OPD exclusions Waiting Periods applicable to Benefit I :

Transcription

1 1.1. Waiting Periods applicable to Benefit I : OPD exclusions Days waiting period We are not liable for any Medical Expenses incurred during Hospitalization for treatment of any Illness which is diagnosed or any Hospitalization which began within 30 days of Policy Period Start Date, except those incurred as a result of an Injury. This exclusion shall not be applicable on subsequent Policy Period provided there is no break in insurance and the Policy is renewed on time with the same or lower Sum Insured Specific waiting period We are not liable for any Medical Expenses incurred during Hospitalization for any treatment of any of the following Illness / Surgery during the first two 1 consecutive years of coverage with us from the Policy Period Start Date : Arthritis if non-infective, Osteoarthritis and Osteoporosis, Gout, Rheumatism & Spinal Disorders, Joint Replacement Surgery Benign ear, nose and throat (ENT) Disorders and Surgeries (including but not limited to Adenoidectomy, Mastoidectomy, Tonsillectomy and Tympanoplasty), Nasal Septum Deviation, Sinusitis and related disorders Benign Prostatic Hypertrophy Cataract Dilatation and Curettage Fissure / Fistula in anus, Hemorrhoids / Piles, Pilonidal Sinus, Gastric and Duodenal Ulcers Surgery of Genito urinary system unless necessitated by malignancy All types of Hernia, Hydrocele Hysterectomy for menorrhagia or fibromyoma or prolapse of uterus unless necessitated by malignancy Internal tumors, skin tumors, cysts, nodules, polyps including breast lumps (each of any kind) unless malignant Kidney Stone / Ureteric Stone / Lithotripsy / Gall Bladder Stone Myomectomy for fibroids Varicose veins and varicose ulcers In case the above Illness / conditions are Pre-existing disease / conditions at the time of commencement of first policy with us, these shall not be covered until 48 2 months of continuous coverage has elapsed, since the first Policy Period Start Date. 1 Can be changed between 0 to 24 months depending upon the Plan 2 Can be changed to between 0 to 48 months depending upon the Plan

2 3.1.3 Any Pre-existing Disease : We are not liable for any Medical Expenses incurred during Hospitalization for any diagnosis / treatment of Pre-existing Disease during the first four 3 consecutive years of coverage with Us from the first Policy Period Start Date In case of enhancement of the Sum Insured upon renewal of this Policy, the waiting periods as defined above in 3.1.1, & shall be applicable afresh to the incremental Sum Insured In case of reduction of the Sum Insured upon renewal of this Policy, any credit for the waiting period shall be restricted to the lowest Sum Insured, under the previous Policy(es) The Waiting Periods as defined in Clause & shall be applicable individually for each Insured Person and Claims shall be assessed accordingly Portability : If You / Insured Person renew with Us, without break, your similar individual health insurance Policy from any other insurance company registered with IRDA, then the Waiting Period as defined in Clause 3.1.1, and of this Policy shall be reduced by the number of years of continuous coverage under such health insurance policy(es) with the previous insurer(s). The credit for the Waiting Period shall be restricted to the lowest Sum Insured, under the previous Policy(es) in the last 48 months before the commencement of this Policy with us; and The credit for the Cumulative Bonus / Additional Sum Insured as accumulated for the Insured Person under expiring policy shall be provided in this Policy. In case the members in the expiring policy are covered on individual basis and thus have accumulated the Cumulative Bonus for each member in the expiring policy, and such expiring policy is renewed with Us on a floater basis, then the Cumulative Bonus to be carried forward for credit in this Policy would be the least Cumulative Bonus amongst all the members. In case where the members in the expiring policy are covered on a floater basis and such members renew such expiring policy with Us by splitting the floater cover in to 2 or more floater / individual covers, then the Cumulative Bonus of the expiring policy shall be apportioned to such renewed Policy(es) with Us in the proportion of the Sum Insured of each of the renewed Policy(es). Provided that the expiring policy is renewed with Us for a Sum Insured, which is at least equal to the expiring policy Sum Insured. The credit for Waiting Period and the Cumulative Bonus / Additional Sum Insured shall be applicable individually for each Insured Person and Claims shall be assessed accordingly Permanent Exclusions applicable to Benefit I : We shall not be liable for any Claim arising out of any Hospitalization or any Medical expenses incurred under Benefit I arising out of or howsoever related to any of the following : 3 Can be changed to between 0 to 48 months depending upon the Plan

3 3.2.1 Any condition directly or indirectly caused by or associated with any sexually transmitted disease, including Genital Warts, Syphilis, Gonorrhoea, Genital Herpes, Chlamydia, Pubic Lice and Trichomoniasis, Acquired Immuno Deficiency Syndrome (AIDS) whether or not arising out of HIV, Human T-Cell Lymphotropic Virus Type III (HTLV III or IITLB-III) or Lymphadinopathy Associated Virus (LAV) or the mutants derivative or Variations Deficiency Syndrome or any Syndrome or condition of a similar kind Any treatment arising from or traceable to pregnancy (including voluntary termination), miscarriage (unless due to an Accident), childbirth, maternity (including caesarian section), abortion or complications of any of these. However, this exclusion will not apply to ectopic pregnancy, which is proved by diagnostic means and certification by gynecologist that it is life threatening Any treatment arising from or traceable to any fertility, infertility, sub fertility or assisted conception procedure or sterilization or procedure, birth control procedures, hormone replacement therapy, contraceptive supplies or services including complications arising due to supplying services or Assisted Reproductive Technology Any dental treatment or surgery unless necessitated due to an Injury Treatment taken from anyone not falling within the scope of definition of Medical Practitioner or from a Medical Practitioner who is practicing outside the discipline for which he is licensed or any kind of self-medication Charges incurred in connection with cost of spectacles and contact lenses, hearing aids, routine eye and ear examinations, laser surgery for correction of refractory errors, dentures, artificial teeth and all other similar external appliances and / or devices whether for diagnosis or treatment Experimental, investigational or unproven treatments which are not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any Illness for which confinement is required at a Hospital. Any Illness or treatment which is result or a consequence of undergoing such experimental or unproven treatment. Any diagnosis / treatment of an Illness / Injury which does not require Hospitalization Any expenses incurred on prosthesis, corrective devices, external durable medical equipment of any kind, like wheelchairs, walker, belts, collar, caps, splints, braces, stockings of any kind, diabetic footwear, glucometer/thermometer, crutches, ambulatory devices, instruments used in treatment of sleep apnoea syndrome (C.P.A.P) or continuous ambulatory peritoneal dialysis (C.A.P.D.) and oxygen concentrator for asthmatic condition, cost of cochlear implant(s) Weight management services and treatment, vitamins and tonics related to weight control programmes, services and supplies including treatment of obesity (including morbid obesity) Any treatment related to sleep disorder or sleep apnoea syndrome, general debility convalescence, cure, rest cure, health hydros, nature cure clinics, sanatorium treatment, Rehabilitation measures, private duty nursing, respite care, long-term nursing care, custodial care or any treatment in an establishment that is not a Hospital Treatment of all Congenital Anomaly / Illness or defects or anomalies or treatment relating to birth defects Any medical or physical condition or treatment or service, which is specifically excluded under this Policy Treatment of mental illness, stress, psychiatric or psychological disorders Aesthetic treatment, Cosmetic Surgery and plastic surgery or related treatment of any description, including any complication arising from these treatments, other than as may be necessitated due to an Injury.

4 Any treatment / surgery for change of sex or gender reassignments including any complication arising from these treatments Circumcision unless necessary for treatment of an Illness or as may be necessitated due to an Accident All preventive care, vaccination, including inoculation and immunizations (except in case of postbite treatment), vitamins & tonics Artificial life maintenance, including life support machine use, where such treatment will not result in recovery or restoration of the previous state of health Any travel or transportation expenses including Ambulance charges All expenses related to donor screening, treatment, including surgery to remove organ(s) from the donor, in case of transplant surgery All expenses related to non-allopathic treatment All expenses related to outpatient treatment All expenses related to any treatment received outside India Any domiciliary hospitalization/ treatment Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, Illness or Injury, for which Hospitalization is required 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 Any Illness / Injury directly or indirectly resulting or arising from or occurring during commission of any breach of any law by the Insured Person with any criminal intent Act of self-destruction or self-inflicted Injury, attempted suicide or suicide while sane or insane or Illness attributable to use, misuse or abuse of intoxicating drugs and alcohol Any charges incurred to procure any medical certificate, treatment / Illness related documents pertaining to any period of Hospitalization / Illness Personal comfort & convenience items or services including but not limited to T.V. (wherever specifically charged separately), charges for access to telephone and telephone calls(wherever specifically charged separately), foodstuffs (except patient s diet), cosmetics, hygiene articles, body care products and bath additive, barber or beauty service, guest service as well as similar incidental services and supplies Stem Cell implantation, harvesting, storage or any kind of treatment using stem cells Expenses related to any kind of RMO charges, service charge, surcharge, admission fees, registration fees, Night charges levied by the hospital under whatever head Any Hospitalization primarily for investigation and / or diagnosis purpose Nuclear, Chemical or Biological attack/ 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 Clause : a. Nuclear attack/ 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 incapacitating disablement or death. b. Chemical attack/ 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 incapacitating disablement or death. c. Biological attack/ weapons means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organism(s) and/or biologically produced toxin(s)

5 (including genetically modified organisms and chemically synthesized toxins) which are capable of causing incapacitating disablement or death. Also excluded herein is any loss, claim or expense of whatsoever nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection with any action taken in controlling, preventing, suppressing, minimizing or in any way relating to the above Impairment of an Insured s intellectual faculties by abuse of stimulants or depressants or by the illegal use of any solid, liquid or gaseous substance Alopecia, wigs and/or toupee and all hair or hair fall treatment and products Permanent Exclusions (Applicable to Benefit II) : We shall not be liable for any Claim for the Medical Expenses incurred, towards any Medical Treatment of the Insured Person, as mentioned under Benefit II arising out of or howsoever related to any of the following : Act of self-destruction or self-inflicted Injury, attempted suicide or suicide while sane or insane or Illness attributable to use, misuse or abuse of intoxicating drugs and alcohol Experimental, investigational or unproven treatments which are not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any Illness for which treatment is being taken. Any Illness or treatment which is result or a consequence of undergoing such experimental or unproven treatment Any Illness / Injury directly or indirectly resulting or arising from or occurring during commission of any breach of any law by the Insured Person with any criminal intent Treatment received outside India Any Illness / Injury, directly or indirectly, caused by or arising from or attributable to war, foreign invasion, act of foreign enemy, hostilities (whether war be declared or not), civil war, rebellion, revolution, insurrection, military or usurped power or confiscation, active participation in riot or civil commotion, nationalization or requisition of or damage by or under the order of any government or public local authority Directly or indirectly arising out of Nuclear, Chemical or Biological weapons, contributed to, caused by, resulting from, or in connection with any of the following regardless of any other cause or event contributing concurrently or in any other sequence to the loss, claim or expense : A. Utilization of Nuclear weapons means the use of any nuclear weapon or device or the emission, discharge, dispersal, release or escape of fissile material emitting a level of radioactivity capable of causing incapacitating disablement or death. B. Utilization of Chemical 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 incapacitating disablement or death. C. Utilization of Biological weapons means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organism(s) and/or biologically produced toxin(s) (including genetically modified organisms and chemically synthesized toxins) which are capable of causing incapacitating disablement or death. Also excluded hereon is any loss, claim or expense of whatsoever nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection with any action taken in controlling, preventing, suppressing, minimizing or in any way relating to the above.