It means any institution in India established for indoor care and treatment of sickness and injuries and which either
Is duly licensed and registered as a Hospital or Nursing Home with the appropriate authorities and is under the supervision of a registered and qualified Medical Practitioner.OR
In areas where licensing and registration facilities with appropriate authorities are not available, the institution must be one recognised in locality as Hospital / Nursing Home and should comply with minimum criteria
Surgical Operation
It means manual and/ or operative procedures for correction of deformities / defects and injuries, cure of diseases, relief of suffering and
prolongation of life.
Hospitalisation Period
Expenses on Hospitalisation are admissible only if hospitalisation is for a minimum period of 24 (twenty four) hours. However,
This time limit SHALL not apply to following specific treatments taken in the Network Hospital / Nursing Home where the Insured is discharged on the same day. Such treatment SHALL be considered to be taken under Hospitalisation Benefit.
Dialysis (haemo dialysis, Peritoneal dialysis)
Parental Chemotherapy (injectible)
Radiotherapy
Eye Surgery
Lithotripsy (kidney stone removal)
Tonsillectomy
Dilation and Curettage (D&C)
Dental surgery following an accident
Hysterectomy
Coronary Angioplasty
Coronary Angiography
Surgery of Gall bladder, Pancreas and bile duct
Surgery of Hernia
Surgery of Hydrocele
Surgery of Prostrate
Gastrointestinal Surgery
Genital Surgery
Surgery of Nose
Surgery of throat and ear
Surgery of Appendix
Surgery of Urinary System
Treatment of fractures / dislocation excluding hair line fracture, Contracture releases and minor reconstructive procedures of limbs which otherwise require hospitalisation
Arthroscopic Knee surgery
Laproscopic therapeutic surgeries
Any surgery under General Anaesthesia
Any such disease / procedure agreed by TPA/Company before treatment
Further if the treatment / procedure / surgeries of above diseases/ bodily inuries are carried out, in Network specialised Day Care Centre which is fully equipped with advanced technology and specialised infrastructure where the insured is discharged on the same day, the requirement of minimum beds SHALL be overlooked provided following conditions are complied with.
The operation theatre is fully equipped for the surgical operation required in respect of the above diseases.
Day Care nursing staff is fully qualified
The doctor performing the surgery or procedure as well as post operative attending doctors should be fully qualified for the specific surgery / procedure
Other than the treatments mentioned , the condition of minimum 24 hours Hospitalisation SHALL also not apply provided
The treatment is such that it necessitates hospitalisation and the procedure involves specialised infrastructural facilities available only in hospitals, OR
Surgical procedure involved has to be done under General Anaesthesia
Due to technological advances hospitalisation in either of the case is required for less than 24 (twenty four) hours
Domiciliary Hospitalisation Benefit
It means Medical treatment for a period exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at a hospital / nursing home as in-patient but actually taken whilst confined at home in India under any of the following circumstances namely:
The MEDICAL condition of the patient is such that the patient cannot be removed to the Hospital/Nursing Home OR
The patient cannot be removed to Hospital/Nursing home due to lack of accommodation in any hospital in that city / town / village
Subject however to the condition that Domiciliary Hospitalisation benefit shall not cover
Expenses incurred for pre and post hospital treatment and
Expenses incurred for treatment for any of the following diseases
Asthma
Bronchitis
Chronic Nephritis and Nephritic Syndrome
Diarrhoea and all types of Dysenteries including Gastro-enteritis
Diabetes Mellitus and Insipidus
Epilepsy
Hypertension
Influenza, Cough and Cold
All Psychiatric or Psychosomatic Disorders
Pyrexia of unknown origin for less than 10 days
Tonsillitis and Upper Respiratory Tract infection including Laryngitis and Pharingitis
Arthritis, Gout and Rheumatism
Ambulance Services
It Means ambulance service charges reasonably and necessarily incurred in case the insured person is to be shifted from residence to hospital or from one hospital to another hospital. The ambulance service charges are payable only if the hospitalisation expenses are admissible. Further the ambulance service charges are admissible only if such expenses are paid to registered ambulance services providers.
Other Definitions and Interpretations
ENTIRE CONTRACT
This POLICY, SCHEDULE, PROPOSAL / DECLARATION given by the insured constitute a complete contract. Only Insurer may alter the terms and conditions of the policy and such alterations made by the insurer shall only be evidenced by a duly signed endorsement on the policy with the Company stamp.
TPA (THIRD PARTY ADMINISTRATOR):
means any company / body who has obtained licence from IRDA to practice as a third party administrator and is appointed as TPA by the Company.
NETWORK HOSPITAL:
means hospital that has agreed with the Company / TPA to participate in providing cashless health services to the insured persons. The list is maintained by and available with the TPA and the same is subject to amendment from time to time without any notice to the insured.
HOSPITALISATION PERIOD
The period for which an insured person is admitted in the hospital as inpatient and stays there for the sole purpose of receiving the necessary and reasonable treatment for the disease / ailment contracted / injuries sustained during the period of policy. The minimum period of stay shall be 24 (twenty four) hours
PRE-HOSPITALISATION
Reasonable and necessary medical expenses incurred for the treatment of disease/ injury during the period upto 30 (thirty) days prior to date of admission in hospital sustained SHALL be considered as part of claim ,br>
POST-HOSPITALISATION
Reasonable and necessary medical expenses incurred for the treatment of disease/ injury for a period upto 60 (sixty) days from discharge from the date of discharge from hospital SHALL be considered as part of claim
PRE EXISTING HEALTH CONDITION OR DISEASE
means any condition, ailment or
injury or related condition(s) for which the insured person/s had signs or symptoms, and / or were diagnosed, and / or received medical advice/ treatment, within 48 months prior to his / her first hospitalization benefit policy with the Company.
IN-PATIENT
An Insured person who is admitted to hospital and stays for at least 24 hours for the sole purpose of receiving the treatment for suffered ailment / illness / disease / injury / accident during the currency of the policy.
REASONABLE & NECESSARY EXPENSES
For a networked hospital means the rate pre-agreed between Network Hospital and the TPA / Company, for surgical / medical treatment that is necessary for treating the insured person who was hospitalized.
For any other hospital it shall mean the cost of surgical / medical treatment that is necessary and reasonable for treating the condition for which insured person was hospitalized.
Note:Any expenses other than the above have to be borne by the insured person himself.
CASHLESS FACILITY
The TPA may authorise upon the request of the insured for direct settlement of admissible claim as per agreed charges between Network Hospitals and the TPA./ Company In such cases, the TPA SHALL directly settle all bills of admissible amounts with the Network Hospitals and the Insured Person may not have to pay such admissible amounts to the Hospital to the extent the claim is covered under the policy.
I.D. CARD
means the card issued to the Insured Person by the TPA to avail Cashless facility in the Network Hospital.
DAY CARE PROCEDURE
It means the course of Medical treatment / surgical procedure carried out, in Network hospitals or network specialised Day Care Centre which is fully equipped with advanced technology and specialised infrastructure and where the insured is discharged on the same day after treatment.
LIMIT OF INDEMNITY
means the amount stated in the schedule which represents maximum liability for any and all claims admissible during the policy period in respect of that insured family.
ANY ONE ILLNESS
Any one illness SHALL be deemed to mean continuous period of illness and it includes relapse within 105 (one hundred and five) days from the date of discharge from the Hospital / Nursing Home / Day Care centre from where the treatment was taken. Occurrence of the same illness after a lapse of 105 (one hundred and five) days as stated above SHALL be considered as fresh illness for the purpose of this policy.
DAILY HOSPITAL CASH ALLOWANCE
When an insured member of the family is hospitalized and a claim is admitted under the GOLD plan of the policy, then the insured person SHALL be paid a daily cash allowance of the policy.
Attendant allowance
When an insured member of the family aged between three months to 10 years is hospitalized and a claim is admitted under the GOLD plan of the policy, a sum as mentioned will become payable under the policy.
