Goactive Policy Document

GoActive Policy Document 1. Preamble Person’s Hospitalization during the Policy Period following an Illness or This is a contract of insurance between You and Us which is subject to Injury that occurs during the Policy Period, provided that: the payment of the full premium in advance and the terms, conditions a. The Hospitalization is Medically Necessary and advised by Medical and exclusions to this Policy. This Policy has been issued on the basis Practitioner and the treatment follows Evidence Based Clinical of the Disclosure to Information Norm, including the information Practices and Standard Treatment Guidelines. provided by You in respect of the Insured Persons in the Proposal Form b. The Medical Expenses incurred are Reasonable and Customary and the Information Summary Sheet. Charges for one or more of the following: i. Room Rent; Please inform Us immediately of any change in the address or any ii. Nursing charges for nursing services under Hospitalization other changes affecting You or any Insured Person. through a qualified nursing staff as an Inpatient; iii. Medical Practitioners’ fees, excluding any charges or fees for Note: The terms listed in Section 11(Definitions & Interpretation) and Standby Services; used elsewhere in the Policy in Initial Capitals shall have the meaning iv. Physiotherapy, investigation and diagnostics procedures set out against them in Section 11 wherever they appear in the Policy. directly related to the current event which lead to Hospitalization; 2. Benefits available under the Policy v. Medicines, drugs as prescribed by the treating Medical a. The Benefits available under this Policy are described below. Practitioner related to the current event that lead to b. The Policy covers Reasonable and Customary Charges incurred Hospitalization and not otherwise; towards medical treatment or consultation taken by the Insured vi. Intravenous fluids, blood transfusion, injection administration Person during the Policy Period for an Illness, Injury or conditions charges, consumables and/or enteral feedings; as described in the sections below, provided such Illness, Injury or vii. Operation theatre charges; conditions contracted or sustained by an Insured Person during viii. The cost of prosthetics and other devices or equipment, if the Policy Period. The Benefits listed in the sections below will implanted internally during Surgery; be payable subject to the terms, conditions and exclusions of this ix. Intensive / Critical Care Unit Charges. Policy and the availability of the Sum Insured and subject always c. If the Insured Person is admitted in the Hospital room where to any sub-limits in respect of that Benefit as specified in the the room category opted or Room Rent incurred is higher than Policy Schedule for the Insured Person. the eligibility as specified in the Policy Schedule, then We shall c. All the benefits (including optional benefits) along with the be liable to pay only a pro-rated portion of the total Associated respective limits / amounts for each respective Sum Insured Medical Expenses (including surcharge or taxes thereon) in the applicable under the product have been summarized in the proportion of the difference between the Room Rent actually Product Benefit Table as specified in Annexure IV. incurred and the Room Rent specified in the Policy Schedule or d. The expenses that are not covered or subsumed into room the Room Rent of the entitled room category to the Room Rent charges / procedure charges / costs of treatment are mentioned actually incurred. in Annexure II. d. We shall not be liable to pay the visiting fees or consultation e. All claims for any benefits under the Policy must be made in charges for any Medical Practitioner visiting the Insured Person accordance with the process defined under Section 7 (Claim unless such: process & Requirements). i. Medical Practitioner’s treatment or advice has been sought f. All claims paid under any benefit except for those paid under by the Hospital; and Section 2.8 (Health Checkup / Diagnostic Tests), Section 2.10 ii. Visiting fees or consultation charges are included in the (Second Medical Opinion), Section 2.11 (OPD Consultation), Hospital’s bill Section 2.12 (Behavioral Assistance Program) and Section 3.3 (Personal Accident Cover) shall reduce the Sum Insured for 2.2 Pre-hospitalization Medical Expenses that Policy Year in which the claim has been incurred, unless We will indemnify the Insured Person’s Pre-hospitalization Medical otherwise specified in the respective section and only the balance Expenses incurred following an Illness or Injury that occurs during the Sum Insured after payment of claim amounts admitted shall be Policy Period provided that: available for all future claims arising in that Policy Year. a. We have accepted a claim for Inpatient Care under Section 2.1 g. For all the benefits under Section 2.8 (Health Checkup / Diagnostic (Inpatient Care) or Section 2.4 (Day Care Treatment) or Section 2.16 Tests), Section 2.10 (Second Medical Opinion), Section 2.11 (OPD (Modern Treatments) or Domiciliary Hospitalization covered in Consultation), Section 2.12 (Behavioral Assistance Program) and Section 2.5 and Pre-hospitalization Medical Expenses are incurred Section 3.3 (Personal Accident Cover), the respective sub-limits for the same condition for which We have accepted the Inpatient or number of consultation / services or Sum Insured as applicable Care or Day Care Treatment or Domiciliary Hospitalization or shall be reduced after payment of claim amounts admitted or Modern Treatments claim. utilization of consultation / services. b. We will not be liable to pay Pre-hospitalization Medical Expenses for more than 90 days immediately preceding the Insured Person’s 2.1 Inpatient Care admission for Inpatient Care/ Day Care Treatment/ Domiciliary We will indemnify the Medical Expenses incurred on the Insured Product Name: GoActive | Product UIN: MAXHLIP21173V022021 Hospitalization / Modern Treatments or such expenses incurred a. The Domiciliary Hospitalization continues for at least 3 prior to inception of the First Policy with Us. consecutive days in which case We will make payment under this c. Pre-hospitalization Medical Expenses can be claimed under the Benefit in respect of Medical Expenses incurred from the first day Policy on a Reimbursement basis only. of Domiciliary Hospitalization; d. Pre-hospitalization Medical Expenses incurred on Physiotherapy b. For Domiciliary Hospitalization, the treating Medical Practitioner will also be payable provided that such Physiotherapy is Medically confirms in writing that the Insured Person’s condition was such Necessary and advised by the Medical Practitioner and such that the Insured Person could not be transferred to a Hospital Physiotherapy is directly related to current event that led to OR the Insured Person satisfies Us that a Hospital bed was Hospitalization or Day Care Treatment. unavailable. e. Sum Insured for the Policy Year in which In-patient Care/ Day Care Treatment/ Domiciliary Hospitalization/ Modern Treatments For Home Health Care Services, the amount, frequency and time claim has been incurred shall be reduced. period of the services needs to be reasonable, and in agreement between treating Medical Practitioner and the Insured Person availing 2.3 Post-hospitalization Medical Expenses the service. We will cover the Medical Expenses incurred for Home We will indemnify the Insured Person’s Post-hospitalization Medical Health Care Services during the Policy Period and availed through Expenses incurred following an Illness or Injury that occurs during the empanelled Service Provider on Cashless Facility basis only if the Policy Period as advised by the treating Medical Practitioner provided following conditions are fulfilled: that: i. The condition of the Insured Person must be expected to improve a. We have accepted a claim for Inpatient Care under Section 2.1 in a reasonable and generally-predictable period of time, or (Inpatient Care) or Section 2.4 (Day Care Treatment) or Section ii. Treatment under this benefit will be provided under the 2.16 (Modern Treatments) or Domiciliary Hospitalization covered supervision of a Medical Practitioner to safely and effectively in Section 2.5 and Post-hospitalization Medical Expenses are administer the treatment plan for the condition of the Insured incurred for the same condition for which We have accepted Person. the Inpatient Care or Day Care Treatment or Domiciliary Hospitalization or Modern Treatments claim. The Home Health Care Services are covered only if We have accepted b. We will not be liable to pay Post-hospitalization Medical a claim under Section 2.1 (Inpatient Care) above and Home Health Expenses for more than 180 days immediately following the Care Services are availed immediately after that Hospitalization. Insured Person’s discharge from Hospital/ Day Care Treatment/ Domiciliary Hospitalization/ Modern Treatments. The Home Health Care Services are provided through empanelled c. Post-hospitalization Medical Expenses can be claimed under the Service Provider in selected cities only. Please contact Us or refer to Policy on a Reimbursement basis only. Our website www.maxbupa.com for updated list of cities where Home d. Post-hospitalization Medical Expenses incurred on Physiotherapy Health Care Services are provided. will also be payable provided that such Physiotherapy is Medically Necessary and advised by the treating Medical Practitioner and 2.6 Living Organ Donor Transplant such Physiotherapy is directly

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