Health Ensure
CUSTOMER INFORMATION SHEET
This document provides key information about your policy. You are advised to go through your policy document
SL
Title Description Section
No
1 Name of Health Ensure
Insurance
Product
2 Policy Number 12-8435-0000111687-00
3 Type of Indemnity and Benefit
Insurance
4 Sum Insured Individual
(Basis)
5 Policy Coverages
Coverage
(What the
Policy Covers)
1. In-patient Hospitalization Treatment - Medical Expenses Section C.I.1
incurred due to admission to a Hospital for Illness or
Accidental Bodily Injury, longer than 24 consecutive hours.
2. Pre-Hospitalization - up to 30 days prior to date of Section C.I.2
admission in hospital
3. Post-Hospitalization- up to 60 days from date of Section C.I.3
discharge from the hospital
4. Road Ambulance - max. up to ₹ 1,000/- per Section C.I.4
Hospitalization
5. Day Care Procedures - Medical Expenses incurred due Section C.I.5
to admission to a Hospital for Illness or Accidental Bodily
Injury, for duration less than 24 consecutive hours as
listed on Annexure I in Policy wordings
SL
Title Description Section
No
6. Organ Donor Expenses - Medical expenses incurred Section C.I.6
towards organ donors treatment for harvesting of the
donated organ
7. Preventive Health Check Up - Free Preventive Health Section C.I.7
check up at the end of every 3 continuous policy years as
per limits specified in policy wordings
8. Ayurvedic / Homeopathic Hospitalization Expenses - Section C.I.8
Hospital admission longer than 24 consecutive hours in a
recognized Ayurvedic / Homeopathic Hospital, max. up to
Sum Insured per policy year
9. Cumulative Bonus 5% increase in base sum insured per Section E 23
claim free policy Year max. up to 25% of base Sum
Insured
Optional Covers
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Title Description Section
No
6 Exclusions General Exclusions Section D II
(What the Standard Exclusions
policy does 1. Any hospital admission primarily for investigation
not cover) diagnostic purpose (Excl04)
2. Expenses related to any admission primarily for
enforced bed rest and not for receiving treatment.
(Excl05)
3. Obesity/Weight Control (Excl06)
4. Change-of-gender treatments (Excl07)
5. Expenses for cosmetic or plastic surgery or any
treatment to change appearance unless for reconstruction
following an Accident, Burn(s) etc. (Excl08)
6. Expenses related to any treatment necessitated due to
participation as a professional in hazardous or adventure
sports (Excl 09)
7. Expenses for treatment arising from Insured
committing or attempting to commit a breach of law with
criminal intent. (Excl10)
8. Excluded Providers (Excl11)
9. Treatment for Alcoholism, drug or substance abuse.
(Excl12)
10. Treatments received in heath hydros, nature cure
clinics, etc. where admission is arranged wholly or partly
for domestic reasons. (Excl 13)
11. Dietary supplements and substances unless
prescribed as part of hospitalization claim or day care
procedure. (Excl14)
12. Expenses related to the treatment for correction of eye
sight due to refractive error less than 7.5 dioptres.
(Excl15)
13. Expenses related to any unproven treatment, services
and supplies. (Excl16)
14. Expenses related to sterility and infertility. (Excl17)
15. Medical Treatment Expenses traceable to pregnancy
and its complications. (Excl 18)
Specific Exclusions
1. Cosmetic dental procedures unless due to Accidental
Injury.
2. Medical expenses where Inpatient care and medical
supervision is not required
3. War, invasion, acts of foreign enemies
4. Circumcision unless required for the treatment of
Illness or Accidental bodily injury
5. The cost of spectacles, contact lenses, hearing aids,
crutches etc.
6. The cost of external durable medical equipment except
Cost of Artificial Limbs, cost of prosthetic devices
implanted during surgical procedure like Pacemaker,
orthopedic implants, etc.
7. External medical equipment of any kind used at home
as post-hospitalization
as post hospitalization
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Title Description Section
No
8. Intentional self-injury
9. Vaccination or inoculation
10. All non-medical Items as per Annexure II in policy
wordings
11. Any treatment received outside India
12. Congenital external diseases or defects or anomalies,
growth hormone therapy, stem cell implantation or
surgery except for Hematopoietic stem cells for bone
marrow transplant for hematological conditions.
Specific Exclusions applicable for Personal Accident
Cover
We shall not be liable to make any payment for any claim
directly or indirectly caused by, based on, arising out of or
attributable to any of the following
1. Accidental Bodily Injury that you/your family member
named in the schedule meets with
a. Through suicide, attempted suicide or self-inflicted
injury or illness.
b. While under the influence of liquor or drugs.
c. Arising or resulting from the insured person committing
any breach of law with criminal intent.
d. Whilst participating as the driver, co-driver or passenger
of a motor vehicle during motor racing or trial runs.
e. As a result of any curative treatments or interventions
that you carry out or have carried out on your body.
f. Arising out of your participation in any naval, military or
air force operations whether in the form of military
exercises or war games or actual engagement with the
enemy, whether foreign or domestic.
g. Whilst engaging in aviation or ballooning
2. Consequential losses of any kind or insured person’s
actual or alleged legal liability.
3. Any injury/disablement/death directly or indirectly
arising out of or contributed to any pre-existing condition.
4. Venereal or Sexually transmitted diseases
5. HIV (Human Immunodeficiency Virus) and/or any HIV
related illness including AIDS (Acquired Immune
Deficiency Syndrome) and/or mutant derivatives or
variations thereof however caused.
6. War (whether declared or not), civil war, invasion, act of
foreign enemies, rebellion, revolution, insurrection, mutiny,
military or usurped power, seizure, capture, arrest,
restraint or detainment, confiscation or nationalization or
requisition of or damage by or under the order of any
government or public local authority.
7. Nuclear energy, radiation.
8. Pregnancy, resulting childbirth, miscarriage, abortion, or
complications arising out of these
SL
Title Description Section
No
7 Waiting Period Initial Waiting period: 30days for all illnesses (Not Section D- I.
ﾷ Time period applicable in case of continuous renewal or accidents)
Specific Waiting period:
during which
specified 12 Months Waiting period:
disease/treatment1. Any types of gastric or duodenal ulcers
are not 2. Surgery of varicose veins and varicose ulcers
covered 3. Hydrocele
ﾷ It is counted
4. Undescended testes
5. Congenital internal diseases
from beginning
6. Surgery for any skin ailment
of the policy
24 months Waiting period
coverage
1. Benign prostatic hypertrophy
2. All types of sinuses
3. Haemorrhoids
4. Dysfunctional uterine bleeding
5. Endometriosis
6. Stonesintheurinary and biliary systems
7. Surgery on ears/tonsils/ adenoids/ paranasal sinuses
8. Cataracts,
9. Hernia of all types
10. Fistulae, Fissure in ano
11. Fibromyoma
12. Hysterectomy
13. Surgery on all internal or external tumours/ cysts/
nodules/polyps of any kind including breast lumps with
exception of Malignant tumor or growth.
14. Mental Illness
15. Parkinson’s Disease
16. Alzheimer Disease
36 months waiting period
1. Joint replacement surgery
2. Surgery for vertebral column disorders (unless
necessitated due to an accident)
3. Surgery to correct deviated nasal septum
4. Hypertrophied turbinate
5. Gout and Rheumatism
6. Treatment for correction of eye sight due to refractive
error recommended by Ophthalmologist for medical
reasons with refractive error greater or equal to 7.5
Pre-existing diseases: 24 months
SL
Title Description Section
No
8 Financial The policy will pay only up to the limits specified Section C.I.1
Limits of hereunder for the following diseases/procedures: Section C.I.4
Coverage Sub limits Section C.I.8
i. Sublimit (it is Covers Limit Section E 22
a pre defined Room Rent Limit** Room -1% of Sum insured per day Section E 22
limt and the up ₹ 5000 whichever is lower. Section E 30
insurance ICU - 2% of Sum Insured per day Section CI.7
company will or up to INR 10,000, whichever is
not pay any lower.
amount in Road Ambulance ₹1000 per hospitalization per
excess of this Policy Year
limit) Cataract Limit (per Sun Insured Limit
ii. Co-payment eye) ₹50000, ₹75000 ₹ 20000
(it is a and
specified ₹ 1lac
amount ₹ 1.5lacs, ₹ 2lacs ₹ 30000
/percentage of and
the admissible ₹ 3lacs
claim amount
₹ 4lacs, ₹ 5lacs ₹ 40000
to be paid by
and
policy
₹ 10lacs
holder/insured)
iii. Deductible ** Proportionate deduction shall be applicable on all
(it is a expenses other than cost of Pharmacy/medicines,
specified consumables, implants, medical devices & diagnostics in
amount: case of admission to a room at rates exceeding the limit
Upto which an specified as per Sum insured
Co-payment
insurance
company will Voluntary co- 10%/ 20% of each and every
not pay any payment claim payable under the Inpatient
claim and (If opted) Hospitalization Treatment
Which will be section
deducted from Zone Co-payment Those, who pay Zone B premium
total claim rates and avail treatment in Zone
amount (if A city will have to pay 20% co-
claim amount payment on admissible claim
is more than amount.
the specified Deductible – Not applicable
amount) Other Limits: The limits against the covers mentioned
iv. Any other below are over and above the In-patient Hospitalisation
limit (as sum insured
applicable) 1. Preventive Health Check Up
1% of the sum insured maximum up to INR 1500 for each
member in Individual policy and available only to proposer
& spouse under Floater Sum Insured Policies during the
block of 3 year
SL
Title Description Section
No
9 Claims/claims Cashless Claim process Section E
procedure Cashless treatment is only available at Network Hospitals 33. A & B
ﾷ You or Your representative must intimate Us 48 hours
before the planned Hospitalization and within 24 hours of
emergency hospitalization and request pre-authorization
by way of the written form
ﾷ We will review each claim for Medical Expenses,
coverage and accordingly issue an authorization letter
either to You or the Network Hospital.
Reimbursement claim process
ﾷ Applicable for claims where treatment is taken at a Non
network hospital OR If we have denied your claim as per
Cashless Claims Procedure.
ﾷ You or Your representative must intimate Us 48 hours
before the planned Hospitalization and within 48 hours of
emergency hospitalization
ﾷ You or someone claiming on Your behalf must promptly
and in any event within 30 days of discharge from a
Hospital give Us the documentation
You or someone claiming on Your behalf must promptly
and in any event within 30 days of discharge from a
Hospital give Us the documentation listed out in policy
wordings and any additional information We ask, for Our
obligation to make payment for it.
Turnaround time(TAT) for claim settlement:
1. Turnaround time (TAT) for claim settlement: 15 Working
Days
2. TAT for preauthorization of cashless facility: Within 60
Mins
TAT for cashless final bill authorization: Within 180 Mins
Weblinks
Network hospital and Black listed hospital list
https://www.bajajallianz.com/branch-locator.htmll
Helpline numbers
Tollfree: 1800-103-2529
Downloading /getting claim forms
Health Insurance Claim Process | Accident Insurance
Claim (bajajallianz.com)
10 Policy Call centre number(Toll free): 1800-209-5858
Servicing Details of Company officials: Branch-wise GRO details can
be found on the below link.
https://www.bajajallianz.com/download-
documents/other-information/GRO-List.pdf
SL
Title Description Section
No
11 Grievances Grievance Redressal Procedure: Section E.17
/Complaints a) Toll-free number 1-800-209- 5858 or 020-30305858,
Say "Hi" on WhatsApp on +91 7507245858
b) Branches for resolution of your grievances /complaints,
the Branch details can be found on our website:
www.bajajallianz.com/branch-locator.html
Register your grievances / complaints on our website:
www.bajajallianz.com/about-us/customer-service.html
c) E-mail
ﾷ Level 1: bagichelp@bajajallianz.co.in and for senior
citizens to seniorcitizen@bajajallianz.co.in
ﾷ Level 2: In case you are not satisfied with the response
given to you at Level 1 you may write to our Grievance
Redressal Officer at ggro@bajajallianz.co.in
ﾷ Level 3: If in case, your grievance is still not resolved,
and you wish to talk to our care specialist, please give a
missed call on +91 8080945060 OR SMS To 575758 and
our care specialist will call you back
d) If you are still not satisfied with the decision of the
Insurance Company, you may approach the Insurance
Ombudsman, established by the Central Government for
redressal of grievance. Detailed process along with list of
Ombudsman offices are available at
www.cioins.co.in/ombudsman
SL
Title Description Section
No
12 Things to Free Look Cancellation: Insured has an option of Section E
remember cancelling his/her policy up to 30 days from the first
inception of policy with Us , subject to rest terms and
conditions.
Policy Renewal: Except on grounds of fraud , moral
hazard or mis representation or non-co-operation, renewal
of your policy shall not be denied
Migration and Portability: At renewal Insured has an
option to migrate his /her policy to other policy with us or
port the policy to another insurer subject to terms and
conditions specified under Migration and Portability
guidelines
For detailed guidelines on Migration and Portability, kindly
refer the link
https://www.irdai.gov.in/ADMINCMS/cms/Circulars_List.a
spx?mid=3.2.3
beneficiary 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
least45days before, butnotearlierthan60days 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 Indian General/Health
insurer, the proposed Insured beneficiary will get the
accrued continuity benefits in waiting periods as per IRDAI
guidelines on portability
Change in Sum Insured: sum insured can be changed
(increased/decreased) only at the time of renewal subject
to underwriting by the company. For increase in Sum
insured , the waiting periods if any shall start afresh only
for the enhance portion of the sum insured
Moratorium period: After the expiry of Moratorium Period
no health insurance policy shall be contestable except for
proven fraud and permanent exclusions specified in the
policy contract
The moratorium would be applicable for the sum insured
of the first policy and subsequently completion of 60
continuous months would be applicable from date of
enhancement of sums insured only on the enhanced
limits
13 Your Please disclose all pre-existing disease/s or condition/s
Obligations before buying a policy. Non-disclosure may affect the
claim settlement
Disclosure of other material information during the policy
period.
Legal Disclaimer Note: The information must be read in conjunction with the product
brochure and policy document. In case of any conflict between the CIS and the policy
document, the terms and conditions mentioned in the policy document shall prevail
, p y p
In-patient Hospitalisation Treatment
Member Name Sum Insured
1.ragini gupta 300000
Declaration by policy holder
I have read the above and confirm having noted the details
Place:
Date: Signature of Policy holder
CIN:U66010PN2000PLC015329 • UIN: BAJHLIP23211V052223
