THE NEW INDIA ASSURANCE CO. LTD.

NEW INDIA MEDICLAIM POLICY

NIA - which has been issued by insurer, relying on the information

disclosed by insured, Proposal for this Policy or its preceding
Policy/Policies of which this is a renewal.
• Topics we are covering here :-

-What NIA Cover

-Definitions

-How much NIA will reimburse

-What are Excluded under this Policy

-Conditions
 1. WHAT IS NIA COVER ?

• If during the Period of Insurance, any Insured Person incurs Hospitalization Expenses which are Reasonable
and Customary, and Medically Necessary for treatment of any Illness or Injury, NIA will reimburse such
expense incurred by Insured, 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
• ACCIDENT means sudden, unforeseen and involuntary event caused by external, visible and violent means.
• AGE means age of the Insured person on last birthday as on date of commencement of the Policy.
• 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 was taken.
• 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.
• AYUSH TREATMENT refers to hospitalization treatments given under Ayurveda, Yoga andNaturopathy, Unani, Siddha and
Homeopathy systems.
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
b Teaching hospital attached to AYUSH College recognized by the Central Government/CentralCouncil 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:
- Having at least 5 in-patient beds;
-Having qualified AYUSH Medical Practitioner in charge round the clock;
-Having dedicated AYUSH therapy sections as required and/or has equipped
-operation theatre where surgical procedures are to be carried out
-Maintaining daily records of the patients and making them accessible to the
-insurance company’s authorized representative
• 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 on day care basis without in-
patient services and must comply with all the following criterion:
- Having qualified registered AYUSH Medical Practitioner in charge;
- Having dedicated AYUSH therapy sections as required and/or has equipped
-operation theatre where surgical procedures are to be carried out;
-Maintaining daily records of the patients and making them accessible to the insurance company’s authorized
representative.
• 2.8 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
2.9 CASHLESS FACILITY means a facility extended by the Insurer to the insured where the payments, of the costs of treatment
undergone by the insured in accordance with the policy terms and conditions, are directly made to the network provider by the
insurer to the extent pre-authorization approved.
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.
CONDITION PRECEDENT shall mean a policy term or condition upon which the Insurer's liability under the policy is conditional
upon.
CONGENITAL ANOMALY means to a condition(s) which is present since birth, and which is abnormal with reference to form,
structure or position.
CONGENITAL INTERNAL ANOMALY means a Congenital Anomaly which is not in the visible and accessible parts of the body

CONGENITAL EXTERNAL ANOMALY means a Congenital Anomaly which is in the visible and accessible parts of the
body.
• 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 copayment does not reduce the Sum Insured.

• CUMULATIVE BONUS means any increase or addition in the Sum Insured granted by the insurer without an associated
increase in premium.

• DAY CARE CENTRE means any institution established for Day Care Treatment of Illness and/or Injury or a medical setup
within a Hospital and which has been registered with the local authorities, wherever applicable, and is under 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 Surgery is carried out;
- Maintains daily record of patients and will make these accessible to the insurance company’s authorized personnel.
• 2.16 DAY CARE TREATMENT refers to medical treatment, and/or Surgical Procedure which is:
- Undertaken under General or Local Anesthesia in a Hospital/Day Care Centre in less than twenty four hours becauseof technological
advancement, and Which would have otherwise required a Hospitalization of more than twenty four hours.
- Treatment normally taken on an out-patient basis is not included in the scope of this definition.

• 2.17 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.

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

• 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 nondisclosure of any material fact.
• 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.

• EMERGENCY CARE: 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.

• 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.
• HOSPITAL means any institution established for Inpatient Care and Day Care Treatment of Illness and/or Injury and
which has been registered as a Hospital with the local authoritieries 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 at least 10 inpatient beds, in those towns having a population of less than 10,00,000 andat least 15 inpatient beds in all other
places;
- has qualified nursing staff under its employment round the clock;
-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
will make these accessible to the Insurance company’s authorized personnel.
• HOSPITALISATION means admission in a Hospital for a minimum period of twenty four consecutive hours of Inpatient Care except
for specified procedures / treatments as mentioned in Annexure I, where such admission could be for a period of less than twenty
four 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. 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
• 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.
• INPATIENT CARE means treatment for which the insured person has to stay in a Hospital for more than twenty four hours for a
covered event.

• INSURED PERSON means You and each of the others who are covered under this Policy as shown in the Schedule.
• ICU (INTENSIVE CARE UNIT) means an identified section, ward or wing of a Hospital which is under the constant
supervision of a dedicated Medical Practitioner(s), and which is specially equipped for the continuous monitoring and
treatment of patients who are in a critical condition, or require life support facilities and where the level of care and
supervision is considerably more sophisticated and intensive than in the ordinary and other wards.
• 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.
• 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.

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

• 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 samelocality would have charged for the same medical
treatment.

• MEDICALLY 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 confirm to the professional standards widely accepted in international medical practice or by the medical community in India.
• 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.

• 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.

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

• NOTIFICATION OF CLAIM means the process of intimating a claim to Us or TPA through any of the recognized modes of
communication.
• PRE-EXISTING CONDITION/DISEASE 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. 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.
• 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 theprocedures (as
listed under PPN package) shall be subject to the rates applicable to PPN package pricing.

• PRE-HOSPITALISATION MEDICAL EXPENSES mean Medical Expenses incurred during thirty days preceding the Hospitalisation of the
Insured Person, provided that:

• i. Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalization was required, and
• ii. The Inpatient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.

• POST-HOSPITALISATION MEDICAL EXPENSES mean Medical Expenses incurred during sixty days immediately after the Insured
Person is discharged from the Hospital provided that:

• i. Such Medical Expenses are for the same condition for which the Insured Person’s Hospitalisation was required, and
ii. The Inpatient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.
• 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.

• 2.46 POLICY PERIOD means period of one policy year as mentioned in the schedule for which the Policy is issued
• 2.47 POLICY SCHEDULE means the Policy Schedule attached to and forming part of Policy
• 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

• PORTABILITY means the right accorded to an individual health insurance policyholder (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.

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

• 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
• 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.
NIAHLIP21277V042021 Page 7 of 33 NEW INDIA MEDICLAIM POLICY

* 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.
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.

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

2.55 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

2.56 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.

2.57 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.
2.58 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.
2.59 UNPROVEN/EXPERIMENTAL TREATMENT means treatment including drug
experimental therapy, which is not based on established medical practice in India, is
treatment experimental or unproven. 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 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
HOW MUCH WE WILL REIMBURSE

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:
 3.1 (a) Room rent, Boarding, DMO / RMO / CMO / RMP Charges, Nursing (Including
Injection / Drugs and Intra venous fluid administration expenses), not
exceeding 1% of the Sum Insured per day
3.1 (b) Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU), Intensivist
charges, Monitor and Pulse Oxymeter expenses not exceeding 2% of the Sum
Insured per day.
3.1 (c) Associate 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.

will reimburse the following Reasonable and

Customary, and Medically Necessary
Expenses admissible as per the terms and
conditions of the Policy:

3.1 (d) Cost of Pharmacy and Consumables, Cost of Implants and Medical Devices and
Cost of Diagnostics.
3.1 (e) Pre-Hospitalization Medical expenses
3.1 (f) Post-Hospitalization Medical expenses
3.2 PROPORTIONATE DEDUCTION
Proportionate Deduction is applicable on the Associate Medical Expenses, if the Insured Person opts for
a higher Room than his eligible category. It shall be effected in the same proportion as the eligible rate
per day bears to the actual rate per day of Room Rent. However, it is not applicable on
1. Cost of Pharmacy and Consumables
2. Cost of Implants and Medical Devices
3. Cost of Diagnostics.

Proportionate Deduction shall also not be applied in respect of Hospitals which do not follow differential
billing or for those expenses in which differential billing is not adopted based on the room category, as
evidenced by the Hospital’s schedule of charges / tariff.
3.3 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. 50,000.
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.
3.4 TREATMENTS UNDER AYURVEDIC / HOMEOPATHIC / UNANI SYSTEMS Expenses
incurred for Ayurvedic / Homeopathic / Unani Treatment 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 centers for spas, massage and health
rejuvenation procedures.
3.5 HOSPITAL CASH
For those Insured Persons, whose Sum Insured is more than or equal to Rs. three lakhs, we will pay Hospital
Cash at the rate of 0.1% of the Sum Insured, for each day of Hospitalisation admissible under the Policy. The
payment under this Clause for Any One Illness shall not exceed 1% of the Sum Insured. The payment under this
Clause is applicable only where the period of Hospitalisation exceeds twenty four consecutive hours. Payment
under this clause shall reduce the Sum Insured.
Hospital Cash will be payable for completion of every twenty four hours and not part thereof.
3.6 ADDITIONAL BENEFIT - HEALTH CHECK-UP
The Insured Person shall be entitled for reimbursement of the cost of Medical check-up at the end of a block of
every three Claim Free Years. Such payment shall be restricted to Rs. 5,000 or 1% of the average Sum Insured
of the Insured Person in the preceding three years, whichever is less. This benefit is available only once in three
years.
Any payment made under this clause shall not be considered as a claim for the purpose of Clauses 5.11 of this
Policy.
3.7 PAYMENT OF AMBULANCE CHARGES

We will pay You the charges for Ambulance services not exceeding 1% of the Sum Insured, 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 Hospitalfor better medical facilities.

3.8 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

NIAHLIP21277V042021 Page 10 of 33 NEW INDIA MEDICLAIM POLICY

amount not exceeding Rs. Twenty thousand, where such payment is made by cheque.

3.9 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 liabilitytowards 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.
3.10 REINSTATEMENT OF SUM INSURED

If the Sum Insured is exhausted due to a claim admissible under the Policy, then the Sum Insured shall be reinstated to the Sum Insured stated in the
Schedule, provided our liability under the Reinstated Sum Insured shall be subject to the following conditions:

1. Such Reinstatement of Sum Insured shall be effected only where the Sum Insured is Rs. Five Lakhs or more.

2. Such Reinstatement shall take effect only after the Date of Discharge from the Hospital for that claim which resulted in exhaustion of the Sum Insured

3. No Illness or Injury, for a Hospitalisation occurring during the Period of Insurance till the Date of Reinstatement, for which a Claim is paid or admissible,
shall be considered under the Reinstated Sum Insured.

4. Such Reinstatement shall be available only once for each Insured Person during a Period of Insurance.

3.11 DAY ONE BABY COVER

A New Born Baby is covered for any Illness or Injury from the date of birth till the expiry of this Policy, within the terms of this Policy. Any expense incurred
towards post natal care, pre-term or pre-mature care or any such expense incurred in connection with delivery of such New Born Baby would not be
covered.

Congenital External Anomaly of the New Born Baby is covered only after 36 months Waiting Period. Waiting Period for Congenital Internal Disease would not
apply to a New Born Baby during the year of Birth and also subsequent renewals, if Premium is paid for such New Born Baby and the renewals are effected
before or within thirty days of expiry of the Policy.

Any Illness or Disease will be covered within the Sum Insured of the mother till the expiry of the Policy and No coverage for the New Born Baby would be
available during subsequent renewals unless the child is declared for insurance and covered as an Insured Person.

Note: New Born Baby means a baby born during the Policy Period to a female Insured Person, who has twenty-four months of Continuous Coverage with Us.
3.12 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.
3.13 OPTIONAL COVER I: NO PROPORTIONATE DEDUCTION
On payment of additional Premium as mentioned in Schedule, it is hereby agreed and
declared that Clause 3.2 stands deleted for the members covered in the Policy as stated in
the Schedule.
You shall continue to bear the differential between actual and eligible Room Rent.
3.14 OPTIONAL COVER II: MATERNITY EXPENSES BENEFIT

On the payment of additional Premium as mentioned in Schedule, it is hereby agreed and declared that Clause 4.4.15 stands
deleted for the members as mentioned in the Schedule. Our liability for claim admitted for Maternity shall not exceed 10% of
the average Sum Insured of the Insured Person in the preceding three years.

Special conditions applicable to Maternity Expenses Benefit:

1. These Benefits are admissible only if the expenses are incurred in Hospital as inpatients in India.

2. A waiting period of thirty-six months is applicable, from the date of opting this cover, for payment of any claim relating to
normal delivery or caesarian section or abdominal operation for extra uterine pregnancy. The waiting period may be relaxed
only in case of miscarriage or abortion induced by accident or other medical emergency.

3. Claim in respect of delivery for only first two children and / or surgeries associated therewith will be considered in respect
of any one Insured Person covered under the Policy or any renewal thereof.

4. Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 weeks from the date of
conception are not covered.

Pre-natal and post-natal expenses are not covered unless admitted in Hospital and treatment is taken there.

The maternity 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.
OPTIONAL COVER III: REVISION IN LIMIT OF CATARACT

This optional cover, if opted, will be in addition to limit specified in Clause 3.3

On payment of additional Premium as mentioned in Schedule, it is declared and

agreed that following additional amount for Cataract shall become payable but not
exceeding the actual expenses incurred:

Sum Insured Additional Cataract limit

Rs. 8,00,000 Rs. 80,000

Rs. 10,00,000 Rs. 1,00,000

3.16 OPTIONAL COVER IV: VOLUNTARY CO-PAY

If the Insured person opts for voluntary co-pay of 20%, a discount of 15% shall be of given
on the premium payable for the Insured Person.

3.17 CUMULATIVE BONUS

The Sum Insured under Policy shall be increased by 25% at each renewal in respect of each
claim free year of insurance, subject to maximum of 50%. If a claim is made in any particular
year; the cumulative bonus accrued may be reduced at the same rate at which it is accrued.

Cumulative bonus will be lost if policy is not renewed before or within 30 days from the date
of expiry. 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.

In case the insured is having more than one policy, the Cumulative Bonus shall be reduced
from the policy/policies in which claim is made irrespective of number of policies.
i. Cumulative Bonus shall be applicable for persons having Sum Insured of 2 Lakh & above. ii. The Cumulative Bonus
Buffer under the expiring policy, if any, shall be converted to Cumulative Bonus.

iii. In case where the policy is on individual basis, the CB shall be added and available individually to the insured person
who has not claimed under the expiring policy. iv. In case where the policy is on floater basis, the CB shall be added and
available to the family on floater basis, provided no claim has been reported under the policy.

v. CB shall be available only if the Policy is renewed within the Grace Period. vi. If the Insured Persons in the expiring policy
are covered on an individual basis as specified in the Policy Schedule and there is an accumulated CB for each Insured
Person under the expiring policy, and such expiring policy has been Renewed on a floater policy basis as specified in the
Policy Schedule then the CB to be carried forward for credit in such Renewed Policy shall be the Lowest among all the
Insured Persons.

vii. In case of floater policies where Insured Persons Renew their expiring policy by splitting the Sum Insured in to two or
more floater policies/individual policies, the same CB of the expiring policy shall be apportioned to each Individual of such
Renewed Policies.

viii. If the Sum Insured has been reduced at the time of Renewal, the applicable Cumulative Bonus percentage shall be
applied on the reduced Sum Insured.

ix. If the Sum Insured under the Policy has been increased at the time of Renewal the Cumulative Bonus shall be
calculated on the Sum Insured of the last completed Policy Year.

x. If a claim is made in the expiring Policy Year, and is notified to Us after the acceptance of Renewal premium any
awarded CB shall be withdrawn.
3.18 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
upto 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
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) Treatment of mental illness, stress or psychological disorders and neurodegenerative disorders The Company shall indemnify the Hospital or the Insured the Medical 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 counselling, cognitive/ family/ group/ behavior/ palliative therapy or other kinds of psychotherapy for
which Hospitalisation is not necessary shall not be covered.

d) 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.

e) 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.

f) 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.

g) 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 3.18, waiting period's, if any, shall be applicable afresh i.e. for both New and Existing
Policyholders w.e.f 1st October 2020. Coverage for such Illness or procedures shall only be available after completion of the
said waiting periods.
3.19 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)

3.19.1 Uterine Artery Embolization and HIFU (High intensity focused Upto 20% of Sum Insured subject
ultrasound) to a Maximum upto Rs. 2 Lakh

3.19.2 Balloon Sinuplasty. Upto 20% of Sum Insured subject

to a Maximum upto Rs. 2 Lakh

3.19.3 Deep Brain stimulation. Upto 50% of Sum Insured subject

to a maximum upto Rs. 5 Lakh

3.19.4 Oral chemotherapy. Upto 10% of Sum Insured subject

to Maximum upto Rs. 1 Lakh

3.19.5 Immunotherapy- Monoclonal Antibody to be given as Upto 25% of Sum Insured subject
injection. to a Maximum of Rs 2 Lakh.

3.19.6 Intravitreal injections. Upto 10% of Sum Insured subject

to a Maximum of Rs.75,000.

3.19.7 Robotic surgeries. Upto 50% of Sum Insured subject

to Maximum of Rs. 5 Lakh.

3.19.8 Stereotactic radio surgeries. Upto 50% of Sum Insured subject

to Maximum Rs. 3 Lakh.

3.19.9 Bronchial Thermoplasty. Upto 50% of Sum Insured subject

to Maximum of Rs. 2.5 Lakh.

3.19.10 Vaporisation of the prostrate (Green laser treatment or Upto 50% of Sum Insured subject
holmium laser treatment). to Maximum of Rs. 2.5 Lakh.

3.19.11 IONM - (Intra Operative Neuro Monitoring). Upto 10% of Sum Insured subject
3.20 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.
Exclusions
• The definition includes the company shall not be liable to make
any payments in respect of any expenses incurred in connection
with or in respect of following conditions as per Clause 4.1, 4.2,
4.3 and 4.4
• There are 2 types of Exclusions
1. Temporary Exclusions
2. Permanent Exclusions
Temporary Exclusions
• Clause 4.1 – Pre- Existing Diseases
• Pre-existing diseases – It is defined as any condition, ailment,
injury or disease that is diagnosed by a physician within 48
months prior to the effective date of the policy issued by the
insurer or its reinstatement.
• Pre – existing diseases are not payable until the expiry of 48
months of continuous coverage after the date of inception of the
first policy.
• Waiting Period = 48 months (4 Years)
• Clause 4.2 – Specific waiting period
• Waiting period – It is defined as a period from the inception of
policy during which specified illness/treatments are not covered
• On completion of the waiting period, illness/ treatments shall be
covered provided the policy has been continuously renewed
without any break.
• Clause 4.3 – First 30 days waiting Period
• 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 in policy.
• Exception – Accidental claims are payable and shall be settled
within 24 hours of hospitalisation.
 Permanent Exclusions
• Clause 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:
• Clause 4.4.1 – Investigation and Evaluation
• Expenses related to any admission primarily for diagnostics and evaluation
purposes are not payable.
• Investigations, diagnostics and Lab tests without any active line of treatment is
not payable.
• Any diagnostic expenses which are not related or not incidental to the current
diagnosis and treatment are not payable.
• Exception – Investigations done for illness/ symptoms/ complications with
‘unknown aetiology’ is payable upto 10% of SI. Ex – ‘ Fever of unknown origin’
is payable.
• Clause 4.4.2 – Rest cure, rehabilitation and respite care.
• Expenses related to any admission primarily for enforced bed rest and
not for receiving treatment are not payable.
• Example – 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 , assistance of nurses for moving around are not payable.
• Any services for people who are terminally ill to address physical, social,
emotional and spiritual needs are not payable under the clause.
• Exception – Hospitalisation due to fasting is payable provided it was not
intended to suicide.
• Clause 4.4.3 – Obesity/ Weight Control
• Expenses related to surgical treatment of obesity is not payable
Except in following conditions –
• Exceptions –
1. Surgery to be conducted is upon the advice of doctor
2. BMI is greater than or equal to 40 with 18 years of age or older.
3. BMI greater than 35 with severe co- morbidities like obesity-
related cardiomyopathy, Coronary Heart Disease, Severe Sleep
apnea and uncontrolled Type 2 Diabetes Mellitus.
• Clause 4.4.4 – Change of gender treatments
• Expenses related to any treatment, including surgical management, to
change characteristics of the body to those of the opposite sex are not
payable
• Exception - True hermaphroditism is payable under the clause.

• Clause 4.4.5 – Cosmetic or plastic surgery

• Expenses for cosmetic or plastic surgery or any treatment to change the
appearance is not payable.
• Exception – Unless the reconstruction following an accident, burn or
cancer or as part of medical necessary treatment to remove a direct or
immediate health risk to insured.
• Clause 4.4.6 – Hazardous or adventure sports
• Expenses related to any treatment necessitated due to
participation in hazardous or adventure sports , including para-
jumping, rock climbing, rafting etc.
• Exception – Occupational hazardous and injuries sustained by
boxers are payable.

• Clause 4.4.7 – Breach of Law

• Expenses for treatment directly arising from criminal intent of
the insured.
• There is permanent null and void of the policy on breach of law.
• Clause 4.4.9 – Drug/ Alcohol abuse
• Treatment for alcoholism, drug or substances abuse or any addictive
condition are not payable
• Example - Alcoholic cirrhosis of liver is not payable.

• Clause 4.4.10 – Non medical admissions

• Treatments received in nature cure clinics, spas and health hydros etc.
are not payable.

• Clause 4.4.11 – Non prescribed drugs

• Dietary supplements and substances that are purchased without
prescription, including vitamins, minerals and organic subsances.
• Clause 4.4.12 – Refractive error
• Expenses related to the treatment for correction of eye sight due to
refractive error less than 7.5 dioptres.

• Clause 4.4.13 – Unproven treatment

• Expenses related to treatment, procedures or supplies that lack significant
medical documentations to support their effectiveness.

• Clause 4.4.14 – Sterility and infertility

• Expenses related to sterility and infertility including contraception,
sterilization, advanced reproductive technologies such as – IVF, ZIFT,
GIFT, ICSI, gestational surrogacy, reversal of sterilization.
• Clause – 4.4.15 – Maternity Expenses
• Medical termination of pregnancy is not payable.
• Exception – Ectopic pregnancy is payable.

• Clause 4.4.16 – Acupuncture, Acupressure and Magnetic therapies

• Clause – 4.4.17 – Domiciliary Hospitalization

• Any expenses incurred on OPD treatment
• Domiciliary Hospitalisation – The patient received treatment at home
itself.

• Clause 4.4.18 - Any kind of service charge, registration charge, luxury

tax levied by the hospital
• Clause 4.4.19 – Self inflicted injury
• Treatment for intentional self – inflicted injury, attempted suicide.

• Clause 4.4.20 – Circumcision

• Clause 4.4.21 – General debility and Venereal disease

• Clause 4.4.22 – Cost of braces, equipment, or external prosthetic devices

and implants.

• Clause 4.4.23 – Dental treatment and surgery

• Exception - Unless some dental injury due to an accident.
• Clause 4.4.24 – External and or durable Medical/ Non- medical equipment
• Including CPAP, CPAD, Oxygen concentrator, ambulatory devices such as – crutches, collars,
splints, etc.

• Clause 4.4.25 – Naturopathy and Siddha treatments

• Clause 4.4.26 – Nuclear, chemical and biological attack

• Clause 4.4.27 – Stem cell surgery/implantation

• Clause 4.4.29 – Treatment taken outside the geographical limit of india.

• Clause 4.4.30 – Vaccination/ Inoculation

• Clause 4.4.31 - War

• Claim intimation – Intimate TPA in writing on detection of any illness/ injury 48 hours before
hospitalisation and within 24 hours for medical emergency.

• Submit all the documents within 7 days from the DOD (Date of Discharge)

• Documents required for claim settlement:-

1. Cancelled cheque of the insured.
2. Bill, receipt and discharge certificate from the hospital.
3. Pathological test reports and receipts
4. Prescription from the treating doctor.
5. KYC documents
6. Surgeon’s certificate stating nature of illness, surgeon's bill and receipt
7. Cash memo
8. Attending doctor’s/ consultant’s certificate regarding diagnosis, bill and receipt.
• Claim should be settled within 30 days of receipt of the last necessary
document.

• Renewal – Occurs once in a year to renew the policy. New participants

can be added to the same policy.
• Ex – Spouse, parents and children can be added to the same policy.

• Cumulative bonus – It is defined as increased in sum insured at renewal

provided there is no claim in previous year

• Claim – Free year – The year in which no claim is made provided the
same policy is renewed and continued.
• Free look Period – A 15 days period is allowed from the date of
receipt of the policy to review the terms and conditions and to
return the same if not acceptable.
ENHANCEMENT OF SUM INSURED:
You may seek enhancement of Sum Insured in writing before payment of premium for renewal, which may be granted at Our discretion. Before granting such
request for enhancement of Sum Insured, We have the right to have You examined by a Medical Practitioner authorized by Us or the TPA. Our consent for
enhancement of Sum Insured is dependent on the recommendation of the Medical Practitioner and subject to limits as stated below:

Age <= 50 years Up to Sum Insured of 15 lakhs without Medical Examination.

Age 51-60 Years By two slabs without Medical Examination
Age 61 – 65 Years By one slab with Medical Examination

Enhancement of Sum Insured will not be considered for:

1) Any Insured Person over 65 years of age.

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

In respect of any enhancement of Sum Insured, exclusions 4.1, 4.2 and 4.3 would apply to the additional Sum Insured from such date.
CUMLATIVE 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.

CANCELLATION CLAUSE:
We may at any time cancel the Policy on grounds of misrepresentation, fraud, non-disclosure of material fact or 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.
On such cancellation, premium corresponding to the unexpired period of Insurance will be refunded, if no claim has been made or paid under the Policy
You may at any time cancel this Policy and in such event We shall allow refund of premium, if no claim has been made or paid under the Policy, at Our short period rate table given
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

FREE LOOK PERIOD:

The free look period shall be applicable at the inception of the first New India Mediclaim Policy.

You will be allowed a period of fifteen days from the date of receipt of the Policy to review the terms and conditions of the Policy and to return the same if not acceptable.

If You have not made any claim during the free look period, You shall be entitled to:

1. A refund of the premium paid less any expenses incurred by Us on medical examination and the stamp duty charges or;

2. where the risk has already commenced and the option of return of the policy is exercised by You, a deduction towards the proportionate risk premium for period on cover or;

3. Where only a part of the risk has commenced, such proportionate risk premium commensurate with the risk covered during such period.
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 twelve 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.

PROTECTION OF POLICY HOLDERS’ INTEREST:

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

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.
ii. All necessary claim documents pertaining to Hospitalization should be furnished by the Insured Person in original to the TPA (as mentioned in the Schedule), within seven 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.
iii. 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.
iv. 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.
v. 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.
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

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 detail of the office of the Insurance Ombudsman is provided in the Annexure III.

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

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.
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 Excision And Destruction Of Diseased
37 38 Other Operations On The Fallopian Tube
Other Operations On The Tonsils And Tissue Of The Nose
3 Stapedectomy 4 Operations On The Turbinates (Nasal
Adenoids
39 40 Dilatation Of The Cervical Canal
5 Revision Of A Stapedectomy 6 Incision On Bone, Septic And Aseptic Concha)
Other Operations On The Auditory Closed Reduction On Fracture, Luxation Or 41 Other Operations On The Nose 42 Conisation Of The Uterine Cervix
7 8 Epiphyseolysis With Osteosynthesis 43 44
Ossicles Nasal Sinus Aspiration Other Operations On The Uterine Cervix
Suture And Other Operations On Tendons 45 Incision Of Tear Glands 46 Incision Of The Uterus (Hysterotomy)
9 Myringoplasty (Type -I Tympanoplasty) 10 And Tendon Sheath 47 48
Other Operations On The Tear Ducts Therapeutic Curettage
Tympanoplasty (Closure Of An 49 Incision Of Diseased Eyelids 50 Culdotomy
Eardrum
11 12 Reduction Of Dislocation Under Ga Excision And Destruction Of Diseased
Perforation/Reconstruction Of The 51 52 Incision Of The Vagina
Tissue Of The Eyelid
Auditory Ossicles)
13 Revision Of A Tympanoplasty 14 Arthroscopic Knee Aspiration Local Excision And Destruction Of Diseased
Operations On The Canthus And Tissue Of The Vagina And The Pouch Of
Other Microsurgical Operations On 53 54
15 16 Incision Of The Breast Epicanthus Douglas
The Middle Ear
17 Myringotomy 18 Operations On The Nipple Corrective Surgery For Entropion And
55 56 Incision Of The Vulva
Incision And Excision Of Tissue In The Ectropion
19 Removal Of A Tympanic Drain 20 57 Corrective Surgery For Blepharoptosis 58 Operations On Bartholin’S Glands (Cyst)
Perianal Region
Incision Of The Mastoid Process And Removal Of A Foreign Body From The
21 22 Surgical Treatment Of Anal Fistulas 59 60 Incision Of The Prostate
Middle Ear Conjunctiva
23 24 Removal Of A Foreign Body From The Transurethral Excision And Destruction Of
Mastoidectomy Surgical Treatment Of Haemorrhoids 61 62
27 Other Excisions Of The Middle And 28 Other Operations On The Anus Cornea Prostate Tissue
Inner Ear Transurethral And Percutaneous Destruction
29 Fenestration Of The Inner Ear 30 Ultrasound Guided Aspirations 63 Incision Of The Cornea 64
Of Prostate Tissue
31 Revision Of A Fenestration Of The 32 SclerotherapyEtc Open Surgical Excision And Destruction Of
Inner Ear 65 Operations For Pterygium 66
Prostate Tissue
Incision (Opening) And Destruction
33 34 Incision Of The Ovary 67 Other Operations On The Cornea 68 Radical Prostatovesiculectomy
(Elimination) Of The Inner Ear
Removal Of A Foreign Body From The Other Excision And Destruction Of Prostate
Other Operations On The Middle And Lens
35 36 Insufflation Of The Fallopian Tubes 69 70 Tissue
Inner Ear Of The Eye
 Removal Of A Foreign Body From The
71 72 Operations On The Seminal Vesicles
Posterior Chamber Of The Eye
Removal Of A Foreign Body From The Orbit Incision And Excision Of Periprostatic
73 74
And Eyeball Tissue
75 Operation Of Cataract 76 Other Operations On The Prostate
Incision Of The Scrotum And Tunica
77 Incision Of A Pilonidal Sinus 78 Vaginalis Testis
Local Excision Of Diseased Tissue Of The Excision And Destruction Of Diseased
81 82
Skin And Subcutaneous Tissues Scrotal Tissue
Other Excisions Of The Skin And Plastic Reconstruction Of The Scrotum And
83 84
Subcutaneous Tissues Tunica Vaginalis Testis
Simple Restoration Of Surface Continuity Other Operations On The Scrotum And
85 86
Of The Skin And Subcutaneous Tissues Tunica Vaginalis Testis
87 Free Skin Transplantation, Donor Site 88 Incision Of The Testes
Excision And Destruction Of Diseased
89 Free Skin Transplantation, Recipient Site 90 Tissue Of The Testes
91 Revision Of Skin Plasty 92 Unilateral Orchidectomy
Other Restoration And Reconstruction Of
93 94 Bilateral Orchidectomy
The Skin And Subcutaneous Tissues
95 Chemosurgery To The Skin 96 Orchidopexy
Destruction Of Diseased Tissue In The Skin
97 And Subcutaneous Tissues 98 Abdominal Exploration In Cryptorchidism
Incision, Excision And Destruction Of Surgical Repositioning Of An Abdominal
99 100 Testis
Diseased Tissue Of The Tongue

101 Partial Glossectomy 102 Reconstruction Of The Testis

Implantation, Exchange And Removal Of A
103 Glossectomy 104 Testicular Prosthesis
105 Reconstruction Of The Tongue 106 Other Operations On The Testis
ANNEXURE II:
List I – Items for which coverage is not available in the policy
S No Item 36 SPACER
1 BABY FOOD 37 SPIROMETRE
2 BABY UTILITIES CHARGES 38 NEBULIZER KIT
3 BEAUTY SERVICES 39 STEAM INHALER
4 BELTS/ BRACES 40 ARMSLING
5 BUDS 41 THERMOMETER
6 COLD PACK/HOT PACK 42 CERVICAL COLLAR
7 CARRY BAGS 43 SPLINT
8 EMAIL / INTERNET CHARGES 44 DIABETIC FOOT WEAR
9 FOOD CHARGES (OTHER THAN PATIENT's DIET PROVIDED BY HOSPITAL) 45 KNEE BRACES (LONG/ SHORT/ HINGED)
10 LEGGINGS 46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER
11 LAUNDRY CHARGES 47 LUMBO SACRAL BELT
12 MINERAL WATER 48 NIMBUS BED OR WATER OR AIR BED CHARGES
13 SANITARY PAD 49 AMBULANCE COLLAR
14 TELEPHONE CHARGES 50 AMBULANCE EQUIPMENT
15 GUEST SERVICES 51 ABDOMINAL BINDER
16 CREPE BANDAGE
52 PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES
17 DIAPER OF ANY TYPE
18 EYELET COLLAR 53 SUGAR FREE Tablets
19 SLINGS 54 CREAMS POWDERS LOTIONS (Toiletries are not payable, only prescribed medical pharmaceuticals
20 BLOOD GROUPING AND CROSS MATCHING OF DONORS SAMPLES payable)
21 SERVICE CHARGES WHERE NURSING CHARGE ALSO CHARGED 55 ECG ELECTRODES
22 Television Charges
56 GLOVES
23 SURCHARGES
25 EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH FORMS PART OF BED CHARGE) 57 NEBULISATION KIT
26 BIRTH CERTIFICATE 58 ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT, ORTHOKIT, RECOVERY KIT, ETC]
27 CERTIFICATE CHARGES 59 KIDNEY TRAY
28 COURIER CHARGES
60 MASK
29 CONVEYANCE CHARGES
30 MEDICAL CERTIFICATE 61 OUNCE GLASS
31 MEDICAL RECORDS 62 OXYGEN MASK
32 PHOTOCOPIES CHARGES
63 PELVIC TRACTION BELT
33 MORTUARY CHARGES
34 WALKING AIDS CHARGES 64 PAN CAN
35 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE HOSPITAL) 65 TROLLY COVER
66 UROMETER, URINE JUG
 List II – Items that are to be subsumed into Room Charges List III – Items that are to be subsumed into Procedure Charges

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

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