New India Assurance Premier Mediclaim Policy

2.8.2 FIRST HEART ATTACK - OF SPECIFIED SEVERITY

I. The first occurrence of myocardial infarction which means the death of a portion of the heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis for this will be evidenced by all of the following criteria:
i. a history of typical clinical symptoms consistent with the diagnosis of Acute Myocardial Infarction (for e.g. typical chest pain)
ii. New characteristic electrocardiogram changes
iii. Elevation of infarction specific enzymes, Troponins or other specific biochemical markers.

II. The following are excluded:
i. Non-ST-segment elevation myocardial infarction (NSTEMI) with elevation of Troponin I or T
ii. Other acute Coronary Syndromes
iii. Any type of angina pectoris.

2.8.3 OPEN CHEST CABG

I. The actual undergoing of open chest Surgery for the correction of one or more coronary arteries, which is/are narrowed or blocked, by coronary artery bypass graft (CABG). The diagnosis must be supported by a coronary angiography and the realization of Surgery has to be confirmed by a specialist Medical Practitioner.

II. The following are excluded:
i. Angioplasty and/or any other intra-arterial procedures
ii. Any key-hole or laser Surgery.

2.8.4 OPEN HEART REPLACEMENT OR REPAIR OF HEART VALVES

I. The actual undergoing of open-heart valve Surgery is to replace or repair one or more heart valves, as a consequence of defects in, abnormalities of, or disease-affected cardiac valve(s). The diagnosis of the valve abnormality must be supported by an echocardiography and the realization of Surgery has to be confirmed by a specialist Medical Practitioner. Catheter based techniques including but not limited to, balloon valvotomy/valvuloplasty are excluded.

2.8.5 COMA OF SPECIFIED SEVERITY

I. A state of unconsciousness with no reaction or response to external stimuli or internal needs. This diagnosis must be supported by evidence of all of the following:
i. No response to external stimuli continuously for at least 96 hours;
ii. Life support measures are necessary to sustain life; and
iii. Permanent neurological deficit which must be assessed at least 30 days after the onset of the coma.
II. The condition has to be confirmed by a specialist Medical Practitioner. Coma resulting directly from alcohol or drug abuse is excluded.

2.8.6 KIDNEY FAILURE REQUIRING REGULAR DIALYSIS

I. End stage renal disease presenting as chronic irreversible failure of both kidneys to function, as a result of which either regular renal dialysis (haemodialysis or peritoneal dialysis) is instituted or renal transplantation is carried out. Diagnosis has to be confirmed by a specialist Medical Practitioner.

2.8.7 STROKE RESULTING IN PERMANENT SYMPTOMS
I. Any cerebrovascular incident producing permanent neurological sequelae. This includes infarction of brain tissue, thrombosis in an intracranial vessel, haemorrhage an demobilisation from an extra cranial source. Diagnosis has to be confirmed by a specialist
Medical Practitioner and evidenced by typical clinical symptoms as well as typical findings in CT scan or MRI of the brain. Evidence of permanent neurological deficit lasting for at least 3 months has to be produced.
II. The following are excluded:
i. Transient ischemic attacks (TIA)
ii. Traumatic injury of the brain
iii. Vascular disease affecting only the eye or optic nerve or vestibular functions.

2.8.8 MAJOR ORGAN /BONE MARROW TRANSPLANT

I. The actual undergoing of a transplant of: i. One of the following human organs: heart, lung, liver, kidney, pancreas, that resulted from irreversible end-stage failure of the relevant organ, or
ii. Human bone marrow using haematopoietic stem cells. The undergoing of a transplant has to be confirmed by a specialist Medical Practitioner.
II. The following are excluded:
i. Other stem-cell transplants
ii. Where only islets of Langerhans are transplanted

2.8.9 PERMANENT PARALYSIS OF LIMBS

I. Total and irreversible loss of use of two or more limbs as a result of injury or disease of the brain or spinal cord. A specialist Medical Practitioner must be of the opinion that the paralysis will be permanent with no hope of recovery and must be present for more than 3 months.

2.8.10 MOTOR NEURONE DISEASE WITH PERMANENT SYMPTOMS

I. Motor neurone disease diagnosed by a specialist Medical Practitioner as spinal muscularatrophy, progressive bulbar palsy, amyotrophic lateral sclerosis or primary lateral sclerosis. There must be progressive degeneration of cortico spinal tracts and anterior horn cells or bulbar efferent neurons. There must be current significant and permanent functional neurological impairment with objective evidence of motor dysfunction that has persisted for a continuous period of at least 3 months.

2.8.11 MULTIPLE SCLEROSIS WITH PERSISTING SYMPTOMS

I. The definite occurrence of multiple sclerosis. The diagnosis must be supported by all of the following:
i. Investigations including typical MRI and CSF findings, which unequivocally confirm the diagnosis to be multiple sclerosis;
ii. There must be current clinical impairment of motor or sensory function, which must have persisted for a continuous period of at least 6 months, and well documented clinical history of exacerbations and remissions of said symptoms or neurological deficits with at least two clinically documented episodes at least one month apart.

Other causes of neurological damage such as SLE and HIV are excluded except as covered under Clause 3.1.11.2.9 DAY CARE CENTRE means any institution established for day care treatment of Illness or Injury, or a medical set-up within a Hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified

Medical Practitioner AND must comply with all minimum criteria as under:
- has qualified nursing staff under its employment
- has qualified Medical Practitioner(s) in charge
- has a fully equipped operation theatre of its own where Surgery is carried out
- maintains daily records of patients and will make these accessible to the Insurance
Company’s authorized personnel.

2.10 DAY CARE TREATMENT refers to medical treatment or Surgery which are:
- undertaken under general or local anesthesia in a Hospital/ Day Care Centre in less than 24 hours because of technological advancement, and
- which would have otherwise required a Hospitalisation of more than 24 hours. Treatment normally taken on an out-patient basis is not included in the scope of this definition.

2.11 DENTAL TREATMENT is treatment carried out by a dental practitioner including examinations, fillings (where appropriate), crowns, extractions and Surgery excluding any form of cosmetic Surgery/implants.

2.12 DOMICILIARY HOSPITALISATION means medical treatment for an Illness/Injury which in the normal course would require care and treatment at a Hospital but is actually taken while confined at home under any of the following circumstances:
- The condition of the patient is such that he/she is not in a condition to be removed to a Hospital, or
- The patient takes treatment at home on account of non-availability of room in a Hospital.

2.13 HOSPITAL means any institution established for Inpatient Care and Day Care Treatment of Illness or Injury and which has been registered as a Hospital with the local authorities under the Clinical Establishment (Registration and Regulation) Act, 2010 or under the enactments specified under the schedule of Section 56(1) of the said act OR complies with all minimum criteria as under:
- Has qualified nursing staff under its employment round the clock;
- Has at least 10 Inpatient beds in towns having a population of less than 10,00,000 and at least 15 In-patient beds in all other places;
- Has qualified Medical Practitioner(s) in charge round the clock;
- Has a fully equipped operation theatre of its own where Surgery is carried out;
- Maintains daily records of patients and makes these accessible to the insurance company’s authorized personnel.

2.14 HOSPITALISATION means admission as an Inpatient in a Hospital for a minimum period of 24 consecutive hours except for the procedures/ treatments mentioned in Annexure I, where such admission could be for a period of less than 24 consecutive hours.
Note: Procedures/treatments usually done in outpatient department are not payable under the
Policy even if converted as an in-patient in the Hospital for more than 24 hours; except for
payments admissible under Clause 3.1.10 and 3.1.11(b).

2.15 ILLNESS means a sickness or a disease or pathological condition leading to the impairment of Normal physiological function which manifests itself during the Policy Period and requiresmedical treatment.

2.16 INFERTILITY is defined by the failure to achieve a clinical pregnancy after twelve months or more of regular unprotected sexual intercourse.

2.17 INJURY means accidental physical bodily harm excluding Illness or disease solely and directly caused by external, violent and visible and evident means which is verified and certified by a Medical Practitioner.

2.18 INPATIENT CARE means treatment for which the Insured Person has to stay in a Hospital for more than 24 hours for a covered event.

2.19 INSURED PERSON means You and each of the others who are covered under this Policy asshown in the Schedule.

2.20 INTENSIVE CARE UNIT (ICU) means an identified section, ward or wing of a Hospital which is under the constant supervision of a dedicated Medical Practitioner and which is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards.

2.21 MATERNITY EXPENSES shall mean:
a. Medical Treatment Expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during Hospitalisation),
b. Expenses towards lawful medical termination of pregnancy during the Policy Period.

2.22 MEDICAL ADVICE means any consultation or advice from a Medical Practitioner including the issue of any prescription or repeat prescription.

2.23 MEDICAL EXPENSES means those expenses that an Insured Person has necessarily and actually incurred for medical treatment on account of Illness or Injury on the advice of a
Medical Practitioner, as long as these are no more than would have been payable, if the Insured Person had not been insured and no more than other Hospitals or doctors in the same locality would have charged for the same medical treatment.

2.24 MEDICALLY NECESSARY means any treatment, tests, medication, or stay in Hospital or part of a stay in Hospital which
- Is required for the medical management of the Illness or Injury suffered by the Insured Person;
- Must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity;
- Must have been prescribed by a Medical Practitioner,
- Must conform to the professional standards widely accepted in international medical
practice or by the medical community in India.

2.25 MEDICAL PRACTITIONER means a person who holds a valid registration from the Medical Council of any state or Medical Council of India or Council for Indian Medicine or for Homeopathy set up by the Government of India or a State Government and is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of his license.
The term Medical Practitioner shall not include any Insured Person or any member of hisfamily.

2.26 NETWORK PROVIDER: All such Hospitals, Day Care Centres or other providers that the Company/TPA has mutually agreed with, to provide services like Cashless access to Insured Person.

2.27 NON-NETWORK PROVIDER: Any Hospital, Day Care centre or other provider that is not part

of the Network.

2.28 NEW BORN BABY means a baby born during the Period of Insurance to a female Insured

Person.

2.29 OPD TREATMENT is one in which the Insured visits a clinic / Hospital or associated facility like

a consultation room for diagnosis and treatment based on the advice of a Medical

Practitioner. The Insured is not admitted as a day care or in-patient.

2.30 PERIOD OF INSURANCE means the period for which this Policy is taken as specified in the

Schedule.

2.31 PRE-EXISTING CONDITION / DISEASE means any condition, ailment or Injury or related

condition(s) for which the Insured Person had signs or symptoms, or was diagnosed, or

received medical advice/treatment, within forty eight months prior to the Date of inception

of Your first Policy with Us as mentioned in the Schedule.

2.32 PRE-HOSPITALISATION MEDICAL EXPENSES means Medical Expenses incurred, for Any One

Illness, immediately before the Insured Person is Hospitalised, provided that:

i. Such Medical Expenses are incurred for the same condition for which the Insured

Person’s Hospitalisation was required, and

ii. The Inpatient Hospitalisation claim for such Hospitalisation is admissible by Us.

iii. Such Medical Expenses are incurred not earlier than sixty days before the Date of

Hospitalisation.

2.33 POST-HOSPITALISATION MEDICAL EXPENSES means Medical Expenses incurred, for Any One

Illness, immediately after the Insured Person is discharged from the Hospital, provided that:

i. Such Medical Expenses are incurred for the same condition for which the Insured

Person’s Hospitalisation was required, and

ii. The In-patient Hospitalisation claim for such Hospitalisation is admissible by Us.

iii. Such Medical Expenses are incurred not later than ninety days after the date of discharge

from the Hospital.

2.34 PORTABILITY means transfer by an individual Health insurance policyholder (including family

cover) of the credit gained for Pre-Existing conditions and time-bound exclusions if he/she

chooses to switch from one insurer to another.

2.35 PSYCHIATRIC DISORDERS means clinically significant psychological or behavioural syndrome

that causes significant distress, disability or loss of freedom (and which is not merely a socially

deviant behaviour or an expected response to a stressful life event) as certified by a Medical

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NEW INDIA PREMIER MEDICLAIM POLICY

Practitioner specialized in the field of Psychiatry after physical examination of the Insured

Person in respect of whom a claim is lodged.

2.36 PSYCHOSOMATIC DISORDERS means one or more psychological or behavioural problems that

adversely and significantly affect the course and outcome of general medical condition or that

significantly increase a person’s risk of an adverse outcome as certified by a Medical

Practitioner specialized in the field of Psychiatry after physical examination of the Insured

Person in respect of whom a claim is lodged.

2.37 QUALIFIED NURSE means a person who holds a valid registration from the Nursing Council of

India or the Nursing Council of any state in India.

2.38 REASONABLE AND CUSTOMARY CHARGES mean 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 / Injury involved .

2.39 RENEWAL defines the terms on which the contract of insurance can be renewed on mutual

consent with a provision of renewing within 30 days from the date of expiry of the Policy for

treating the renewal continuous for the purpose of all waiting periods.

2.40 ROOM RENT means the amount charged by a Hospital for the occupancy of a bed per day (24

hours) basis and shall include associated Medical Expenses.

2.41 SUM INSURED is the maximum amount of coverage under this Policy opted cumulatively for

You and all Insured Persons shown in the Schedule.

2.42 SURGERY means manual or operative procedure required for treatment of an Illness or Injury,

correction of deformities and defects, diagnosis and cure of diseases, relief of suffering or

prolongation of life, performed in a Hospital or Day Care Centre by a Medical Practitioner.

2.43 THIRD PARTY ADMINISTRATORS (TPA) means any person who is licensed under the IRDA

(Third Party Administrators - Health Services) Regulations,2001 by the Authority, and is

engaged, for a fee or remuneration by Insurance Company, for the purposes of providing

health services.

2.44 UNPROVEN / EXPERIMENTAL TREATMENT is treatment, including drug Experimental

therapy, which is not based on established medical practice in India, is treatment

experimental or unproven.

2.45 WE/OUR/US/COMPANY means The New India Assurance Co. Ltd.

2.46 YOU/YOUR means the person who has taken this Policy and is shown as Insured Person or

the first Insured Person (if more than one) in the Schedule.

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NEW INDIA PREMIER MEDICLAIM POLICY