Outpatient

The scope of cover of outpatient benefit, if covered as per the Policy schedule and Table of benefits, includes the following:

• Physician’s Consultation fees
• Diagnostic Procedures
• Prescribed drugs
• Physiotherapy on referral by a Physician
• Bandages, splints, crutches and plaster casts only if medically necessary and prescribed by a Physician.

The scope of cover of In-patient benefit, if covered as per the Policy schedule and Table of benefits, includes the following:

Hospital accommodation & services which include:

• Consultant’s & Physician’s fees
• Surgeon’s & anesthetists fees
• Surgery fees
• General nursing care
• Consultant’s & Physician’s fees
• Diagnostic procedures
• Operating Theatre charges
• Recovery room charges
• Intensive care unit charges
• Drugs and medications dispensed in the Hospital
• Dressings
• Other eligible services whilst hospitalized
• Operative physiotherapy, if medically necessary
• Ambulance
• Parent accompanying an insured child under ten (10) years of age (if covered)
• Hospital cash benefit if the Treatment is received in a government Hospital where the Treatment is provided free of charge.
• Nursing at home, for recovery and in lieu of Hospital stay up to a maximum of fourteen (14) days per admission or procedure (if covered)

Dental

The scope of cover of dental benefit, if covered as per the Policy schedule and Table of benefits, includes the following:

• Dentist’s Consultation
• Diagnostic Procedures
• Related prescription
• Extractions
• All fillings including amalgam, composite and glass ionomer fillings.
• Gum and root canal Treatment

Exclusions: The following Treatment and services are excluded:

• Routine dental Treatment including but not limited to cleaning, scaling and polishing
• Dentures, bridges and crowns
• Cosmetic Treatment

Optometry/Optical

The scope of cover of dental benefit, if covered as per the Policy schedule and Table of benefits, includes the following:

• Vision tests to diagnose the following errors of retraction’
• Hyperopia
• Myopia
• Astigmatism
• Anisometropia
• Presbyopia

Plain lenses only for the correction of the above mentioned errors of refraction subject to sub-limit.

If pre-existing condition benefit is included in the policy, then Treatment for the following conditions are covered:

• Cataract
• Diabetic Retinopathy
• Retinal detachment
• Glaucoma
• All Ophthalmic conditions other than those mentioned in the below exclusions

Exclusions:The following Treatment and services are excluded:

• Spectacle Frames
• Contact lenses
• Photo chromatic lenses
• Surgeries for correction of errors of refraction
• Strabismus
• Ptosis
• Ophthalmic surgery

Maternity

The scope of cover of maternity benefit, if covered, is as per the Policy schedule and Table of benefits, which includes following:

• Physicians’ Consultation fees
• Antenatal care, delivery and pre natal care
• Caesarian section, if medically necessary
• Hospital services
• Vitamin and mineral supplements
• Complications arising from pregnancy
• Legal abortion, approved as medically necessary by a Physician
• Care of the child whilst the mother is in Hospital

Exclusions: The following Treatment and services are excluded:

• Investigations or Treatment related to maternity within the moratorium period of two hundred eighty (280) days from the Insured member’s joining date, unless otherwise stated in the Table of benefits.
• Abortion due to voluntary, psychological or social reasons, and its consequences.
• Elective cesarean deliveries, if not medically necessary.

GENERAL EXCLUSIONS The items procedures and medical conditions listed below and their related or consequential expenses are excluded from the coverage provided under this policy unless specifically stated to be included in the table of benefits or endorsement(s) to this policy:

1. All pre-existing conditions, unless agreed otherwise in the schedule of benefits.

2. Services, accommodation or treatment charges incurred in Health Hydros, Spas, Ayurvedic Resorts/Centres, Nature Cure Clinics, Rest Homes or any similar place even if it is registered as a hospital, residential stay in a hospital or any similar institution arranges wholly or partly for domestic reasons and which is not directly related to treatment, or beyond the period required for recovery from treatment. Services received before the effective date of coverage or during an inpatient stay that began before the effective date or services received after coverage ends.

3. Routine medical examinations or check-ups, routine eye and ear examination, routine foot care, optometric examinations (vision tests), spectacles, contact lenses and correction of vision, vaccinations, inoculations, medical certificates and examination for residence, employment or travel. Optical or Maternity or complications of pregnancy or Dental and/or orthodontic treatment unless listed in the table of benefits.

4. Any pharmaceutical products which are not on the approved list of drugs and which are not considered to be medically necessary for the specific treatment of the medical condition or bodily injury as per the list attached to the policy contract.

5. Elective/cosmetic treatment or circumcision unless medically necessary and pre-authorized by the insurer.

6. Bulmia, anorexia nervosa, obesity, baldness, anxiety, insomnia, homesickness, loss of appetite and any other eating disorders. Health Services and associated expenses for the surgical treatment and non-surgical, medical treatment of obesity (including morbid obesity), and any other weight control programs, services, or supplies.

7. Tests or treatment related to contraception or sterilization, infertility, impotency, sexual dysfunction or any similar condition.

8. Birth defects, congenital illness or hereditary conditions, Deviated Nasal Septem & Nasal Conchae and associated conditions, Septoplasty, maternity examinations/complications and any treatment/conditions related to or caused by pregnancy and childbirth, unless listed in the table of benefits.

9. Treatment of mental illness and psychiatric and development disorder unless related to treatment covered by the policy or listed as covered in the table of benefits.

10. Any treatment or test for acquired immune deficiency syndrome (AIDS) and AIDS/HIV related conditions or sexually transmitted diseases, self inflicted injury, suicide alcohol or drug addiction/abuse

11. Treatments resulting from racing of any form and professional participation in hazardous sports.

12. Treatment for any illnesses or injuries resulting from active participation in war, riots, civil disturbances, terrorism, acts against any foreign hostility, whether war has been declared or not treatment for any medical conditions arising directly or indirectly from chemical contamination, radioactivity or any nuclear material whatsoever, including the combustion of nuclear fuel.

13. Unless otherwise provided for under the plan and listed in the table of benefits, treatment of chronic conditions including palliative treatment. 14. All vaccinations and routine or preventive medical examinations including routine follow up consultations.

15. Treatment received outside the territorial limits described in the table of benefits and/or expenses incurred where the insured against medical advise.

16. Costs incurred in connection with locating or the acquisition of a replacement organ or any costs incurred for the removal of the organ from the donor, transportation costs of same and all associated administration costs.

17. Prosthesis corrective devices or durable appliances and medical appliances that are not surgically required, including hearing aids and/or any substance not considered as medicine.

18. Complimentary medicine applications such as chiropractic, KKT and Osteopath.

19. Treatment of any allergic condition or disorder, however, the initial visit to diagnose an allergy will be covered.

20. All substances which are not considered medicines such as but not limited to mouthwash, toothpaste, lozenges, antiseptic solutions, milk formulas, food supplements, skincare products, sanitary pad, shampoos etc.

21. Home visits unless it is an emergency as defined in the policy definitions.

22. Hormone replacement therapy (HRT) unless carried out as part of or immediately after a surgical procedure which is covered under the table of benefits to this plan.

23. Skin disorders like warts, keloid, acne, Lipoma and Mollusum contagiosum

24. Any treatment or test, second or subsequent opinion for which the required insurer’s pre-authorization is not obtained. 25. Benefits recoverable under Workmen’s compensation act insurance.

26. Claims directly or indirectly occasioned by happening through, or in consequence of, aviation, other than as a fare paying passenger in a fully certified passenger carrying aircraft, flown in the course of licensed operation for the transportation of passengers by properly licensed crew.

27. Consultations or Treatment of speech and voice problems.

28. All Auditory Accessories, Eyeglasses and contact lenses.

29. Loss of hearing unless caused by a medical condition covered under the policy, hearing aids, ear and body piercing.

30. Any medical prescription relative to a special diet, weight control, children’s food, baby supplies, slimming pills, scalp and hair lotions and shampoos etc.

31. Vitamins or multivitamins are not covered. However, vitamins prescribed by a doctor along with antibiotic are covered. Also, in case of severe vitamin deficiency, wherein injectible vitamins are prescribed, same would be covered.

32. All maternity related benefits unless provided for under the plan and listed in the table of benefits.

33. Claims for cryopreservation, implantation of living cells or living tissue, whether autologous or provided by a donor.

34. Medical practitioner fees for the completion of a claim form or other administration charges.

35. Expenses incurred because of complications directly caused by an illness, injury or treatment for which cover is excluded or limited under your plan.

36. Road Traffic Accidents where the claim is payable under Motor Insurance Policy

37. All Hepatitis except Hepatitis A are not covered

38. Upper and lower jawbone surgery (including that related to the tempanomandibular joint) except for direct treatment of acute traumatic Injury or cancer. No Coverage is provided for orthodontic surgery, jaw alignment, or treatment for the tempanomandibular joint.

39. Custodial care; domiciliary care; private duty nursing; respite care; rest cures. (Custodial care means (1) non health related services, such as assistance in activities of daily living, or (2) health related services which do not seek to cure or which are provided during periods when the medical condition of the patient is not changing or (3) services which do not require continued administration by trained medical personnel.)

40. Personal comfort and convenience items or services such as television, telephone, barber or beauty service, guest service and similar incidental services and supplies.

41. Health Services and associated expenses for cosmetic and/or reconstructive treatment and procedures.

42. Health Services and associated expenses for Experimental, Investigational or Unproven Services, treatments, devices and pharmacological regimens, except for Health Services which are otherwise Experimental, Investigational or Unproven that are deemed to be, in the Company’s judgment, Covered Health Services. The fact that an Experimental, Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Coverage if the procedure is considered to be Experimental, Investigational or Unproven in the treatment of that particular condition.

43. Health Services that are performed outside of the country in which this contract is issued, unless prior approval is received from the Company, or International Coverage is provided through a separate Rider.

44. Any Health Services and associated expenses for alopecia, baldness, hair falling, dandruff, wigs, or toupees. 45. Services and supplies for smoking cessation programs and the treatment of nicotine addiction are excluded.

46. Non-Medically Necessary amniocentesis.

47. Health Services and associated expenses for sex transformation operations, voluntary sterilization and for reversal of sterilizations. Contraceptive supplies or services. All services related to fertility/infertility as varicocele or polycystic ovary/ ovarian cyst or hormonal disturbances etc. and sexual dysfunction. VaricoCele and associated conditions in Males are not covered. PCOD & associated conditions in Females are not covered

48. Growth hormone therapy.

49. Outpatient prescribed or non prescribed medical supplies including elastic stockings, ace bandages, gauze, syringes, diabetic test strips, and like products; non-Prescription Drugs and treatments. (Bandages, gauze etc. are covered as a part of emergency treatment given at any medical facility)

50. Mental Health and/or Substance Abuse Services, including pharmaceuticals, in-patient and out-patient treatments.

51. Services rendered by a Provider with the same legal residence as a Covered Person or who is a member of a Covered Person's family, including spouse, brother, sister, parent or child.

52. Enteral feedings (infusion formulas via a tube into the upper gastrointestinal tract) and other nutritional and electrolyte supplements, unless done as a consequence to other Medically Necessary Inpatient care.

53. All cases resulting from alcoholism use of drugs & hallucinatory substances.

54. Senile dementia, Alzheimer’s disease, Menopause and Osteoporosis

55. Acupuncture; acupressure; hypnotism, Rolfing; massage therapy; aromatherapy;.

56. Health Services and associated expenses for in-vitro fertilization (IVF), gamete intra-fallopian transfer (GIFT) procedures, and zygote intrafallopian transfer (ZIFT) procedures, and any related prescription medication treatment; embryo transport; donor ovum and semen and related costs, including collection and preparation.

57. Elective non-accident related surgery for correction of refraction errors and/or Improvement of vision (quantitative or qualitative).

58. Charges by a provider for telephone consultations.

Download Section

– HD Medical
– Sample Policy
– Medical Data format