Group Hospital Cash

What it Covers?

We will pay the amount as specified in the schedule/ certificate of insurance as Hospital Daily Cash, for each continuous and completed period of 24 hours, upto the benefit period per year, that the Insured Person is Hospitalised during the policy period due to an illness or accidental bodily injury.

In case of each continuous and completed period of 24 hours of hospitalization within the Intensive Care Unit (ICU), We will pay twice the benefit amount as specified in the schedule/ certificate of insurance as Hospital Daily Cash.

Other Benefits -

1. Day Care Surgeries – We will pay the One day Daily Cash benefit as mentioned in the schedule/ certificate of insurance, for the Day care surgeries as listed in Annexure – “List of Day Care Procedures” of the policy document.

2. Treatment Methods and Advancement in Technologies - We will pay the Daily cash benefit for each day of hospitalization or One day Daily Cash benefit (depending upon the nature of procedure), upto the benefit period specified in the policy schedule/ certificate of insurance, during the policy period for the following procedures (wherever medically indicated):

   1. Uterine Artery Embolization and HIFU (High intensity focused ultrasound)
   2. Balloon Sinuplasty
   3. Deep Brain stimulation
   4. Oral chemotherapy
   5. Immunotherapy- Monoclonal Antibody to be given as injection
   6. Intra vitreal injections
   7. Robotic surgeries
   8. Stereotactic radio surgeries
   9. Vaporisation of the prostrate (Green laser treatment or holmium laser treatment)
   10. IONM - (Intra Operative Neuro Monitoring)
   11. Stem cell therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered.

Note: The benefit period as specified in the policy schedule/ certificate of insurance is cumulative of all hospitalizations, whether single or multiple, occurring in each policy year.

What is Not Covered

We will not pay for any claim caused by, based on, arising out of or attributable to any of the following:

1. Pre-existing Diseases -
   • Any claim for hospitalization relating to a pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer.
   • In case of enhancement of Daily Cash Limit/ benefit period, the exclusion shall apply afresh to the extent of Daily Cash Limit/ benefit period increase.
   • Coverage under the policy after the expiry of 48 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by Us.
2. 30-day waiting period -
   • Any claim for hospitalization relating to the treatment of any illness within 30 days from the first policy commencement date shall be excluded except claims arising due to an accident.
   • This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve months.
   • The within referred waiting period is made applicable to the enhanced Daily Cash Limit /benefit period in the event of granting higher Daily Cash Limit /benefit period in subsequent renewals.
3. Specified disease/procedure waiting period –
   • Any claim for hospitalization relating to the treatment of the listed Conditions, surgeries/treatments shall be excluded until the expiry of 12 months of continuous coverage after the date of inception of the first policy with us. This exclusion shall not be applicable for claims arising due to an accident.
   • In case of enhancement of Daily Cash Limit/ benefit period in subsequent renewals, the exclusion shall apply afresh to the extent of Daily Cash Limit/ benefit period increase.
   • If any of the specified disease/procedure falls under the waiting period specified for pre-Existing diseases, then the longer of the two waiting periods shall apply.
   • The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a specific exclusion.
   • List of specific diseases/ procedures excluded under the first year of policy with us:
     • Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Mennorrahagia or Fibromyoma
     • Hernia, Hydrocele
     • Fistula in anus, Piles, Sinusitis and related disorders
4. Refractive Error: Any claim if the hospitalization relates to treatment for correction of eyesight due to refractive error less than 7.5 dioptres.
5. Any claim of hospitalization for Dental treatment or other dental examination and/or tests not incidental to the treatment or diagnosis of an injury, sickness or disease.
6. Sterility and Infertility – Any claim for hospitalization relating to Birth Control, sterility and infertility. This includes:
   1. Any type of contraception, sterilization
   2. Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
   3. Gestational Surrogacy
   4. Reversal of sterilization
7. Maternity -Any claim for hospitalisation relating to -
   1. Childbirth (including complicated deliveries and caesarean sections incurred during hospitalization) except ectopic pregnancy;
   2. Miscarriage (unless due to an accident) and lawful medical termination of pregnancy during the policy period.
8. Sleep disorder, Parkinson and Alzheimer’s disease, general debility or exhaustion (“run-down condition”); or growth hormone therapy.
9. Venereal disease, sexually transmitted disease or illness.
10. Change of Gender – Any claim relating to hospitalization of treatment, including surgical management, to change characteristics of he body to those of the opposite sex.
11. Circumcisions unless required as a part of treatment of an illness or injury.
12. Cosmetic or Plastic Surgery: Any claim if hospitalization necessitated due to cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an accident, burn(s) or cancer or as part of medically necessary treatment to remove a direct or immediate health risk to the insured. For this to be considered a medical necessity, it must be certified by the Attending Medical Practitioner
13. Rest Cure, Rehabilitation and respite care – Any claim if hospital admission is primarily for enforced bed rest and not for receiving treatment. This also includes:
    1. Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing, dressing, moving around either by skilled nurses or assistant or non-skilled persons.
    2. Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.
14. Obesity/ Weight Control – Any claim if hospitalisation is related to the surgical treatment of obesity that does not fulfill all the below conditions:
    1. Surgery to be conducted is upon the advice of the Doctor
    2. The surgery/procedure conducted is supported by clinical protocols
    3. The member is 18 years of age or older and
    4. Body Mass Index (BMI);
       • Obesity-related cardiomyopathy
       • Coronary heart disease
       • Severe Sleep Apnea
       • Uncontrolled Type2 Diabetes
15. Intentional self-injury, suicide or attempted suicide.
16. War (whether declared or not) and war like occurrence or invasion, acts of foreign enemies, hostilities, civil war, rebellion, revolutions, insurrections, mutiny, military or usurped power, seizure, capture, arrest, restraints and detainment of all kinds.

17. Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from or from any other cause or event contributing concurrently or in any other sequence to the loss, claim or expense.

18. Breach of Law – Any claim for hospitalisation if treatment arises from or is consequent upon You/ any insured person committing or attempting to commit a breach of law with criminal intent.

19. Treatment of alcoholism, drug or substance abuse or any addictive condition and consequences thereof.

20. Hazardous or Adventure Sports : Any claim if the hospitalisation is necessitated due to participation as a professional in hazardous or adventure sports, including but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.

21. Participation in a naval, military, airforce or law enforcement operation.

22. Any sporting risk in so far as they involve, the training or participation in competitions of professional or semi professional sportsmen or women or riding or driving in any form of race or competition.

23. Participation by the Insured Person in any flying activity, except as a bona fide, farepaying passenger, pilot or crew of a recognized airline on regular routes and on a scheduled timetable.

24. Unproven Treatments – Any claim for hospitalisation relating to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are treatments, procedures or supplies that lack significant medical documentation to support their effectiveness.

25. Investigation, Prevention & Evaluation - Any claim if admission in hospital is primarily for diagnostics, preventive and evaluation purposes which are not related or not incidental to the current diagnosis and treatment.

26. Narcotics used by the Insured Person unless taken as prescribed by a registered Medical Practitioner.

27. Any external congenital anomaly or birth defects.

28. Treatments received in health hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing home attached to such establishments or where admission is arranged wholly or partly for domestic reasons.

29. Hospitalisation for treatment with alternative medicines like Ayurvedic, Homeopathic, Accupuncture, Accupressure, Osteopath, Naturopathy, Chiropractic, Reflexology and Aroma Therapy or any other non-allopathic treatment.

30. Hospitalisations which are not followed by active treatment/ management during the hospitalisation period and which could have been treated on outpatient basis.

31. In respect of existing diseases disclosed by the insured and mentioned on the schedule/ certificate of insurance (based on insured’s consent), the insured person is not entitled to get coverage for specified ICD codes.