The coverages available under this policy are classified as Base Cover and Optional Cover. Base Cover refers to the coverage available as default under Super Top-Up Medicare Policy whereas Optional Cover is available only upon payment of additional premium.

BASE COVER

The Policy provides base coverage as described below in this section:

1. In-Patient Hospitalisation Expenses Cover

We will pay the Reasonable and Customary Charges for the following Medical Expenses of an Insured Person in case of Hospitalisation provided that the admission date of the Hospitalisation due to Illness or Injury is within the Policy Period:

1. Room, Boarding and Nursing expenses (all-inclusive) incurred as provided by the Hospital/Nursing Home. These expenses will include nursing care, RMO charges, IV Fluids/Blood transfusion/injection administration charges and similar expenses
2. Charges for accommodation in Intensive Care Unit (ICU)/ Intensive Cardiac Care Unit (ICCU)
3. The fees charged by the Medical Practitioner, Surgeon, Specialists and anaesthetists treating the Insured Person;
4. Anaesthesia, blood, oxygen, operation theatre charges, surgical appliances, implants, prosthetic devices implanted during surgical procedure, medicines and drugs, costs towards diagnostics, diagnostic imaging modalities and such similar other expenses.
5. Other In-patient Expenses
   
   1. Dental treatment, necessitated due to disease or injury
   2. Plastic surgery necessitated due to disease or injury
   3. All the day care treatments
   4. v. Mental illness cover

2. Pre-Hospitalisation and Post-Hospitalisation Expenses

We will cover, on a reimbursement basis, the Insured Person’s:

1. Pre-hospitalisation Medical Expenses incurred due to an Illness or Injury during the period subject to following limits:

2. Post- hospitalisation Medical Expenses incurred due to an Illness or Injury during the period subject to following limits

Provided that:

1. We have accepted a claim for primary In-patient Hospitalization
2. The Pre-hospitalisation and/or Post-hospitalisation Medical Expenses are related to the same Illness or Injury.
3. Home Care Treatment also will be deemed as hospitalisation for this cover.

3. Home Care Treatment Expenses:

We will pay the Reasonable and Customary Charges for Home Care Treatment for any epidemic/ pandemic subject to the limits linked to the Threshold, as mentioned in the table below:

Home Care Treatment means Treatment availed by the Insured Person at home for any epidemic/ pandemic on positive diagnosis of the epidemic/ pandemic in a Government authorised diagnostic Centre, which in normal course would require care and treatment at a hospital but is actually taken at home maximum up to 14 days per incident provided that:

1. the Medical Practitioner advises the Insured Person to undergo treatment at home;
2.  there is a continuous active line of treatment with monitoring of the health status by a medical practitioner for each day throughout the duration of the home care treatment;
3.  daily monitoring chart including records of treatment administered duly signed by the treating doctor is maintained;
4.  in case the insured intends to avail the services of a non-network provider, claim shall be subject to reimbursement, a prior approval from the Insurer needs to be taken before availing such services. In this benefit, the following shall be covered if prescribed by the treating Medical Practitioner and is related to treatment of epidemic/ pandemic,

a. Diagnostic tests undergone at home or at diagnostics centre;

b. Medicines prescribed in writing;

c. Consultation charges of the medical practitioner;

d. Nursing charges related to medical staff;

e. Medical procedures limited to the parenteral administration of medicines;

f. Cost of Pulse oximeter, Nebulizer and Rental cost for Oxygen cylinder, oxygen concentrator, if needed.

4. Organ Donor Expenses Cover:

We will cover the In-patient Hospitalization Medical Expenses incurred for an organ donor’s treatment during the Policy Period for the harvesting of the organ donated up to the Sum Insured provided that:

1. The donation conforms to The Transplantation of Human Organs Act 1994 and the organ is for the use of the Insured Person;
2.  We have admitted a claim towards In-patient Hospitalisation under the Base Cover and it is related to the same condition; organ donated is for the use of the Insured Person as certified in writing by a Medical Practitioner;
3. We will not cover:

a. pre-hospitalization Medical Expenses or Post-hospitalisation Medical Expenses of the organ donor;

b. screening expenses of the organ donor;

c. costs directly or indirectly associated with the acquisition of the donor’s organ;

d. transplant of any organ/tissue where the transplant is experimental or investigational;

e. expenses related to organ transportation or preservation;

f. any other medical treatment or complication in respect of the donor, consequent to harvesting.

5. Road Ambulance Cover

We will cover the expenses incurred:

i. subject to a maximum of Rs. 2500 per event; and further

ii. subject to a maximum of Rs. 5000 per policy period on transportation of the Insured Person by road Ambulance to a Hospital for treatment in an Emergency following an Illness or Injury which occurs during the Policy Period.

The necessity of use of an Ambulance must be certified by the treating Medical Practitioner and becomes payable if a claim has been admitted under In-patient hospitalization and the expenses are related to the same illness or Injury. We will also cover the costs incurred on transportation

of the Insured Person by road Ambulance in the following circumstances up to the limits specified above under this cover, if:   

a. it is medically required to transfer the Insured Person to another Hospital or diagnostic centre during the course of Hospitalization for advanced diagnostic treatment in circumstances where such facility is not available in the existing Hospital;

b. it is medically required to transfer the Insured Person to another Hospital during the course of Hospitalization due to lack of super speciality treatment in the existing Hospital.

6.   Modern Treatment Methods & Advancement in Technologies

In case of an admissible claim under In-patient hosptalization, expenses incurred on the following procedures (wherever medically indicated) either as in-patient or as part of day care treatment in a hospital, shall be covered. The claim shall be subject to additional sub-limits indicated against them in the table below:

OPTIONAL COVERS

Daily Cash Allowance on Hospitalisation

We will pay Daily Cash Allowance to the insured person for every continuous and completed period of 24 hours of Hospitalisation, subject to the hospitalisation claim being admissible under the policy, as per the table below:

The aggregate of Daily Cash Allowance during the policy period shall not exceed ‘per policy period limits’ as mentioned in the table above. Daily Cash Allowance will not be payable for Day Care Procedure claims where the hospitalisation is less than 24 hours. A deductible equivalent to Daily Cash Allowance for the first 24-hours of Hospitalization will be levied on each Hospitalisation during the Policy Period.