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DHFL General Insurance Limited Cococure POLICY WORDINGS

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DHFL General Insurance Limited Cococure POLICY WORDINGS COCOCure POLICY WORDINGS This is Your COCOCure Policy, which has been issued by Us, relying on the Information disclosed by You in Your Proposal for this Policy or its preceding Policy/Policies of which this is a Renewal. The terms set out in this Policy and its Schedule will be the basis for any claim or benefit under this Policy. 1. DEFINITIONS The words defined in this document are assigned specified meanings and they are appearing in italics. Wherever the context permits, the singular will be deemed to include the plural, one gender shall be deemed to include the other genders and references to any statute shall be deemed to refer to any replacement or amendment of that statute. 1.1 Accident or Accidental - means a sudden, unforeseen and involuntary event caused by external, visible and violent means. 1.2 Admissible claim amount - means the amount that is admissible as per policy terms and conditions before applying deductible/co-payment. Any deductible/co-payment will be applied on the admissible claim amount. The amount so arrived after application of deductible/co- payment, will be payable under the policy but not exceeding the Sum Insured. 1.3 Adventure Sports – means those sports / activities which involves speed, height, a high level of physical exertion and high degree of inherent danger. Such sports are racing on wheels or horseback, power boat racing, ski racing, hunting or equestrian activities, big game hunting, rock climbing/trekking/mountaineering, winter sports, Skydiving, Parachuting, paragliding/parapenting, Scuba Diving, ski doo riding, cavin/pot holing, bungee jumping, hell skiing, ski acrobatics, ski jumping, water ski jumping, ice hockey, ice speedway, ballooning, hand gliding, river rafting, black water rafting, yachting or boating outside coastal waters, canoeing involving rapid waters, micro-lighting, motor rallying, piloting aircraft, power lifting, quad biking, river boarding, river bugging, rodeo, roller hockey. 1.4 Age or Aged – means completed age in years as at the Policy Commencement Date. 1.5 Any one Illness - means continuous period of Illness and it includes relapse within 45 days from the date of last consultation with the Hospital/Nursing Home where treatment was taken. 1.6 Authority means the Insurance Regulatory and Development Authority of India established under the provisions of section 3 of the Insurance Regulatory and development authority Act, 1999 (41 of 1999). DHFL General Insurance Limited (A Wholly Owned Subsidiary Of WGC) Registered & Corporate Office: 402, 403 & 404, A&B Wing, 4th Floor, Fulcrum, Sahar Road, Next to Hyatt Regency, Andheri (E), Mumbai - 400 099 Phone: 022 - 4001 8100/8200 COCOCure - Policy Wordings IRDAI Reg No.: 155 CIN: U66000MH2016PLC283275 Web: www.dhflinsurance.com PRODUCT UIN: DHFHLIP18051V011819 GSTIN: 27AAFCD7985H1Z4 Email: [email protected] Page 1 of 82 1.7 Bank Rate means Bank Rate fixed by the Reserve Bank of India (RBI) at the beginning of the financial year in which claim has fallen due. 1.8 Base Sum Insured means the amount stated in the Policy Schedule. 1.9 Complaint or Grievance means written expression (includes communication in the form of electronic mail or other electronic scripts), of dissatisfaction by a Complainant with Insurer, distribution channels, intermediaries, insurance intermediaries or other regulated entities about an action or lack of action about the standard of service or deficiency of service of such Insurer, distribution channels, intermediaries, insurance intermediaries or other regulated entities. 1.10 Complainant means a Policyholder or prospect or any beneficiary of an insurance Policy who has filed a Complaint or Grievance against an Insurer or a distribution channel. 1.11 Cashless Facility - means a facility extended by the Insurer to the Insured where the payments, of the costs of treatment undergone by the Insured in accordance with the Policy terms and conditions, are directly made to the Network Provider by the Insurer to the extent pre- authorization is approved. 1.12 Condition Precedent - means a Policy term or condition upon which the Insurer`s liability under the Policy is conditional upon. 1.13 Congenital Anomaly - means a condition which is present since birth, and which is abnormal with reference to form, structure or position. (a) Internal Congenital Anomaly – congenital anomaly which is not in the visible and accessible parts of the body. (b) External Congenital Anomaly - congenital anomaly which is in the visible and accessible parts of the body. 1.14 Cumulative Bonus – means any increase or addition in the Sum Insured granted by the Insurer without an associated increase in premium. 1.15 Co-Payment - means a cost-sharing requirement under a health insurance Policy that provides that the Policyholder/Insured will bear a specified percentage of the admissible claim amount. A Co-Payment does not reduce the Sum Insured. 1.16 Day Care Centre - means any institution established for Day Care Treatment of Illness and / or Injuries or a medical setup with a Hospital and which has been registered with the local authorities, wherever applicable, and is under supervision of a registered and qualified Medical Practitioner AND must comply with all minimum criterion as under: DHFL General Insurance Limited (A Wholly Owned Subsidiary Of WGC) Registered & Corporate Office: 402, 403 & 404, A&B Wing, 4th Floor, Fulcrum, Sahar Road, Next to Hyatt Regency, Andheri (E), Mumbai - 400 099 Phone: 022 - 4001 8100/8200 COCOCure - Policy Wordings IRDAI Reg No.: 155 CIN: U66000MH2016PLC283275 Web: www.dhflinsurance.com PRODUCT UIN: DHFHLIP18051V011819 GSTIN: 27AAFCD7985H1Z4 Email: [email protected] Page 2 of 82 i. has qualified nursing staff under its employment; ii. has qualified Medical Practitioner (s) in charge; iii. has a fully equipped operation theatre of its own where Surgical Procedures are carried out; iv. maintains daily records of patients and will make these accessible to the Insurance company’s authorized personnel. 1.17 Day Care treatment - means medical treatment, and/or Surgical Procedure which is: i. undertaken under General or Local Anaesthesia in a Hospital / Day Care Centre in less than 24 hrs because of technological advancement, and ii. which would have otherwise required Hospitalisation of more than 24 hours. Note - Treatment normally taken on an Out-patient basis is not included in the scope of this definition. 1.18 Deductible - means a cost sharing requirement under a health insurance Policy that provides that the Insurer will not be liable for a specified rupee amount in case of indemnity policies and for a specified number of days/hours in case of hospital cash policies which will apply before any benefits are payable by the Insurer. A Deductible does not reduce the Sum Insured. 1.19 Dental Treatment - means a treatment related to teeth or structures supporting teeth including examinations, fillings (where appropriate), crowns, extractions and Surgery. 1.20 Dependent Child – means biologically or legally adopted son or daughter of the Policyholder whose completed age is less than or equal to 30 years and who is financially dependent on the Policyholder with no source of income and have not established his/her own independent households. 1.21 Diagnosis - means conclusion drawn by a registered Medical Practitioner, supported by acceptable clinical, radiological, histological, histo-pathological, and laboratory evidence wherever applicable. 1.22 Disclosure of information norm - means the Policy shall be void and all premiums paid thereon shall be forfeited to the Company, in the event of misrepresentation, mis-description or non- disclosure of any Material Fact. 1.23 Domiciliary Hospitalisation - means medical treatment for an Illness/disease/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: i. the condition of the patient is such that he/she is not in a condition to be removed to a Hospital, or ii. the patient takes treatment at home on account of non-availability of room in a Hospital. DHFL General Insurance Limited (A Wholly Owned Subsidiary Of WGC) Registered & Corporate Office: 402, 403 & 404, A&B Wing, 4th Floor, Fulcrum, Sahar Road, Next to Hyatt Regency, Andheri (E), Mumbai - 400 099 Phone: 022 - 4001 8100/8200 COCOCure - Policy Wordings IRDAI Reg No.: 155 CIN: U66000MH2016PLC283275 Web: www.dhflinsurance.com PRODUCT UIN: DHFHLIP18051V011819 GSTIN: 27AAFCD7985H1Z4 Email: [email protected] Page 3 of 82 1.24 Emergency - means a severe Illness or Injury which results in symptoms which occur suddenly and unexpectedly and requires immediate care by a Medical Practitioner to prevent death or serious long-term impairment of the Insured Person's health. 1.25 Emergency Care - means management for an Illness or Injury which results in symptoms which occur suddenly and unexpectedly and requires immediate care by a Medical Practitioner to prevent death or serious long-term impairment of the Insured Person's health. 1.26 Family - means the persons named in the Policy Schedule who are the Policyholder’s legal spouse, dependent children, parents/ parents-in-Law. 1.27 Family Floater - means a Policy described as such in the Policy Schedule where You and Your Family named in the Policy Schedule are covered under this Policy as at the Commencement Date. The Sum Insured for a Family Floater is the amount shown in the Policy Schedule which represents Our maximum liability for any and all claims made by You and/or all of Your Family during each Policy Year. 1.28 Non-Floater – means a Policy where You and Your Family members named in the Policy Schedule are covered under this Policy as at the commencement date. The Sum Insured for Non-Floater is the amount shown in the Policy Schedule against each individual Insured Person which also represents Our maximum liability for that Insured Person. 1.29 Grace Period - means the specified period of time immediately following the premium due date during which a payment can be made to renew or continue a Policy in force without loss of continuity benefits such as waiting periods and coverage of Pre-existing diseases.
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