Making every policy wording comparable

SHEESHAM PERSONAL COVER Health insurance policy wording MOCK POLICY WORDING. Written for the IIB board pack demo from the product's terms in the test data. Not a real product. No real insurer is named. Unique identification number: HLT-012-85-V03 KEY FEATURES AT A GLANCE Room rent: no room rent limit, choose any room. Pre-existing diseases: covered after 4 years of continuous cover. Co-pay: none, whatever your age. Maternity: not covered. Restore benefit: 100% of the sum insured restored once in a policy year. The key features above are a summary. The policy terms below are the contract. PREAMBLE This policy is a contract between the Company and the Policyholder. The Company shall, subject to the terms, conditions and exclusions of this policy, and in return for the premium paid, indemnify the Insured Person for the medical expenses set out below, up to the Sum Insured shown in the Schedule. The proposal, the declaration, the Schedule and any endorsement form part of this policy. WORDS AND MEANINGS Accident means a sudden, unforeseen and involuntary event caused by external, visible and violent means. AYUSH treatment means hospitalisation treatment given under the Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems. Cashless facility means a facility under which the payment of the costs of treatment is made by us directly to the Network Provider, to the extent pre-authorisation is approved. Condition precedent means a policy term or condition upon which our liability under this policy depends. Congenital anomaly means a condition present since birth which is abnormal with reference to form, structure or position. An internal congenital anomaly is not in the visible and accessible parts of the body. An external congenital anomaly is in the visible and accessible parts of the body. Continuous coverage means uninterrupted coverage under one or more health insurance policies issued in India, without a break, including cover carried over through portability or migration. Day care treatment means medical treatment or a surgical procedure undertaken under general or local anaesthesia in a hospital or day care centre in less than 24 hours because of technological advancement, and which would otherwise have needed a stay of more than 24 hours. Dental treatment means treatment by a dentist, including examinations, fillings where appropriate, crowns, extractions and surgery. Emergency care means management of an illness or injury which results in symptoms that occur suddenly and unexpectedly, and needs immediate care by a medical practitioner to prevent death or serious long term impairment of health. Grace period means the period of 30 days immediately after the premium due date, during which a payment can be made to renew or continue the policy in force without loss of continuity benefits such as waiting periods and cover for pre-existing diseases. Cover is not available for the period for which no premium is received. Hospital means any institution established for in-patient care and day care treatment of illness or injuries, registered as a hospital with the local authorities, which has at least 10 in-patient beds in towns with a population of less than ten lakh and at least 15 in-patient beds in all other places, qualified nursing staff and medical practitioners in charge round the clock, a fully equipped operation theatre of its own where surgical procedures are carried out, and which keeps daily records of patients. Hospitalisation means admission in a hospital for a minimum period of 24 consecutive in-patient care hours, except for specified procedures or treatments where the admission could be for less than 24 consecutive hours. Illness means a sickness or a disease or a pathological condition leading to the impairment of normal physiological function which shows itself during the policy period and needs medical treatment. Injury means accidental physical bodily harm, excluding illness or disease, solely and directly caused by external, violent and visible means, which is verified and certified by a medical practitioner. Medical advice means any consultation or advice from a medical practitioner, including the issue of any prescription or follow up prescription. Network provider means a hospital enlisted by us, or by a third party administrator and us together, to provide medical services to an insured person by a cashless facility. Pre-existing disease means any condition, ailment, injury or disease that is diagnosed by a physician, or for which medical advice or treatment was recommended by or received from a physician, not more than 36 months before the date of commencement of the first policy issued by the insurer. Pre-hospitalisation medical expenses means medical expenses incurred during the 60 days immediately before the insured person is hospitalised, provided they relate to the same condition for which the hospitalisation was needed and the in-patient claim is admissible. Post-hospitalisation medical expenses means medical expenses incurred during the 180 days immediately after the insured person is discharged from hospital, provided they relate to the same condition and the in-patient claim is admissible. Portability means the right given to a policyholder to transfer the credit gained for pre-existing conditions and time bound exclusions from one insurer to another, or from one plan to another plan of the same insurer. Reasonable and customary charges means the charges for services or supplies which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness or injury involved. Room rent means the amount charged by a hospital towards room and boarding expenses, and shall include the associated medical expenses. Unproven treatment means any treatment, including drug experimental therapy, which is not based on established medical practice in India. Sum insured means the amount shown in the Schedule, which is the most we will pay for all claims in a policy year, together with any cumulative bonus earned. Policy year means a period of twelve months beginning from the date of commencement of the policy period and ending on the last day of that twelve month period. WHAT IS COVERED We will pay the medical expenses for in-patient care when your hospitalisation is medically necessary and lasts at least 24 consecutive hours. Room, boarding and nursing: no room rent limit, choose any room. Intensive care unit (ICU) charges are paid as charged by the hospital. Pre-hospitalisation medical expenses incurred in the 60 days before the date of admission are covered, if they relate to the same condition. Post-hospitalisation medical expenses incurred in the 180 days after discharge are covered, if they relate to the same condition. Day care treatment taken in a hospital or day care centre is covered, for the procedures listed on our website. Domiciliary hospitalisation is covered when treatment at home lasts more than three days and the patient cannot be moved to a hospital, or no hospital bed is available. In-patient AYUSH treatment taken in a government hospital or an accredited AYUSH hospital is covered up to the sum insured. Road ambulance charges are covered up to ₹3,000 for each hospitalisation, when the ambulance is run by a hospital or an ambulance service provider. The in-patient expenses of an organ donor for harvesting the organ are covered when the recipient is an insured person under this policy. Modern treatments such as robotic surgery, stem cell therapy, oral chemotherapy and immunotherapy are covered up to 50% of the sum insured. For every claim-free policy year, the sum insured will be increased by 10% of the expiring base sum insured, up to a maximum of 100%. If a claim is made, the bonus will be reduced at the same rate. A preventive health check-up is available once in every policy year, up to 1% of the sum insured, with a maximum of ₹5,000. Restore benefit: 100% of the sum insured restored once in a policy year. WAITING PERIODS Initial waiting period: thirty (30) days from the first policy start date, for all illnesses. Accidents are covered from day one. Pre-existing diseases: covered after 4 years of continuous cover. Named illnesses and procedures: covered after twenty-four (24) months of continuous cover. The list is cataract, benign prostatic hypertrophy, hernia of all types, hydrocele, fistula in ano, piles and fissures, sinusitis, tonsils and adenoids, gall bladder stones, kidney stones, joint replacement unless needed after an accident, osteoarthritis and osteoporosis, varicose veins, internal congenital anomalies, hysterectomy, polycystic ovarian disease, and benign tumours, cysts and polyps. If a condition falls under more than one waiting period, the longest of them applies. A waiting period is reduced by the period of continuous coverage already completed under a ported or migrated policy. WHAT IS NOT COVERED We do not pay for the following. Supplements. Dietary supplements and substances that can be bought without a prescription, including vitamins, minerals and organic substances, unless prescribed by a medical practitioner as part of hospitalisation. Treatment outside India. Any treatment taken outside India. Alcohol and substance abuse. Treatment for alcoholism, drug or substance abuse or any addictive condition, and the consequences of it. Rest cure, rehabilitation and respite care. Expenses related to any admission primarily for enforced bed rest and not for receiving treatment, including custodial care and respite care. Investigation and evaluation. Expenses related to any admission primarily for diagnostics and evaluation purposes only, and any diagnostic expenses which are not related or incidental to the current diagnosis and treatment. Excluded providers. Expenses incurred at any hospital or by any medical practitioner or other provider specifically excluded by us and disclosed on our website, except in a life threatening situation or after an accident, up to the stage of stabilisation. Breach of law. Expenses for treatment directly arising from or as a consequence of the commission of, or attempt to commit, a breach of law with criminal intent. Self-inflicted injury. Treatment of intentional self-injury or attempted suicide, by any means. Maternity. Medical treatment expenses traceable to childbirth, including complicated deliveries and caesarean sections incurred during hospitalisation, and expenses towards the lawful medical termination of pregnancy, except ectopic pregnancy. Dental treatment. Dental treatment or surgery of any kind, unless it is needed because of an accident and requires hospitalisation. Change of gender treatments. Expenses related to any treatment, including surgical management, to change the characteristics of the body to those of the opposite sex. War and nuclear risks. Treatment directly or indirectly caused by war, invasion, acts of foreign enemies, hostilities, civil war, rebellion or revolution, or by nuclear, chemical or biological weapons or radiation of any kind. SHARING THE COST OF A CLAIM Co-pay: none, whatever your age. Voluntary co-payment. A voluntary co-payment of 10% or 20% of every claim may be chosen at the start of the policy, in return for a premium discount of up to 15%. Unless the Schedule shows a voluntary co-payment, none applies. GENERAL CONDITIONS This policy will be void and all premium paid on it forfeited to us in the event of misrepresentation, mis-description or non-disclosure of any material fact. The terms and conditions of this policy must be fulfilled for us to make any payment for a claim under this policy. We will settle or reject a claim within 30 days of the receipt of the last necessary document. If the payment is made later than that, we will pay interest at a rate 2% above the bank rate, from the date of receipt of the last necessary document to the date of payment. Any payment to the insured person, the nominee or the legal representative will be a valid and complete discharge of our liability for that claim. If two or more policies are held with one or more insurers, the policyholder may choose which policy to claim under. Where the amount to be claimed is more than the sum insured of a single policy, the balance may be claimed under any other policy. If any claim is in any respect fraudulent, or if any false statement or declaration is made or used in support of it, all benefits under this policy and the premium paid will be forfeited. This policy may be cancelled at any time by giving 7 days notice in writing. We will refund the premium for the unexpired period of cover on a pro rata basis, provided no claim has been paid under this policy. A free look period of 30 days is given from the date of receipt of the policy document, to review its terms. If any term is not acceptable, this policy may be returned, stating the reason, and we will refund the premium paid, less the cost of any medical tests and stamp duty. This policy is renewable for life, except on grounds of fraud or misrepresentation. A grace period of 30 days is allowed to pay the renewal premium. Continuity benefits are kept if the premium is paid within the grace period. The policyholder may migrate to a similar health insurance policy with us at the time of renewal, with all accrued continuity benefits such as the cumulative bonus, if the request is made at least 30 days before the renewal date. The policyholder may transfer this policy to another insurer at renewal by applying at least 15 days, and not earlier than 60 days, before the premium renewal date. The credit gained for waiting periods will be passed on to the new insurer. After the completion of sixty continuous months of coverage, including any portability or migration, no claim under this policy will be contestable on grounds of non-disclosure or misrepresentation, except for proven fraud and the permanent exclusions in this policy. This policy remains subject to all limits, sub-limits, co-payments and deductibles in the policy contract. The premium may be paid in monthly, quarterly or half-yearly instalments. A grace period of 15 days is allowed for monthly instalments and 30 days for the others. We may revise the terms of this policy, including the premium rates, with the approval of the regulator. Notice of any revision will be given at least three months before it takes effect. A nominee must be named when this policy is bought, and may be changed at any time during the policy period by notice in writing. MAKING A CLAIM For cashless treatment at a network provider, a request for pre-authorisation must be sent through the hospital at least 72 hours before a planned admission, or within 24 hours of an emergency admission. We will decide on a cashless request within one hour and on the final bill within three hours of the discharge request. For a reimbursement claim, the documents must be sent within 30 days of discharge from hospital. They are the completed claim form, the original bills and receipts, the discharge summary, investigation reports, prescriptions, and a police report or medico-legal certificate for an accident. We may ask for further documents if they are needed to decide the claim. Claims not notified in time may still be considered if the delay was for reasons beyond the control of the claimant. COMPLAINTS Any grievance may be raised with us through the website, the toll-free number in the Schedule, by email or in writing to the Grievance Redressal Officer at our head office. We will acknowledge the complaint within 3 days and resolve it within 14 days. If the grievance is not resolved, or if no reply is received within 14 days, the complaint may be taken to the Insurance Ombudsman under the Insurance Ombudsman Rules, 2017, or registered on the regulator's online grievance portal. ANNEXURE I. LIST OF NON-PAYABLE ITEMS Baby food. Baby utility charges. Beauty services. Belts and braces. Buds. Cold packs and hot packs. Carry bags. Email and internet charges. Food charges other than the patient's diet provided by the hospital. Leggings. Laundry charges. Mineral water. Sanitary pads. Telephone charges. Guest services. Crepe bandage. Diapers of any type. Eyelet collar. Slings. Blood grouping and cross matching of donors' samples. Service charges where nursing charges are also charged. Television charges. Surcharges. Attendant charges. Extra diet of the patient. Birth certificate. Certificate charges. Courier charges. Conveyance charges. Medical certificate. Medical records. Photocopy charges. Mortuary charges. Walking aid charges. Oxygen cylinder for use outside the hospital. Spacer. Spirometer. Nebuliser kit. Steam inhaler. Arm sling. Thermometer. Cervical collar. Splint. Diabetic footwear. Knee brace. Lumbo sacral belt. Water or air bed charges. Ambulance collar. Ambulance equipment. Abdominal binder. Private nurse charges. Sugar free tablets. Creams, powders and lotions, unless payable as part of treatment. ECG electrodes. Gloves. Kidney tray. Mask. Ounce glass. Oxygen mask. Pelvic traction belt. Pan can. Trolley cover. Urometer and urine jug.