MaxBupaTermsAndConditions

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Heartbeat Health Insurance PolicyPolicy Document


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1. Terms & Conditions

The insurance cover provided under this Policy to theInsured Person up to the Sum Insured is and shall be

subject to (a) the terms and conditions of this Policyand (b) the receipt of premium, and (c) theinformation You provided to Us (including by way ofthe Proposal or Information Summary Sheet) on Yourbehalf and on behalf of all persons to be insured.Please inform Us immediately of any change in theaddress, occupation, state of health, or of any otherchanges affecting You or any Insured Person.

2. Benefits

The Policy covers reasonable expenses incurredtowards medical treatment taken during the PolicyPeriod for an Illness, Accident or condition described

below if this is contracted or sustained by an InsuredPerson during the Policy Period and subject always tothe Sum Insured, any subsidiary limit specified in theProduct Benefits Table, the terms, conditions,limitations and exclusions mentioned in the Policyand eligibility as per the insurance plan opted for inthe Product Benefits Table and as shown in theSchedule:

2.1. In-patient Treatment

We will cover Medical Expenses for:

a. Doctors fees

b. Diagnostics proceduresc. Medicines, drugs and consumables

d. Intravenous fluids, blood transfusion, injectionadministration charges

e. Operation Theatre charges

f. The cost of prosthetics and other devices orequipment if implanted internally during aSurgical Operation

g. Intensive Care Unit charges

2.2. Hospital Accommodation

We will cover Reasonable and Customary charges forHospital accommodation.

2.3. Pre-hospitalisation Medical Expenses

We will cover Medical Expenses incurred due to Illnessup to 30 days immediately before an Insured Personsadmission to a Hospital for the same Illness as long asWe have accepted an in-patient Hospitalisation claimunder 1 above. Pre-hospitalisation expenses can beclaimed as reimbursement only.

2.4. Post-hospitalisation Medical Expenses

We will cover Medical Expenses incurred due toIllness up to 60 days immediately after an InsuredPersons discharge from Hospital for the same Illness

as long as We have accepted an in-patientHospitalisation claim under 1 above.Post-hospitalisation expenses can be claimed asreimbursement only.

2.5. Day-Care Procedures

We will cover Medical Expenses for Day-CareProcedures where such procedures are undertakenby an Insured Person as an in-patient in a Hospital fora continuous period of less than 24 hours. Anyprocedure undertaken on an out-patient basis in aHospital will not be covered.

2.6. Domiciliary Treatment

We will cover Medical Expenses for medical treatmenttaken at home if this continues for an uninterruptedperiod of 3 days and the condition for whichtreatment is taken would otherwise have necessitatedhospitalisation as long as either (i) the attendingDoctor confirms that the Insured Person could not betransferred to a Hospital or (ii) You satisfy Us that aHospital bed was unavailable.

2.7. Maternity Benefits

1. We will cover Medical Expenses for thedelivery of a child subject to the following:

a. This benefit is available only under a FamilyFloater Policy.

b. This benefit is available for You or Yourspouse provided You and Your spouse, bothare covered under the same Policy.

c. We must have received at least 3continuous annual premiums from Yousince the date of commencement of thefirst Policy Period and cover will be availableunder Maternity Benefit only after 24months of continuous coverage have

elapsed since the inception of the firstPolicy with Us.

d. Our maximum liability per pregnancy willbe subject to the specified sub-limit asshown in the Product Benefits Table.

e. We will cover Pre or Post-hospitalisationMedical Expenses only where Sum Insuredis more than Rs 10 lacs.

Policy Document - Part II

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2. We will cover Medical Expenses related to aMedically Necessary termination ofpregnancy subject to the conditionsmentioned in 2.7 (1) above.

3. The benefit under section 2.7 (1) and 2.7

(2) above may be claimed only twice duringthe lifetime of the Insured Person.

4. The following expenses are not coveredunder Maternity Benefit:

a. Medical Expenses in respect of theharvesting and storage of stem cellswhen carried out as a preventivemeasure against possible futureillnesses.

b. Medical Expenses for ectopicpregnancy. However, these expenses arecovered under the in-patient benefit.

2.8 New Born Baby

If We have accepted a Maternity Benefits claim under2.7 above, then We will:

a. Cover Medical Expenses towards the medicaltreatment of the Insured Persons new bornbaby while the Insured Person is Hospitalisedas an in-patient for delivery.

b. Cover the new born baby as an InsuredPerson until the expiry date of the Policywithout the payment of any additionalpremium.

c. Cover the Reasonable and Customaryvaccination expenses of the new born babyfor the vaccinations shown in Annexure I tothis Policy until the new born baby completesone year. If the Policy ends before the newborn baby has completed one year, then, Wewill only cover such vaccinations until thebaby completes one year, and only if We haveaccepted the baby as an Insured Person atthe time of renewal and You have paid thepremium accordingly.

2.9 Organ Donor

We will cover Medical Expenses for an organ donorstreatment for the harvesting of the organ donatedprovided that:

a. The donation conforms to TheTransplantation of Human Organs Act 1994and the organ is for the use of the InsuredPerson.

b. The Insured Person has been medicallyadvised to undergo an organ transplant.

We will not cover:

a. Pre-hospitalisation or post-hospitalisationMedical Expenses or screening expenses ofthe donor or any other Medical Expenses as aresult of the harvesting from the donor;

b. Costs directly or indirectly associated with theacquisition of the donors organ.

2.10 Emergency ambulance

We will cover Reasonable and Customary ambulanceexpenses incurred to transfer the Insured Personfollowing an Emergency to the nearest Hospital withadequate facilities if:

a. The ambulance service is offered by ahealthcare or ambulance service provider;

b. We have accepted an In-patientHospitalisation claim under the provisions of

2.1 above;

In the case of Out Of Network Hospitalisation Ourmaximum liability for ambulance expenses is limitedto Rs 2,000/- per event.

2.11 Health Relationship Loyalty Programme

If the Policy is renewed with Us without any break,You become eligibile for Health Relationship LoyaltyProgramme announced by Us from time to time.Under this programme, We offer vouchers, in eitherelectronic or physical form, worth up to 10% of your

renewal premium for availing certain health servicesand products. You or any Insured Person may avail ofsuch services and products within next 3 Policy Yearsif all of the following requirements are met:

a. The vouchers are used for health services andbenefits communicated from time to time;

b. The conditions or limitations specified in thevouchers are adhered to;

c. The vouchers are used (and will only be valid)at empanelled service provider(s); and

d. The Policy is continuously renewed.

2.12 Health Check-upWe will cover the cost of a health check-up as perYour plan eligibility as defined in the Product BenefitsTable. We will only cover health check-ups arrangedby Us through Our empanelled service providers.

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2.13 Specialist Consultation and Diagnostic Tests (ForPlatinum Policyholders only)

We will cover an Insured Persons Reasonable andCustomary consultation expenses of MedicallyNecessary consultation with a Specialist, as an

out-patient to assess the Insured Persons healthcondition for any Illness. We will also pay for anydiagnostic tests prescribed by the Specialist up to thesub-limits shown in the Product Benefits Table.

If the Policy is renewed with Us without any break andthere is an unutilized amount (not used by theInsured Person) under the applicable sub-limit in aPolicy Year, then We will carry forward 80% of thisunutilized amount to the next Policy Year, providedthat the total amount (including the unutilizedamount available under this benefit) shall at no timeexceed 2.5 times the amount of the entitlement inrespect of this benefit under the plan You opted for asper the Product Benefits Table.

2.14. Child Care Benefits

(For Platinum Policyholders only)

We will cover Reasonable and Customary expenses forthe vaccinations shown in Annexure I to this Policy forchildren who are included as Insured Persons untilthey have completed 12 years of age. We will alsocover expenses towards one consultation for nutritionand growth provided to the child during a visit forvaccination.

3. Co-pay

If any Insured Person is 65 years of age or over on thedate of commencement of the current Policy Period,then it is agreed that We will only pay 80% of anyamount We assess for payment or reimbursement inrespect of any claim made by that Insured Person andthe balance will be borne by the Insured Person.

4. Exclusions

We shall not be liable under this Policy for any claim inconnection with or in respect of the following:

a. Pre-Existing ConditionsBenefits will not be available for Pre-existingConditions until 48 months of continuouscoverage have elapsed since the inception ofthe first Policy with Us.

b. 90 Days Waiting Period

We will not cover any treatment taken duringthe first 90 days since the date ofcommencement of the Policy, unless thetreatment needed is the result of an Accident

or Emergency. This waiting period does notapply for any subsequent and continuousrenewals of Your Policy.

c. Specific Waiting Periods

For all Insured Persons who are above 60 yearsof age as on the date of commencement of thefirst Policy Period, the conditions listed below willbe subject to a waiting period of 24 months andwill be covered in the third Policy Year as long asthe Insured Person has been insuredcontinuously under the Policy without any break:

1. Stones in the urinary system

(eg. kidney/bladder)

2. Stones in billiary system (eg. gall stones)

3. Cataract

4. BPH - Benign prostatic hypertrophy

5. Mennoraghia, Fibromyoma, Uterineprolapse including any condition requiringHysterectomy

6. Piles (Haemorrhoids)

7. Hernia (Inguinal/umbilical and gastric)

8. Degenerative disorders of knee/hip

9. Chronic renal failure or end stage renalfailure

10. Retinopathy

11. Diabetes and related treatments

d. Personal Waiting Periods

Conditions mentioned under Personal WaitingPeriod in the Schedule will be subject to awaiting period of 24 months and will becovered in the third Policy Year as long as theInsured Person has been insured continuouslyunder the Policy without any break.

e. Permanent Exclusions

We will not be liable under any circumstances,for any claim in connection with or withregard to any of the following permanentexclusions

i. Addictive conditions and disordersTreatment related to rehabilitation fromaddictive conditions and disorders, or fromany kind of substance abuse or misuse.

ii. Ageing and puberty

Treatment to relieve symptoms caused byageing, puberty, or other naturalphysiological cause, such as menopauseand hearing loss caused by maturing orageing.

iii. Artificial life maintenance

Artificial life maintenance, including life

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support machine use, where suchtreatment will not result in recovery orrestoration of the previous state of health

iv. Circumcision

Circumcision unless necessary for the

treatment of a disease or necessitatedby an Accident.

v. Conflict and disaster

Treatment for any Illness or injuryresulting from nuclear or chemicalcontamination, war, riot, revolution, actsof terrorism or any similar event (otherthan natural disaster or calamity), if oneor more of the following conditionsapply:

1. Insured Person put himself in dangerby entering a known area of conflict

where active fighting or insurrectionsare taking place.

2. Insured Person was an activeparticipant in the above mentionedacts or events of a similar nature.

3. Insured Person displayed a blatantdisregard for personal safety.

vi. Congenital conditions

Treatment for any Congenital Anomaly.

vii. Convalescence and rehabilitation

Hospital accommodation when it isused solely or primarily for any of the

following purposes:1. Convalescence, rehabilitation,

supervision or any other purposeother than for receiving eligibletreatment of a type that normallyrequires a stay in Hospital.

2. Receiving general nursing care or anyother services that do not requirethe Insured Person to be in Hospitaland could be provided in anotherestablishment that is not a Hospital.

3. Receiving services from a therapist orcomplementary medical practitioneror a practitioner of alternativemedicine.

viii. Cosmetic surgery

Treatment undergone purely forcosmetic or psychological reasons toimprove appearance including:

1. Treatment related to or arising fromthe removal of non-diseased, orsurplus or fat tissue, whether or notit is needed for medical orpsychological reasons.

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2. Any treatment or procedure to changethe shape or appearance of breast(s)whether or not it is needed formedical or psychological reasons,unless for reconstruction carried out

within two years of surgery for breastcancer.

ix. Dental/oral treatment

Treatment for any dental or oralcondition, which includes surgicaloperations for the treatment of bonedisease when related to gum disease ordamage, or treatment for, or treatmentarising from, disorders of thetempromandibular joint.

EXCEPTION: However We will pay for asurgical operation undertaken as an

in-patient in a Hospital for a continuousminimum period of 24 hours carried outby a Doctor to:

1. put a natural tooth back into a jawbone after it is knocked out ordislodged in an Accident .

2. treat irreversible bone diseaseinvolving the jaw which cannot betreated in any other way, but not if itis related to gum disease or toothdisease or damage.

3. surgically remove a complicated,buried or impacted tooth root, for

example in the case of an impactedwisdom tooth.

x. Drugs and dressings for out-patient ortake-home use

Any drugs or surgical dressings that areprovided or prescribed in the case ofOut-patient treatment, or for an InsuredPerson to take home on leaving Hospital,for any condition, except as included inpost-hospitalisation expenses underclause 2.4 above.

xi. Eyesight

Treatment to correct eyesight, unlessrequired as the result of an Accident. Wewill not pay for routine eye examinations,contact lenses, spectacles or laser eyesight correction.

xii. Experimental treatment

Treatment, including medication, which inOur opinion is experimental or has notgenerally been proved to be effective.


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xiii. Health hydros, nature cure, wellnessclinics etc.

Treatment or services received in healthhydros, nature cure clinics or anyestablishment that is not a Hospital.

xiv. HIV and AIDSAny treatment for, or treatment arisingfrom, Human Immunodeficiency Virus(HIV) or Acquired Immuno DeficiencySyndrome (AIDS), including anycondition that is related to HIV or AIDS.

xv. Hereditary conditions

Treatment of abnormalities, deformities,or Illnesses present only because theyhave been passed down through thegenerations of the family.

xvi. Items of personal comfort and

convenience, including but not limitedto:

1. Telephone, television, diet charges(unless included in room rent),personal attendant or barber orbeauty services, baby food,cosmetics, napkins, toiletry items,guest services and similar incidentalexpenses or services.

2. Private nursing/attendants chargesincurred during Pre-Hospitalisationor Post-Hospitalisation.

3. Non-prescribed drugs and medicalsupplies.

4. Issue of medical certificate andexaminations as to suitability foremployment or travel or any othersuch purpose.

5. Any charges incurred to procure anytreatment/illness related documentspertaining to any period ofhospitalisation/illness.

6. External and or durable Medical/Nonmedical equipment of any kind usedfor diagnosis and or treatment

including CPAP, CAPD, Infusionpump etc.

7. Ambulatory devices i.e. walker,crutches, belts, collars, caps, splints,slings, braces, stockings of any kind,diabetic foot wear, glucometer/thermometer and similar items andalso any medical equipment which issubsequently used at home.

8. Nurses hired in addition to theHospitals own staff.

xvii. Non-allopathic treatment

Any other streams of medicine apartfrom allopathy. We will not pay forother streams of treatment includingayurvedic, homeopathic or unani

medicine.xviii. Neurological and Psychiatric

Conditions

Treatment of any mental illness orsickness or disease including apsychiatric condition, disorganisationof personality or mind, or emotions orbehaviour, Parkinsons or Alzheimersdisease even if caused or aggravated byor related to an Accident or Illness orgeneral debility or exhaustion(run-down condition).

xix. ObesityTreatment for obesity where the bodymass index (BMI) is greater than 29.

xx. Out-patient Treatment

Out-patient treatment is not coveredexcept those out-patient benefitsexplicitly stated as an eligible benefitfor Your chosen plan.

xxi. Reproductive medicine - Birth control &Assisted reproduction:

1. Any type of contraception,sterilization, termination of

pregnancy (except as provided forunder Benefit 2.7 above) or familyplanning.

2. Treatment to assist reproduction,including IVF treatment.

xxii. Self-inflicted injuries

Treatment for, or arising from, an injurythat is intentionally self-inflicted,including attempted suicide.

xxiii. Sexual problems and gender issues

Treatment of any sexual problemincluding impotence (irrespective ofthe cause) and sex changes or genderreassignments or erectile dysfunction.

xxiv. Sexually transmitted diseases

Treatment for any sexually transmitteddisease, including Genital Warts,Syphilis, Gonorrhoea, Genital Herpes,Chlamydia, Pubic Lice andTrichomoniasis.

xxv. Sleep disorders

Treatment for sleep apnea, snoring, orany other sleep-related breathingproblem.

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xxvi. Speech disorders

Treatment for speech disorders,including stammering.

xxvii. Treatment for developmental problems

Treatment for, or related todevelopmental problems, including:

1. Learning difficulties, such asdyslexia;

2. Behavioral problems, includingattention deficit hyperactivitydisorder (ADHD).

xxviii. Treatment received outside India

Any treatment received outside India isnot covered under this policy.

xxix. Unrecognised physician or Hospital:

1. Treatment provided by a medicalpractitioner who is not recognisedby the Medical Council of India.

2. Treatment in any Hospital or by anyMedical Practitioner or any otherprovider of services that We haveblacklisted. Details of the same canbe viewed on Our website.

3. Treatment provided by anyone withthe same residence as InsuredPerson or who is a member of theInsured Persons immediate family.

5. Standard Terms and Conditions

a. Reasonable Care

The Insured Person shall take all reasonablesteps to safeguard against any Accident orIllnesses that may give rise to any claim underthis Policy.

b. Observance of terms and conditions

The due observance and fulfillment of theterms, conditions and endorsement of thisPolicy in so far as they relate to anything to bedone or complied with by the Insured Person,shall be a condition precedent to any liabilityto make payment under this Policy.

c. SubrogationThe Insured Person shall do and concur indoing and permit to be done all such acts andthings as may be necessary or required by Us,before or after indemnification, in enforcing orendorsing any rights or remedies, or ofobtaining relief or indemnity, to which We areor would become entitled or subrogated.Neither You nor any Insured Person shall doany acts or things that prejudice thesesubrogation rights in any manner. Anyrecovery made by Us pursuant to this clause

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shall first be applied to the amounts paid orpayable by Us under this Policy and the costsand expenses incurred by Us in effecting therecovery, whereafter We shall pay the balanceamount to You.

d. ContributionIf the Insured Person is covered by any otherpolicy which covers any claim in whole or inpart made under this Policy (or would coverany claim made under this Policy, if this Policydid not exist) then We shall not be liable topay or contribute more than Our rateableproportion of the claim.

e. Fraudulent claims

If a claim is in any way found to be fraudulent,or if any false statement, or declaration ismade or used in support of such a claim, or if

any fraudulent means or devices are used bythe Insured Person or anyone acting on behalfof the Insured Person to obtain any benefitunder this Policy, then this Policy shall be voidand all claims being processed shall beforfeited for all Insured Persons. And all sumspaid under this Policy shall be repaid to Us byall Insured Persons who shall be jointly liablefor such repayment.

f. Free Look Provision

You have a period of 15 days from the date ofreceipt of the Policy document to review theterms and conditions of this Policy. If You have

any objections to any of the terms andconditions, You have the option of cancellingthe Policy stating the reasons for cancellationand You shall be refunded the premium paidby You after adjusting the amounts spent onany medical check-up, Stamp duty chargesand proportionate risk premium. You cancancel your Policy only if You have not madeany claims under the Policy. All Your rightsunder this Policy shall immediately standextinguished on the free look cancellation ofthe Policy. Free look provision is not applicableand available at the time of renewal of the

Policy.g. Cancellation/ Termination (other than freelook

cancellation)

1. Cancellation by Insured Person:

The Insured Person may terminate this Policyby giving 7 days prior written notice to Us.We shall cancel the Policy and refund thepremium for the period as mentioned herein


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below, provided that no claim has been filedunder the Policy by or on behalf of anyInsured Person:

Length of time Refund of premiumPolicy in force

up to 30 days 75%

up to 90 days 50%

up to 180 days 25%

exceeding 180 days 0%

2. Automatic Cancellation:

a. Individual Policy:

The Policy shall automatically terminate incase of death of the Policyholder.

b. Family Floater Policy:The Policy shall automatically terminate inthe case of the death of the Policyholder.However, and subject to Our acceptance,the Policy may be continued on anapplication by another adult InsuredPerson under the Policy.

c. Refund:

Refund as per table in section 5(g)(1)above shall be payable in case of anautomatic cancellation of the Policyprovided that no claim has been filedunder the Policy.

3. Cancellation by Us:

Without prejudice to e above, We mayterminate this Policy by sending 30 daysprior written notice to Your address shownin the Schedule without refund ofpremium if in Our opinion:

i. You or any Insured Person or any personacting on behalf of either has acted in adishonest and fraudulent manner underor in relation to this Policy; and/or

ii. Continuance of the Policy poses amoral hazard;

h. Territorial JurisdictionAll benefits are available in India only, andall claims shall be payable in India inIndian Rupees only.

i. Policy Disputes

Any dispute concerning the interpretationof the terms, conditions, limitationsand/or exclusions contained herein shallbe governed by Indian law and shall besubject to the jurisdiction of the IndianCourts.

j. Renewal of Policy

The renewal premium is payable on the due datein the amount shown in the Schedule or at suchaltered rate as may be reviewed and notified byUs. We are under no obligation to notify You of

the renewal date of Your Policy. We will allow aGrace Period of 30 days from the due date of therenewal premium for payment to Us.

If the Policy is not renewed within the GracePeriod then We may agree to issue a fresh policysubject to Our underwriting criteria and nocontinuing benefits shall be available from theexpired Policy.

k. Notices

Any notice, direction or instruction given underthis Policy shall be in writing and delivered by

hand, post, or facsimile toi. The Insured Person at the address specified in

the Schedule or at the changed address ofwhich We must receive written notice.

ii. Us at the following address.

Max Bupa Health Insurance Company Limited

D-1, 2nd Floor, Salcon Ras Vilas,

District Centre, Saket, New Delhi - 110 017.

Fax No. : 1800-3070-3333

In addition, we may send You other informationthrough electronic and telecommunication

means with respect to Your Policy from time totime.

l. Claims Procedure

(a). Cashless Hospitalisation Facility for NetworkHospitals:

(i). The health card We provide will enable anInsured Person to access treatment on acashless basis only at any NetworkHospital on the production of the card tothe Hospital prior to admission, providedthat:

1. The Insured Person has notified Us in

writing at least 72 Hours before aplanned Hospitalisation. In anemergency the Insured Person shouldnotify Us in writing within 48 hours ofHospitalization; and

2. We have pre-authorised the in-patientor day care procedure.

(ii) Cashless treatment will not be available ifYou take treatment in an Out Of NetworkHospital.

(iii) For cashless Hospitalisation We will makethe payment of the amounts assessed to

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be due directly to the NetworkHospital. The treatment must takeplace within 15 days of thepre-authorisation date andpre-authorization is only valid if all the

details of the authorised treatment,including dates, Hospital andlocations, match with the details ofthe actual treatment received.

(iv) If pre-authorisation is not obtainedthen the cashless facility will not beavailable and the claims procedureshall be as per (b)(ii) below.

(b). Out Of Network Hospitals & All OtherClaims for Reimbursement:

(i) We should be notified in writing with a

request to pre-authorise expenditure tobe reimbursed under this Policy at least72 hours prior to the planned date ofsuch treatment, consultation orprocedure being taken and We must havepre-authorised such treatment,consultation, service or procedure. In anemergency the Insured Person shouldnotify Us in writing within 48 hours ofHospitalisation.

(ii) For any Illness or Accident or medicalcondition that requires Hospitalisation,the Insured Person shall deliver to Us the

documents listed below, at his ownexpense, within 30 days of the InsuredPerson's discharge from Hospital (whenthe claim is only in respect ofpost-hospitalisation within 30 days of thecompletion of the post-hospitalisation):

1. Duly filled claim form(s).

2. Original bills, receipts and dischargecertificate/card from the Hospital/Doctor.

3. Original bills from chemistssupported by proper prescription.

4. Original investigation test reportsand payment receipts.

5. Doctor's referral letter advisinghospitalisation in non-accidentcases.

6. Details of any other insurance policythat may respond to the claim.

7. First Information Report (FIR) formedico-legal cases.

(iii) For any medical treatment takenfrom an Out-Of-Network Hospital

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We will only pay Medical Expenseswhich are Reasonable andCustomary.

(c). For Network and Out-Of-Network

Hospitals

In all cases:

(i) We reserve the right to call for:

1. Any other documentation orinformation that We believe may berequired; and

2. A medical examination by OurDoctor or for an investigation asoften as We believe this to benecessary. Any expenses related tosuch examinations or investigationsshall be borne by Us.

(ii) In the event of the Insured Person'sdeath during Hospitalisation, writtennotice accompanied by a copy of thepost mortem report (if any) shall begiven to Us within 14 days regardlessof whether any other notice has beengiven to Us. We reserve the right torequire an autopsy.

(iii) For the purposes of benefit 2, it isunderstood and agreed that if aHospital room of the categorypermitted by the insurance planopted for, as shown in the Product

Benefits Table, is unavailable, then Wewill only be liable to make paymentfor a Hospital room of a lowercategory that is actually occupied.

(d). It is hereby agreed and understood thatin providing pre-authorisation or accepting aclaim for reimbursement under this Policy ormaking a payment under this Policy, Wemake no representation and/or give noguarantee and/or assume no responsibilityfor the appropriateness, quality or

effectiveness of the treatment sought orprovided.

m. Alteration to the Policy

This Policy constitutes the complete contractof insurance. Any change in the Policy willonly be evidenced by a written endorsementsigned and stamped by Us. No one exceptUs can change or vary this Policy.


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n. Change of Policy holder

If You do not renew the Policy, any other adultInsured Person may apply to renew the Policywithin 7 days of the end of the Policy Periodprovided that We receive an application andthe premium from such Insured Person andevidence satisfactory to Us of the agreementof all other Insured Persons. If We accept suchapplication and the premium for the renewedPolicy is paid on time, then the Policy shall betreated as having been renewed without abreak in cover.

o. Nominee

You can at the inception or at any time beforethe expiry of the Policy, make a nomination forthe purpose of payment of claims.

Any change of nomination shall becommunicated to Us in writing and suchchange shall be effective only when an

endorsement on the Policy is made by Us.In case of any Insured Person other than Youunder the Policy, for the purpose of paymentof claims in the event of death, the defaultnominee would be You.

p. Customer Service and Grievances Reddressal:

(i). In case of any query orcomplaint/grievance, You may approachOur office at the following address:

Customer Services Department

Max Bupa Health Insurance CompanyLimited, D-1, 2nd Floor, Salcon Ras Vilas,

District Centre, Saket, New Delhi -110 017. Phone No: 1800-3010-3333

Fax No. : 1800-3070-3333

Email ID: [email protected]

(ii). In case You are not satisfied with thedecision of the above office, or have notreceived any response within 10 days,You may contact the following official forresolution:

Head Customer Services

Max Bupa Health Insurance CompanyLimited, D-1, 2nd Floor, Salcon Ras Vilas,

District Centre, Saket, New Delhi -110 017. Phone No : 1800-3010-3333

Fax No. : 1800-3070-3333

Email ID: [email protected]

(iii). In case You are not satisfied with Ourdecision/resolution, You may approachthe Insurance Ombudsman at theaddresses given in Annexure II.

(iv). The complaint should be made in writingduly signed by the complainant or byhis/her legal heirs with full details of thecomplaint and the contact information of

the complainant.

(v). As per provision 13(3) of the Redressalof Public Grievances Rules 1998, thecomplaint to the Ombudsman can bemade

1. only if the grievance has been

rejected by the Grievance RedressalMachinery of the Insurer;

2. within a period of one year from thedate of rejection by the insurer;

3. if it is not simultaneously under anylitigation.

6. Interpretations & Definitions

In this Policy the following words or phrases shallhave the meanings attributed to them whereverthey appear in this Policy and for this purpose thesingular will be deemed to include the plural, the

male gender includes the female where thecontext permits:

Def. 1. Accident or Accidental means a sudden,unforeseen and involuntary event caused byexternal and visible means.

Def. 2. Congenital Anomaly refers to either:

i) an external condition(s) which ispresent since birth, in the visible andaccessible parts of the body, and whichis abnormal with reference to form,

structure or position, ORii) a condition(s) which is present sincebirth, but is internal and not visible

Def. 3. Co-pay is a cost-sharing requirement under ahealth insurance policy that provides thatthe insured will bear a specified percentageof the admissible costs. A co-pay does notreduce the Sum Insured.

Def. 4. Day Care Procedure refers to medicaltreatment, and/or surgical procedure whichis:

undertaken under General or LocalAnaesthesia in a Hospital/day care centrein less than 24 hrs because oftechnological advancement, and

which would have otherwise required ahospitalisation of more than 24 hours.

Treatment normally taken on anout-patient basis is not included in thescope of this definition.

Def. 5. Dependents means those of Your familymembers as listed below:

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i) Legally married spouse as long as he/she continues to be married to You;

ii) Unmarried children aged less than 21years, who are financially dependanton You and do not have their ownindependent households;

Def. 6. Diagnostic tests: Investigations, such asX-Ray or blood tests, to find the cause ofyour symptoms and medical condition.

Def. 7. Domiciliary Treatment: Domiciliary treatmentmeans medical treatment for a periodexceeding 3 days, for an llness/disease/injurywhich in the normal course would requirecare and treatment at a Hospital but isactually taken while confined at home underany of the following circumstances:

the condition of the patient is such thathe/she is not in a condition to be movedto a Hospital, or

the patient takes treatment at home onaccount of non availability of room in aHospital.

Def. 8. Doctor is a medical practitioner who holds avalid registration from the medical council ofany state of India and is thereby entitled topractice medicine within its jurisdiction; andis acting within the scope and jurisdiction ofhis licence.

Def. 9. Emergency means a severe illness or injurywhich results in symptoms which occursuddenly and unexpectedly, and requiresimmediate care by a Doctor to prevent deathor serious long term impairment of theInsured Persons health.

Def. 10.Family Floater Policy means a policy in termsof which You and Your Dependents named inthe Schedule are insured as at the date ofcommencement.

Def. 11.Grace Period means the specified period oftime immediately following the premium duedate during which a payment can be madeto renew or continue a policy in forcewithout loss of continuity benefits such aswaiting periods and coverage of Pre-existingconditions. Coverage is not available for theperiod for which no premium is received.

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Def. 12.Hospital means any institution establishedfor In-patient care and day care treatment ofsickness and/or injuries and which has beenregistered as a hospital with the localauthorities, wherever applicable, and isunder the supervision of a registered andqualified medical practitioner AND mustcomply with all minimum criteria as under:

a) has at least 10 inpatient beds, inthose towns having a population ofless than 10,00,000 and 15inpatient beds in all other places;

b) has qualified nursing staff under itsemployment round the clock;

c) has qualified Doctor (s) in chargeround the clock;

d) has a fully equipped operation theatreof its own where surgical proceduresare carried out;

e) maintains daily records of patientsand will make these accessible to theInsurance companys authorisedpersonnel.

Def. 13.Hospitalisation or Hospitalised means theadmission as an In-patient into a Hospital fornecessary medical treatment for a continousminimum period of 24 hours as aconsquence of an Illness or Accidentoccurring during the Policy Period.

Def. 14.Information Summary Sheet means therecord and confirmation of informationprovided to Us or Our representatives overthe telephone for the purposes of applyingfor this Policy.

Def. 15.Intensive CareUnit means an identifiedsection, ward or wing of a hospital which isunder the constant supervision of adedicated Doctor(s), and which is speciallyequipped for the continuous monitoring andtreatment of patients who are in a criticalcondition, or require life support facilities

and where the level of care and supervisionis considerably more sophisticated andintensive than in the ordinary and otherwards.


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Def. 16. Illness means sickness (which is a conditionor an ailment that impacts on the generalsoundness and health of the body of theInsured Person) or a disease (which is anaffliction of the Insured Persons bodily

organs that has a distinct and recognisedpattern of symptoms) or a pathologicalcondition which results in detriment tonormal physiological function and whichshows itself during the Policy Period andnecessitates medical Treatment. Illness doesnot mean and this Policy does not cover anymental illness or sickness or disease(including but not limited to a psychiatriccondition, disorganisation of personality ormind, or emotions or behaviour) even ifcaused by or aggravated by or related to anAccident or Illness.

Def. 17. In-patient: Treatment for which the InsuredPerson has to stay in a hospital for more than24 hours for a covered event.

Def. 18. Insured Person means You and the personnamed as insured in the Schedule.

Def. 19. Medical Expenses means expenses necessailyand actually incurred for medical treatmentduring the Policy Period on the advice of aDoctor due to Illness or Accident, by an

Insured Person, which are Reasonable andCustomary.

Def. 20.Medically Necessary: Medically necessarytreatment is defined as any treatment, tests,medication, or stay in Hospital or part of astay in Hospital which:

a) is required for the medicalmanagement of the illness or injurysuffered by the insured;

b) must not exceed the level of carenecessary to provide safe, adequateand appropriate medical care in scope,duration, or intensity;

c) must have been prescribed by a Doctor;

d) must conform to the professionalstandards widely accepted ininternational medical practice or by themedical community in India.

Def. 21.Network means all such Hospitals, day carecentres or other providers that the We havemutually agreed with, to provide services likecashless access to Policyholders. The list is

available with Us and subject to amendmentfrom time to time.

Def. 22.Out-Of-Network means any Hospital, daycare centre or other provider that is not part

of the Network.

Def. 23.Out-patient Treatment means treatmentgiven at a hospital, doctors' consulting room,office or out-patient clinic where You are notadmitted for Day Care Procedures orIn-patient treatment.

Def. 24.Policy means these terms and conditions ,any annexure thereto and the schedule

(as amended from time to time), Yourstatements in the proposal form and the

Information Summary Sheet and the policywording (including endorsements, if any).

Def. 25. Policy Period means the period between thedate of commencement and the Expiry Datespecified in the Schedule.

Def. 26.Pre-existing Condition means any condition,ailment or injury or related condition(s) forwhich the Insured Person had signs orsymptoms, and/or were diagnosed, and/orreceived medical advice/treatment, within

48 months prior to the first Policy issuedby Us.

Def. 27.Product Benefits Table means the ProductBenefits Table issued by Us andaccompanying this Policy and annexuresthereto.

Def. 28.Qualified Nurse is a person who holds a validregistration from the Nursing Council ofIndia or the Nursing Council of any state inIndia.

Def. 29.Rehabilitation: Treatment aimed at restoringhealth or mobility, or to allow a person to livean independent life, such as after a stroke.

Def. 30.Reasonable and Customary charges meansthe charges for services or supplies, whichare the standard charges for the specificprovider and consistent with the prevailingcharges in the geographical area for identicalor similar services among comparableproviders, taking into account the nature ofthe Illness/injury involved.

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Def. 34.Surgical Operation means manual and/oroperative procedure (s) required fortreatment of an Illness or injury, correctionof deformities and defects, diagnosis andcure of diseases, relief of suffering or

prolongation of life, performed in a Hospitalor day care centre by a Doctor.

Def. 35. We/Our/Us means Max Bupa HealthInsurance Company Limited

Def. 36.You/Your/Policyholder means the personnamed in the Schedule who has concludedthis Policy with Us.

Def. 31.Schedule means the schedule issued by Us,and, if more than one, then the latest intime.

Def. 32. Specialist Doctor means a Doctor who is

registered and licensed by a state council,governed by the Medical Council of India,and having specialised qualification in thefield of, or expertise in, the treatment of theillness or injury being treated but does notinclude a general practitioner.

Def. 33.Sum Insured means the sum shown in theSchedule which represents Our maximumtotal and cumulative liability for any and allclaims under the Policy during the PolicyPeriod.

12

Any reference to any statute shall be deemed to refer to any replacement or amendment to that statute.


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Silver Gold Platinum

Complete Blood Count and ESR Tests Complete Blood Count and ESR Tests Complete Blood Count and ESR Tests

Urine Routine Analysis Urine Routine Analysis Urine Routine Analysis

Pre and Post Fasting Blood Sugar Test Pre and Post Fasting Blood Sugar Test Pre and Post Fasting Blood Sugar Test




Serum Cholesterol & Triglycer ides Chest X-Ray Chest X-Ray

ECG ECG ECG

Blood test for blood sugar levels status in past 90 days Blood test for blood sugar levels status in past 90 days

Serum Cholesterol and Triglycerides Serum Cholesterol and Triglycerides

Kidney Function Test

PSA (males only)

Prostate Exams (males only)

Mammography (females only)

Cervical Smear (females only)




Lipid Profile Chest X-Ray Chest X-Ray

ECG ECG ECG

Blood test for average plasma sugar concentration

in past 90 daysBlood test for average plasma sugar concentrationin past 90 days

Serum Cholesterol and Triglycerides Serum Cholesterol and Triglycerides

Liver Function Test Liver Function Test

Kidney Function Test Kidney Function Test

Hepatitis B surface Antigen

Tread Mill Test or Stress Test

Abdominal Ultrasound

Prostate Exams (males only)

Mammography (females only)

Age band 50 years

Health check-up tests on Policy renewal


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Office of the Ombudsman Name of the Ombudsmen Contact Details Areas of Jurisdiction

AHMEDABAD Shri Amitabh Shri Amitabh, Gujarat , UT of Dadra &Insurance Ombudsman, Office Nagar Haveli, Daman and Diuof the Insurance Ombudsman,2nd Floor, Ambica House,Nr. C.U. Shah College,Ashram Road,AHMEDABAD-380 014.Tel.:- 079-27546840Fax : 079-27546142Email [email protected]

BHOPAL Shri N.A.Khan Shri N.A. Khan, Madhya Pradesh & ChhattisgarhInsurance Ombudsman,Office of the Insurance Ombudsman,Janak Vihar Complex,2nd Floor, 6, Malviya Nagar, Opp.Airtel, Near New Market,BHOPAL(M.P.)-462 023.Tel.:- 0755-2569201Fax : 0755-2769203Email [email protected]

BHUBANESHWAR Shri S.K.Dhal Shri S.K. Dhal, Insurance Ombudsman, OrissaOffice of the Insurance Ombudsman,62, Forest Park,BHUBANESHWAR-751 009.Tel.:- 0674-2596455Fax : 0674-2596429Email [email protected]

CHANDIGARH Shri K.M.Chadha Insurance Ombudsman,Office of the Insurance Ombudsman, Punjab , Haryana,

S.C.O. No.101-103, 2nd Floor, Himachal Pradesh, JammuBatra Building. Sector 17-D, & Kashmir , UT of ChandigarhCHANDIGARH-160 017.Tel.:- 0172-2706468Fax : 0172-2708274Email [email protected]

CHENNAI Shri V. Ramasaamy Shri V. Ramasaamy, Tamil Nadu, UTPondicherryInsurance Ombudsman, Town and Karaikal (which areOffice of the Insurance Ombuds part of UT of Pondicherry)man, Fathima Akhtar Court,4th Floor, 453 (old 312),Anna Salai, Teynampet,CHENNAI-600 018.Tel.:- 044-24333668 /5284Fax : 044-24333664

Email [email protected] DELHI Insurance Ombudsman,

Office of the Insurance Ombudsman, Delhi & Rajashthan2/2 A, Universal Insurance Bldg.,Asaf Ali Road, NEW DELHI-110 002.Tel.:- 011-23239633Fax : 011-23230858Email [email protected]

GUWAHATI Shri Sarat Chandra Sarma Shri Sarat Chandra Sarma, Assam , Meghalaya,Insurance Ombudsman, Manipur, Mizoram,Office of the Insurance Ombudsman, Arunachal Pradesh, NagalandJeevan Nivesh, 5th Floor, Near and TripuraPanbazar Overbridge, S.S. Road,GUWAHATI-781 001 (ASSAM).Tel.:- 0361-2132204/5

Fax : 0361-2732937Email [email protected]

Annexure II List of Insurance Ombudsmen


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Smt. Rita Bhattacharya, Shri D V Dixit,Secretary General Dy. Secretary3rd Floor, Jeevan Seva Annexe, 3rd Floor, Jeevan Seva Annexe,S.V. Road, Santacruz(W), S.V. Road, Santacruz(W),

Mumbai - 400 021 Mumbai - 400 021Tel: 022-26106245 Tel: 022-26106980Fax: 022-26106949 Fax: 022-26106949Email- [email protected]

OFFICE OF THE GOVERNING BODY OF INSURANCE COUNCIL


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Max Bupa Health Insurance Company LimitedCorporate Office: D-1, 2nd Floor, Salcon Ras Vilas, District Centre, Saket, New Delhi - 110 017.

Registered Office: Max House, 1, Dr. Jha Marg, Okhla, New Delhi - 110 020.

www.maxbupa.com

Max, Max Logo, 'Bupa' and HEARTBEAT logo are trademarks of their respective owners and are beingused by Max Bupa Health Insurance Company Limited under license.

Insurance is the subject matter of solicitationUAN MB/BR/09 10/19

HB/TC/031

0/V1.0

Documents

MaxBupaTermsAndConditions