being issued by us, provided however, benefits payable shall
be subject to the terms contained in such other Policy; or
3. You fail to remit Premium for renewal before expiry of the Period of Insurance. We will accept
renewal of the Policy if it is effected within thirty days of the expiry of the Period of Insurance.
On such acceptance of renewal, We, however shall not be liable for any claim arising out of
Illness contracted or Injury sustained or Hospitalization commencing in the interim period after
expiry of the earlier Policy and prior to date of commencement of subsequent Policy.

Note: In case of revision including the premium, modification, or withdrawal of the Policy a notice,
by suitable mode of communication, will be provided to You 90 days before such revision,
modification or withdrawal. You will have the option to migrate to similar Health Insurance
Policy with Us at the time of renewal with all the accrued continuity benefits such as waiver
of waiting period etc. Provided the policy has been maintained without a break as per
portability guidelines prescribed by IRDAI.

There will be no loading on renewals on Individual claims experience basis

5.4 CANCELLATION CLAUSE:

The policy shall be null and void, and no benefits shall be payable in case of Fraud,
misrepresentation, misdescription or nondisclosure of any material fact / particular. Premium paid
shall also stand forfeited.
We may at any time cancel the Policy on non-cooperation by You by sending fifteen days’ notice in
writing by Registered A/D to You at the address stated in the Policy. Even if there are several insured
persons, notice will be sent to You. We shall allow refund of premium, if no claim has been made
or paid under the Policy, at short period rate which is tabulated below.
PERIOD ON RISK RATE OF PREMIUM TO BE CHARGED (RETAINED)
Up to one month 1/4th of the annual rate
Up to three months 1/2 of the annual rate
 Up to six months 3/4th of the annual rate
Exceeding six months Full annual rate

You may also at any time cancel this Policy. We shall allow refund of premium, if no claim has been
made or paid under the Policy, at short period rate which is tabulated below, provided no claim
has occurred up to the date of cancellation.

PERIOD ON RISK RATE OF PREMIUM TO BE CHARGED (RETAINED)

0% of the Annual Rate subject to a deduction of Rs.100/- as
Up to 45 days
charges
Up to three months 1/2 of the annual rate
Up to six months 3/4th of the annual rate
Exceeding six months Full annual rate

Policy once cancelled shall not be reinstated under any circumstances and no claim shall be
admissible under the policy, if option for cancellation is notified to CITIBANK either in writing or
over phone. Citibank’s confirmation of receipt of request for such cancellation will be binding upon
the insured.

The company does not undertake any responsibility to the insured and / or insured persons if
Citibank arranges to have the insurance cover(s) withdrawn in case of delayed payment or non –
payment of the dues in respect of this policy by the insured to Citibank.

5.5 FREE LOOK PERIOD:

The insured will be allowed a period of at least 45 days from the date of commencement of the
policy to review the terms and conditions of the policy and to return the same if not acceptable at
inception of policy and at each renewal if the same was done on an auto renewal basis without the
consent of Insured.

In case insured opts to use the free look option then full premium charged will be refunded
after deduction of Rs 100 as charges.

5.6 SETTLEMENT/REJECTION OF CLAIM:

i. We shall settle or reject a claim, as may be the case, within thirty days of the receipt of the last
‘necessary’ document.
ii. While efforts will be made by Us to not call for any document not listed in Clause 5.5, where
any additional document or clarification is necessary to take a decision on the claim, such
additional documents will be called for.
iii. All necessary claim documents pertaining to Hospitalisation should be furnished by the Insured
Person in original to the TPA (as mentioned in the Schedule), within thirty days from the date
of discharge from the Hospital. However, claims filed even beyond such period will be
considered if there are valid reasons for delay in submission.
a. In case of any deficiency in submission of documents, the TPA shall issue a deficiency
request.
b. In case of non-submission of documents requested in the deficiency request within seven
days from the date of receipt of the deficiency request, three reminders shall be sent by
the TPA at an interval of seven days each.
 c. The claim shall stand repudiated if the documents, mandatory for taking the decision of
admissibility of the Claim, are not submitted within seven days of the third reminder.
If the required documents are such that it does not affect the admissibility of the claim
and is limited to payment of certain expenditure only, the Claim will be paid after
reducing such amount from the admissible amount.

iv. In the case of delay in the payment of a claim, we shall be liable to pay interest from the date of
receipt of last necessary document to the date of payment of claim at a rate 2% above the bank
rate.

v. However, where the circumstances of a claim warrant an investigation in the opinion of the insurer,
we shall initiate and complete such investigation at the earliest, in any case not later than 30 days
from the date of receipt of last necessary document. In such cases, we shall settle the claim within
45 days from the date of receipt of last necessary document.

vi. In case of delay beyond stipulated 45 days, we shall be liable to pay interest at a rate 2% above the
bank rate from the date of receipt of last necessary document to the date of payment of claim.

vii. Repudiation of Claim : A claim, which is not covered under the Policy conditions, can be rejected.
All the documents submitted to TPA shall be electronically collected by us for settlement and
denial of the claims by the appropriate authority. Communication of repudiation shall be sent to
you by us, explicitly mentioning the grounds for repudiation.

5.7 PORTABILITY AND MIGRATION:

Migration:
You will have the option to migrate the policy to other Health Insurance products/plans
offered by the company by applying for migration of the policy at-least 30 days before the
policy renewal date as per IRDAI guidelines on Migration. If You are presently covered and
has been continuously covered without any lapses under any Health Insurance
product/plan offered by the Company, then You will get the accrued continuity benefits in
waiting periods as per IRDAI guidelines on Migration. For detailed guidelines on Migration.
Kindly refer the link
https://www.irdai.gov.in/ADMINCMS/cms/frmGeneral_NoYearList.aspx?DF=RL&mid=4.2

Portability:

You will have the option to port the policy to other Insurers by applying to such Insurer to
port the entire policy along with all the members of the family, if any, at-least 45 days
before, but not earlier than 60 days from the policy renewal date as per IRDAI guidelines
related to portability. If such person is presently covered and has been continuously
covered without any lapses under any Health Insurance policy with an India
General/Health Insurer, the proposed Insured person will get the accrued continuity
benefits in waiting periods as per IRDAI guidelines on portability. For detailed guidelines
on Portability. Kindly refer the link
https://www.irdai.gov.in/ADMINCMS/cms/frmGeneral_NoYearList.aspx?DF=RL&mid=4.2
5.8 GRIEVANCE REDRESSAL:

In the event of your having any grievance relating to the insurance or any claim thereunder, , you
may contact any of the Customer Care Cells at Regional Offices of the Company or Office of the
Insurance Ombudsman under the jurisdiction of which the Policy Issuing Office falls. The contact
details of the office of the Insurance Ombudsman is provided in the Annexure III.

Senior Citizens may write to seniorcitizencare.ho@newindia.co.in

5.9 MORATORIUM PERIOD: After completion of eight continuous years under this policy no look back
would be applied. This period of eight years is called as moratorium period. The moratorium would
be applicable for the Sums Insured of the first policy and subsequently completion of eight
continuous years would be applicable from date of enhancement of Sums Insured only on the
enhanced limits. After the expiry of Moratorium Period no claim under this policy shall be contestable
except for proven fraud and permanent exclusions specified in the policy contract. The policies would
however be subject to all limits, sub limits, co-payments as per the policy.

SPECIFIC TERMS AND CLAUSES

5.10 BASIS OF INSURANCE:

This Policy is issued on the basis of the truth and accuracy of statements given in the prescribed
application/Proposal form or by providing details and confirmations via telephonic mode along
with the prescribed Medical Practitioner’s Report and diagnostic test reports, wherever applicable.
If there is a misrepresentation or non-disclosure we will be entitled to treat the Policy as void.

5.11 PREMIUM:

The proposer authorizes Citibank to debit Good Health Policy premium to his Citibank Credit
Card/Account for self and/or family members.

5.12 PLACE OF TREATMENT AND PAYMENT:

This Policy covers only medical/surgical treatment taken in India. Any expense incurred for
Diagnostic tests outside India would not be covered under this Policy.

Admissible claims shall be payable only in Indian Rupees.

Payment shall be made directly to Network Hospital if Cashless facility is applied for before
treatment and accepted by TPA. If request for Cashless facility is not accepted by TPA, bills shall be
submitted to the TPA after payment of Hospital bills by You.

Note: Cashless facility is only a mode of claim payment and cannot be demanded in every claim.
If We/TPA have doubts regarding admissibility of a claim at the initial stage, which cannot
be decided without further verification of treatment records, request for Cashless facility
may be declined. Such decision by TPA or Us shall be final. Denial of Cashless facility would
not imply denial of claim. If Cashless facility is denied, You may submit the papers on
completion of treatment and admissibility of the claim would be subject to the terms,
 conditions and exceptions of the Policy.

5.13 COMMUNICATION:
You must send all communications and papers regarding a claim to the TPA at the address shown
in the Schedule. For all other matters relating to the policy, communication must be sent to our
Policy issuing office. Communications you wish to rely upon must be in writing.

5.14 NOTICE OF CLAIM:

If You intend to make any claim under this Policy You must:

a. Intimate TPA in writing on detection of any Disease/Injury being suffered immediately or forty-
eight hours before Hospitalisation.
b. In case of Hospitalisation due to medical emergency, intimate TPA within twenty-four hours
from the time of Hospitalisation.
c. Submit following supporting documents TPA/Policy issuing office (as the case may be) relating
to the claim within thirty
d. days from the date of discharge from the Hospital:

i. Bill, Receipt and Discharge certificate / card from the Hospital.

ii. Cash Memos from the Hospitals (s) / Chemists (s), supported by proper
prescriptions.
iii. Receipt and Pathological test reports from Pathologist supported by the note from
the attending Medical Practitioner / Surgeon recommending such Pathological
tests / pathological.
iv. Surgeon's certificate stating nature of operation performed and Surgeons’ bill and
receipt.
v. Attending Doctor's/ Consultant's/ Specialist's / Anesthetist’s bill and receipt, and
certificate regarding diagnosis.
e. In case of Post-Hospitalisation treatment (limited to sixty days), submit all claim documents
within 7 days after completion of such treatment.
f. Provide TPA with authorization to obtain medical and other records from any Hospital,
Laboratory or other agency.

Note: The above stipulations are not intended merely to prejudice Your claims, but their
compliance is of utmost importance and necessity for Us to identify and verify all facts and
surrounding circumstances relating to a claim and determine whether it is payable.
Waiver of delay may be considered in extreme cases of hardship, but only if it is proved to
Our satisfaction it was not possible for You or any other person to comply with the
prescribed time-limit.

5.15 The Insured Person shall submit to the TPA all original bills, receipts and other documents upon
which a claim is based and shall also give the TPA / Company such additional information and
assistance as the TPA / Company may require.

5.16 Any Medical Practitioner authorised by the TPA / Company shall be allowed to examine the
Insured Person, at Our cost, if We deem Medically necessary in connection with any claim.
5.17 ENHANCEMENT OF SUM INSURED:

Enhancement of Sum Insured shall be allowed based on the following table:

Age<=60 years Enhancement up to Sum Insured of 10 lakhs

Age 61-65 Years Enhancement by one slab

Enhancement of Sum Insured will not be considered for:

1) Insured Persons over 65 years of age.

2) Insured Person who had undergone Hospitalization in the preceding two years.
3) Insured Persons suffering from one or more of the following Illnesses/Conditions:
a) Any chronic Illness/ailment
b) Any recurring Illness/ailment
c) Any Critical Illness

In respect of any increase in Sum Insured, exclusion 4.1, 4.2, 4.3.1 and 4.3.2 would apply to the
additional Sum Insured from the date of such increase

5.18 CUMULATIVE BONUS

Cumulative Bonus could be carried over to the next year only if the renewal is effected before, or
within thirty days of, expiry of the Policy.

5.19 ARBITRATION
If We admit liability for any claim but any difference or dispute arises as to the amount payable
for any claim the same shall be decided by reference to Arbitration. The Arbitrator shall be
appointed in accordance with the provisions of the Arbitration and Conciliation Act, 1996. No
reference to Arbitration shall be made unless We have Admitted Our liability for a claim in
writing. If a claim is declined and within 12 calendar months from such disclaimer any suit or
proceeding is not filed then the claim shall for all purposes be deemed to have been abandoned
and shall not thereafter be recoverable hereunder.

5.20 PROTECTION OF POLICY HOLDERS’ INTEREST:

This policy is subject to IRDAI (Protection of Policyholders’ Interests) Regulation, 2017.

5.21 The expenses that are not covered in this policy are placed under List-I of Annexure-II. The list of
expenses that are to be subsumed into room charges, or procedure charges or costs of treatment
are placed under List-II, List-III and List-IV of Annexure-II respectively.
ANNEXURE I: LIST OF DAY CARE PROCEDURES :

1 Stapedotomy 2 Excision And Destruction Of A Lingual Tonsil

3 Stapedectomy 4 Other Operations On The Tonsils And Adenoids
5 Revision Of A Stapedectomy 6 Incision On Bone, Septic And Aseptic
7 Other Operations On The Auditory Ossicles 8 Closed Reduction On Fracture, Luxation Or
Epiphyseolysis With Osteosynthesis
9 Myringoplasty (Type -I Tympanoplasty) 10 Suture And Other Operations On Tendons And
Tendon Sheath
11 Tympanoplasty (Closure Of An Eardrum 12 Reduction Of Dislocation Under Ga
Perforation/Reconstruction Of The Auditory
Ossicles)
13 Revision Of A Tympanoplasty 14 Arthroscopic Knee Aspiration
15 Other Microsurgical Operations On The Middle Ear 16 Incision Of The Breast
17 Myringotomy 18 Operations On The Nipple
19 Removal Of A Tympanic Drain 20 Incision And Excision Of Tissue In The Perianal
Region
21 Incision Of The Mastoid Process And Middle Ear 22 Surgical Treatment Of Anal Fistulas
23 Mastoidectomy 24 Surgical Treatment Of Haemorrhoids
25 Reconstruction Of The Middle Ear 26 Division Of The Anal Sphincter (Sphincterotomy)
27 Other Excisions Of The Middle And Inner Ear 28 Other Operations On The Anus
29 Fenestration Of The Inner Ear 30 Ultrasound Guided Aspirations
31 Revision Of A Fenestration Of The Inner Ear 32 SclerotherapyEtc
33 Incision (Opening) And Destruction 34 Incision Of The Ovary
(Elimination) Of The Inner Ear
35 Other Operations On The Middle And Inner 36 Insufflation Of The Fallopian Tubes
Ear
37 Excision And Destruction Of Diseased Tissue 38 Other Operations On The Fallopian Tube
Of The Nose
39 Operations On The Turbinates (Nasal Concha) 40 Dilatation Of The Cervical Canal
41 Other Operations On The Nose 42 Conisation Of The Uterine Cervix
43 Nasal Sinus Aspiration 44 Other Operations On The Uterine Cervix
45 Incision Of Tear Glands 46 Incision Of The Uterus (Hysterotomy)
47 Other Operations On The Tear Ducts 48 Therapeutic Curettage
49 Incision Of Diseased Eyelids 50 Culdotomy
51 Excision And Destruction Of Diseased Tissue 52 Incision Of The Vagina
Of The Eyelid
53 Operations On The Canthus And Epicanthus 54 Local Excision And Destruction Of Diseased
Tissue Of The Vagina And The Pouch Of
Douglas
55 Corrective Surgery For Entropion And 56 Incision Of The Vulva
Ectropion
57 Corrective Surgery For Blepharoptosis 58 Operations On Bartholin’S Glands (Cyst)
59 Removal Of A Foreign Body From The 60 Incision Of The Prostate
Conjunctiva
61 Removal Of A Foreign Body From The Cornea 62 Transurethral Excision And Destruction Of
Prostate Tissue
63 Incision Of The Cornea 64 Transurethral And Percutaneous Destruction
Of Prostate Tissue
65 Operations For Pterygium 66 Open Surgical Excision And Destruction Of
Prostate Tissue
67 Other Operations On The Cornea 68 Radical Prostatovesiculectomy
69 Removal Of A Foreign Body From The Lens Of 70 Other Excision And Destruction Of Prostate
The Eye Tissue
71 Removal Of A Foreign Body From The 72 Operations On The Seminal Vesicles
Posterior Chamber Of The Eye
73 Removal Of A Foreign Body From The Orbit 74 Incision And Excision Of Periprostatic Tissue
And Eyeball
75 Operation Of Cataract 76 Other Operations On The Prostate
77 Incision Of A Pilonidal Sinus 78 Incision Of The Scrotum And Tunica Vaginalis
Testis
79 Other Incisions Of The Skin And Subcutaneous 80 Operation On A Testicular Hydrocele
Tissues
81 Local Excision Of Diseased Tissue Of The Skin 82 Excision And Destruction Of Diseased Scrotal
And Subcutaneous Tissues Tissue
83 Other Excisions Of The Skin And 84 Plastic Reconstruction Of The Scrotum And
Subcutaneous Tissues Tunica Vaginalis Testis
85 Simple Restoration Of Surface Continuity Of 86 Other Operations On The Scrotum And Tunica
The Skin And Subcutaneous Tissues Vaginalis Testis
87 Free Skin Transplantation, Donor Site 88 Incision Of The Testes
89 Free Skin Transplantation, Recipient Site 90 Excision And Destruction Of Diseased Tissue
Of The Testes
91 Revision Of Skin Plasty 92 Unilateral Orchidectomy
93 Other Restoration And Reconstruction Of The 94 Bilateral Orchidectomy
Skin And Subcutaneous Tissues
95 Chemosurgery To The Skin 96 Orchidopexy
97 Destruction Of Diseased Tissue In The Skin 98 Abdominal Exploration In Cryptorchidism
And Subcutaneous Tissues
99 Incision, Excision And Destruction Of Diseased 100 Surgical Repositioning Of An Abdominal Testis
Tissue Of The Tongue
101 Partial Glossectomy 102 Reconstruction Of The Testis
103 Glossectomy 104 Implantation, Exchange And Removal Of A
Testicular Prosthesis
105 Reconstruction Of The Tongue 106 Other Operations On The Testis
107 Other Operations On The Tongue 108 Surgical Treatment Of A Varicocele And A
Hydrocele Of The Spermatic Cord
109 Incision And Lancing Of A Salivary Gland And 110 Excision In The Area Of The Epididymis
A Salivary Duct
111 Excision Of Diseased Tissue Of A Salivary 112 Epididymectomy
Gland And A Salivary Duct
113 Resection Of A Salivary Gland 114 Reconstruction Of The Spermatic Cord
115 Reconstruction Of A Salivary Gland And A 116 Reconstruction Of The Ductus Deferens And
Salivary Duct Epididymis
117 Other Operations On The Salivary Glands And 118 Other Operations On The Spermatic Cord,
Salivary Ducts Epididymis And Ductus Deferens
119 External Incision And Drainage In The Region 120 Operations On The Foreskin
Of The Mouth, Jaw And Face
121 Incision Of The Hard And Soft Palate 122 Local Excision And Destruction Of Diseased
Tissue Of The Penis
 123 Excision And Destruction Of Diseased Hard 124 Amputation Of The Penis
And Soft Palate
125 Incision, Excision And Destruction In The 126 Plastic Reconstruction Of The Penis
Mouth
127 Plastic Surgery To The Floor Of The Mouth 128 Other Operations On The Penis
129 Palatoplasty 130 Cystoscopical Removal of Stones
131 Other Operations in the Mouth 132 Lithotripsy
133 Transoral Incision And Drainage Of A 134 Coronary Angiography
Pharyngeal Abscess
135 Tonsillectomy Without Adenoidectomy 136 Haemodialysis
137 Tonsillectomy With Adenoidectomy 138 Radiotherapy For Cancer
139 Parenteral chemotherapy 140 Eye Surgery
141 Accidental Dental Surgery 142 D&C
143 Appendectomy 144 Anti Rabies Vaccination
145 Coronary Angioplasty 146 ERCP (Endoscopic Retrograde
Cholangiopancreatography)
147 Excision of Cyst/Granuloma/Lump 148 FESS (Functional Endoscopic Sinus Surgery)
149 Fissurectomy/Fistulectomy 150 Fracture/dislocation excluding hairline
fracture
151 Hydrocelectomy 152 Hysterectomy
153 Inguinal/Venetral/umbilical/femoral hernia 154 Laparoscopic Cholecystectomy
repair
155 Liver Aspiration 156 Polypectomy
157 Septoplasty 158 Surgery for Sinustis
159 Varicose Vein Ligation 160 ERCP (Extracorporeal Shock Wave
Lithotripsy)

ANNEXURE II:

List I – Items for which coverage is not available in the policy

S No Item
1 BABY FOOD
2 BABY UTILITIES CHARGES
3 BEAUTY SERVICES
4 BELTS/ BRACES
5 BUDS
6 COLD PACK/HOT PACK
7 CARRY BAGS
8 EMAIL / INTERNET CHARGES
9 FOOD CHARGES (OTHER THAN PATIENT's DIET PROVIDED BY HOSPITAL)
10 LEGGINGS
11 LAUNDRY CHARGES
12 MINERAL WATER
13 SANITARY PAD
14 TELEPHONE CHARGES
15 GUEST SERVICES
16 CREPE BANDAGE
17 DIAPER OF ANY TYPE
18 EYELET COLLAR
19 SLINGS
20 BLOOD GROUPING AND CROSS MATCHING OF DONORS SAMPLES
21 SERVICE CHARGES WHERE NURSING CHARGE ALSO CHARGED
22 Television Charges
23 SURCHARGES
24 ATTENDANT CHARGES
25 EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH FORMS PART OF BED CHARGE)
26 BIRTH CERTIFICATE
27 CERTIFICATE CHARGES
28 COURIER CHARGES
29 CONVEYANCE CHARGES
30 MEDICAL CERTIFICATE
31 MEDICAL RECORDS
32 PHOTOCOPIES CHARGES
33 MORTUARY CHARGES
34 WALKING AIDS CHARGES
35 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE HOSPITAL)
36 SPACER
37 SPIROMETRE
38 NEBULIZER KIT
39 STEAM INHALER
40 ARMSLING
41 THERMOMETER
42 CERVICAL COLLAR
43 SPLINT
44 DIABETIC FOOT WEAR
45 KNEE BRACES (LONG/ SHORT/ HINGED)
46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER
47 LUMBO SACRAL BELT
48 NIMBUS BED OR WATER OR AIR BED CHARGES
49 AMBULANCE COLLAR
50 AMBULANCE EQUIPMENT
51 ABDOMINAL BINDER
52 PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES
53 SUGAR FREE Tablets
54 CREAMS POWDERS LOTIONS (Toiletries are not payable, only prescribed medical pharmaceuticals
payable)
55 ECG ELECTRODES
56 GLOVES
57 NEBULISATION KIT
58 ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT, ORTHOKIT, RECOVERY KIT, ETC]
59 KIDNEY TRAY
60 MASK
61 OUNCE GLASS
62 OXYGEN MASK
63 PELVIC TRACTION BELT
64 PAN CAN
65 TROLLY COVER
66 UROMETER, URINE JUG
67 AMBULANCE
68 VASOFIX SAFETY
 List II – Items that are to be subsumed into Room Charges

S No Item
1 BABY CHARGES (UNLESS SPECIFIED/INDICATED)
2 HAND WASH
3 SHOE COVER
4 CAPS
5 CRADLE CHARGES
6 COMB
7 EAU-DE-COLOGNE / ROOM FRESHNERS
8 FOOT COVER
9 GOWN
10 SLIPPERS
11 TISSUE PAPER
12 TOOTH PASTE
13 TOOTH BRUSH
14 BED PAN
15 FACE MASK
16 FLEXI MASK
17 HAND HOLDER
18 SPUTUM CUP
19 DISINFECTANT LOTIONS
20 LUXURY TAX
21 HVAC
22 HOUSE KEEPING CHARGES
23 AIR CONDITIONER CHARGES
24 IM IV INJECTION CHARGES
25 CLEAN SHEET
26 BLANKET/WARMER BLANKET
27 ADMISSION KIT
28 DIABETIC CHART CHARGES
29 DOCUMENTATION CHARGES / ADMINISTRATIVE EXPENSES
30 DISCHARGE PROCEDURE CHARGES
31 DAILY CHART CHARGES
32 ENTRANCE PASS / VISITORS PASS CHARGES
33 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE
34 FILE OPENING CHARGES
35 INCIDENTAL EXPENSES / MISC. CHARGES (NOT EXPLAINED)
36 PATIENT IDENTIFICATION BAND / NAME TAG
37 PULSEOXYMETER CHARGES

List III – Items that are to be subsumed into Procedure Charges

S No Item
1 HAIR REMOVAL CREAM
2 DISPOSABLES RAZORS CHARGES (for site preparations)
3 EYE PAD
4 EYE SHEILD
5 CAMERA COVER
6 DVD, CD CHARGES
7 GAUSE SOFT
8 GAUZE
9 WARD AND THEATRE BOOKING CHARGES
10 ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS
11 MICROSCOPE COVER
12 SURGICAL BLADES, HARMONICSCALPEL,SHAVER
13 SURGICAL DRILL
14 EYE KIT
15 EYE DRAPE
16 X-RAY FILM
17 BOYLES APPARATUS CHARGES
18 COTTON
19 COTTON BANDAGE
20 SURGICAL TAPE
21 APRON
22 TORNIQUET
23 ORTHOBUNDLE, GYNAEC BUNDLE

List IV – Items that are to be subsumed into costs of treatment

S No Item
1 ADMISSION/REGISTRATION CHARGES
2 HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC PURPOSE
3 URINE CONTAINER
4 BLOOD RESERVATION CHARGES AND ANTE NATAL BOOKING CHARGES
5 BIPAP MACHINE
6 CPAP/ CAPD EQUIPMENTS
7 INFUSION PUMP– COST
8 HYDROGEN PEROXIDE\SPIRIT\ DISINFECTANTS ETC
9 NUTRITION PLANNING CHARGES - DIETICIAN CHARGES- DIET CHARGES
10 HIV KIT
11 ANTISEPTIC MOUTHWASH
12 LOZENGES
13 MOUTH PAINT
14 VACCINATION CHARGES
15 ALCOHOL SWABES
16 SCRUB SOLUTION/STERILLIUM
17 Glucometer& Strips
18 URINE BAG
 ANNEXURE III: CONTACT DETAILS OF INSURANCE OMBUDSMEN

AHMEDABAD - Shri Kuldip Singh BHOPAL - Shri Guru Saran Shrivastava

Office of the Insurance Ombudsman, Office of the Insurance Ombudsman,
Jeevan Prakash Building, 6th floor, Janak Vihar Complex, 2nd Floor, 6, Malviya Nagar,
Tilak Marg, Relief Road, Ahmedabad – 380 001. Opp. Airtel Office, Near New Market, Bhopal – 462
Tel.: 079 - 25501201/02/05/06 003.
Email: bimalokpal.ahmedabad@ecoi.co.in Tel.: 0755 - 2769201 / 2769202
Fax: 0755 - 2769203
Email: bimalokpal.bhopal@ecoi.co.in
BHUBANESHWAR - Shri Suresh Chandra Panda CHANDIGARH - Dr. Dinesh Kumar Verma
Office of the Insurance Ombudsman, Office of the Insurance Ombudsman,
62, Forest park, Bhubneshwar – 751 009. S.C.O. No. 101, 102 & 103, 2nd Floor,
Tel.: 0674 - 2596461 /2596455 Batra Building, Sector 17 – D, Chandigarh – 160 017.
Fax: 0674 - 2596429 Tel.: 0172 - 2706196 / 2706468
Email: bimalokpal.bhubaneswar@ecoi.co.in Fax: 0172 - 2708274
Email: bimalokpal.chandigarh@ecoi.co.in
CHENNAI - Shri M. Vasantha Krishna DELHI - Shri Sudhir Krishna
Office of the Insurance Ombudsman, Office of the Insurance Ombudsman, 2/2 A, Universal
Fatima Akhtar Court, 4th Floor, 453, Insurance Building,
Anna Salai, Teynampet, CHENNAI – 600 018. Asaf Ali Road, New Delhi – 110 002.
Tel.: 044 - 24333668 / 24335284 Tel.: 011 - 23232481/23213504
Fax: 044 - 24333664 Email: bimalokpal.delhi@ecoi.co.in
Email: bimalokpal.chennai@ecoi.co.in
GUWAHATI - Shri Kiriti .B. Saha HYDERABAD - Shri I. Suresh Babu
Office of the Insurance Ombudsman, Office of the Insurance Ombudsman,
Jeevan Nivesh, 5th Floor, 6-2-46, 1st floor, "Moin Court",
Nr. Panbazar over bridge, S.S. Road, Guwahati – Lane Opp. Saleem Function Palace, A. C. Guards, Lakdi-Ka-Pool,
781001(ASSAM). Hyderabad - 500 004.
Tel.: 0361 - 2632204 / 2602205 Tel.: 040 - 67504123 / 23312122
Email: bimalokpal.guwahati@ecoi.co.in Fax: 040 - 23376599
Email: bimalokpal.hyderabad@ecoi.co.in
ERNAKULAM - Ms. Poonam Bodra KOLKATA - Shri P. K. Rath
Office of the Insurance Ombudsman, Office of the Insurance Ombudsman, Hindustan Bldg.
2nd Floor, Pulinat Bldg., Opp. Cochin Shipyard, M. G. Road, Annexe, 4th Floor, 4, C.R. Avenue, KOLKATA - 700
Ernakulam - 682 015. 072.
Tel.: 0484 - 2358759 / 2359338 Tel.: 033 - 22124339 / 22124340
Fax: 0484 - 2359336 Fax : 033 - 22124341
Email: bimalokpal.ernakulam@ecoi.co.in Email: bimalokpal.kolkata@ecoi.co.in
LUCKNOW -Shri Justice Anil Kumar Srivastava MUMBAI - Shri Milind A. Kharat
Office of the Insurance Ombudsman, Office of the Insurance Ombudsman,
6th Floor, Jeevan Bhawan, Phase-II, 3rd Floor, Jeevan Seva Annexe,
Nawal Kishore Road, Hazratganj, Lucknow - 226 001. S. V. Road, Santacruz (W), Mumbai - 400 054.
Tel.: 0522 - 2231330 / 2231331 Tel.: 022 - 26106552 / 26106960
Fax: 0522 - 2231310 Fax: 022 - 26106052
Email: bimalokpal.lucknow@ecoi.co.in Email: bimalokpal.mumbai@ecoi.co.in
JAIPUR - Smt. Sandhya Baliga PUNE - Shri Vinay Sah
Office of the Insurance Ombudsman, Office of the Insurance Ombudsman,
Jeevan Nidhi – II Bldg., Gr. Floor, Bhawani Singh Marg, Jeevan Darshan Bldg., 3rd Floor,
Jaipur - 302 005. C.T.S. No.s. 195 to 198, N.C. Kelkar Road, Narayan Peth, Pune –
Tel.: 0141 - 2740363 411 030.
Email: bimalokpal.jaipur@ecoi.co.in Tel.: 020-41312555
Email: bimalokpal.pune@ecoi.co.in
BENGALURU - Smt. Neerja Shah NOIDA - Shri Chandra Shekhar Prasad
Office of the Insurance Ombudsman, Office of the Insurance Ombudsman,
Jeevan Soudha Building,PID No. 57-27-N-19 Ground Floor, 19/19, Bhagwan Sahai Palace, 4th Floor, Main Road, Naya Bans, Sector
24th Main Road, 15, Distt: Gautam Buddh Nagar, U.P-201301.
JP Nagar, Ist Phase, Bengaluru – 560 078. Tel.: 0120-2514250 / 2514252 / 2514253
Tel.: 080 - 26652048 / 26652049 Email: bimalokpal.noida@ecoi.co.in
Email: bimalokpal.bengaluru@ecoi.co.in
PATNA - Shri N. K. Singh
Office of the Insurance Ombudsman,
1st Floor,Kalpana Arcade Building,,
Bazar Samiti Road, Bahadurpur, Patna 800 006.
Tel.: 0612-2680952
Email: bimalokpal.patna@ecoi.co.in