The terms defined below have the meanings ascribed to them wherever they appear in this Policy and, where appropriate, references to the singular include references to the plural; references to the male include the female and references to any statutory enactment include subsequent changes to the same and vice versa.
Accident/ Accidental: It is a sudden, unforeseen and involuntary event caused by external, visible and violent means.
Age: The completed age of the Insured Person as on his last birthday.
Ambulance: A road vehicle operated by a licensed / authorized service provider and equipped for the transport and paramedical treatment of the person requiring medical attention.
Annexure: A document attached and marked as Annexure to this Policy.
Anyone Illness: Continuous period of Illness/Injury and it includes relapse within 45 days from the date of last consultation with the Hospital/Day Care centre where the treatment was taken.
Base Sum Insured: The sum shown against each Insured Person in the Policy Schedule which represents the Company's maximum liability in aggregate for each Insured Person for any and all claims incurred for that Insured Person during the Policy Period.
Cashless Facility: It means a facility extended by the Company to the Insured where the payments, of the cost of treatment undergone by the Insured in accordance with the policy Terms and Conditions, are directly made to network provider by the Company to the extent preauthorization approved.
Child: Means biological or legally adopted son or daughter of the Policyholder whose completed age is less than 21 years as on the Policy Period Start Date.
Claim: A demand made by the Policyholder or on his behalf, for payment of Medical Expenses under Benefit 1 or under any other Benefit, as covered under the Policy.
Company: Reliance General Insurance Company Limited.
Congenital Anomaly: It refers to a condition which is present since birth and which is abnormal with reference to form, structure or position.
- An external Congenital Anomaly refers to a congenital anomaly which is in the visible and accessible parts of the body.
- An internal Congenital Anomaly refers to a congenital anomaly which is not in the visible and accessible parts of the body.
Co-payment: It means a cost sharing requirement under this Policy that provides that the Policyholder/Insured will bear a specified percentage of the assessed claim amount/costs. A co-payment does not reduce the Sum Insured.
Cosmetic Surgery: Surgery/ treatment which is primarily done for the enhancement of appearance through surgical and medical techniques. It concerns with maintaining normal appearance, restoring or enhancing it. Cosmetic Surgery is a multi-disciplinary and comprehensive approach directed to all areas of body and involves specialists in the anatomy, physiology, pathology and/or a physician across disciplines including contributing disciplines like dermatology, general surgery, plastic surgery, otolaryngology, maxillofacial surgery, oculoplastic surgery and others.
Cumulative Bonus: It means any increase in Base Sum Insured granted by the Company without an associated increase in premium.
Day Care Centre: It means any institution established for Day Care Treatment of illness &/or injuries 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 surgical procedures are carried out;
- maintains daily records of patients and will make these accessible to the Insurance company's authorized personnel.
Day Care Treatment: It refers to medical treatment, and/ or surgical procedure which is:
- undertaken under general or local anesthesia in a Hospital/ Day Care center in less than 24 hours because of technological advancement, and which would have otherwise required a Hospitalization of more than 24 consecutive hours.
- Treatment normally taken on an out-patient basis is not included in the scope of this definition.
- Day Care Treatment shall only include procedures listed in Annexure “1”.
Dependant means financially dependant on the Policyholder and does not have independent source of income
Emergency/Emergency Care means management for a severe illness or injury which results in symptoms which
occur suddenly and unexpectedly, and requires immediatecare by a medical practitioner to prevent death or serious long term impairment of the Insured person's health.
Extended Family: It shall include the relationship of son & daughter who are not dependant, siblings (brother and
sister), grandparents, grand children , daughters –in – law and sons –in – law of the Policyholder.
Family: It shall include the Policyholder, his legally wedded spouse, dependant children and parents.
Hospital means any institution in India established for In-patient care and Day Care Treatmen t of Illness and / or Injuries and which has been registered as a Hospital with the local authorities, under the Clinical Establishments (Registration & Regulations) 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 in-patient beds, in those towns having a population of less than 10,00,000 and 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 surgical procedures are carried out;
- maintains daily records of patients and make these accessible to the Insurance company's authorized personnel.
Hospitalization means admission in a Hospital for a minimum period of 24 (Twenty Four) in-patient care consecutive hours except for Day Care Treatment.
Illness: A sickness or a disease or a pathological condition leading to the impairment of normal physiological function which manifests itself during the Policy Period and requires medical treatment. For the avoidance of doubt, Illness does not mean and this Policy does not cover any mental Illness or sickness or disease (including but not limited to a psychiatric condition, disorganization of personality or mind, or emotions or behavior) even if caused by or aggravated by or related to an Injury or Illness.
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.
In-patient Care means treatment for which the Insured Person has to stay in a Hospital for more than 24 hours for a covered event.
Insured Person/Insured: A person accepted by the Company to be insured under this Policy and who meets and continues to meet all the eligibility requirements and whose name specifically appears under Insured /Insured Person in the Policy Schedule and with respect to whom the premium has been received by the Company.
Intensive / Critical Care Unit: 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.
Life Threatening Medical Condition: A medical condition suffered by the Insured Person which has any of the following characteristics:
- Markedly unstable vital parameters (blood pressure, pulse, temperature and respiratory rate);or
- Acute impairment of one or more vital organ systems (involving brain, heart, lungs, liver, kidneys and pancreas); or
- Critical care being provided, which involves highly complex decision making to assess, manipulate and support vital system function(s) to treat single or multiple vital organ failure(s) and requires interpretation of multiple physiological parameters and application of advanced technology; or
- Critical Care being provided in critical care areas such as coronary care unit, intensive care unit, respiratory care unit, or the emergency department; and
- Is certified by the attending Medical Practitioner as a Life Threatening Medical Condition.
Medical Advice: Any consultation or advice from a Medical Practitioner including the issue of any prescriptions or repeat prescriptions.
Medical Expenses means those expenses that that the Policyholder/Insured Person has necessarily and actually incurred, during the Policy Period, for medical treatment on account of illness or injury on the written Medical 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 Medical Practitioners in the same locality would have charged for the same medical treatment.
Medical Expenses includes the following:
- Room Rent of the Hospital where the Insured Person availed medical treatment
- Intensive Care Unit (ICU) charges
- Fees of Surgeon, anesthetist, Medical Practitioner
- Anesthesia, blood, oxygen, operation theatre charges, surgical consumables, medicines and drugs, diagnostic materials and X-ray, dialysis, chemotherapy, radiotherapy, cost of pacemaker, joint replacement and similar prosthetic devices if implanted internally during a surgical procedure unless specifically excluded.
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Medically Necessary: Any treatment , test , medication or stay in Hospital or part of stay in Hospital which
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- Is required for the medical management of the illness/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
Medical Practitioner: A person who holds a valid registration from the Medical Council of any state or Medical Council of India and is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of license.
The Medical Practitioner should not be the Policyholder/Insured or their close family member
Network/Network Provider means Hospitals or other Service /Health Care Providers enlisted by the Company to provide medical services to an Insured Person on payment by a cashless facility. The Network list is available with the Company and is subject to amendment from time to time.
Nominee: The person whose name specifically appears as such in the Policy Schedule and is the person to whom the proceeds under this Policy, if any, shall become payable in the event of the death of the Policyholder.
Nominee for all other Insured Person(s) shall be the Policyholder himself.
Non-Network: Any Hospital/Day Care centre or other provider that is not part of the Network.
Policy: The Company's contract of insurance with the Policyholder providing cover as detailed in this Policy Terms & Conditions, the Proposal Form, Policy Schedule, Endorsements, if any and Annexures, which form part of the contract and must be read together.
Policy Schedule: The Schedule attached to and forming part of this Policy mentioning apart from other details, Policyholder's details, details of the Insured Person, the Base Sum Insured, the Policy Period, Premium paid (including duties, taxes and levies thereon) and the limits to which benefits under the Policy are subject to.
Policyholder: The person who is the Proposer and whose name specifically appears in the Policy Schedule as such.
Policy Period: The period commencing from the Policy Period Start Date and ending on the Policy Period End Date and as specifically appearing in the Policy Schedule. However where the Policy is issued for a Tenure of 2 years “Policy Period” shall mean a period of 12 consecutive months commencing from the Policy Period Start Date and ending on the Policy Period End Date. The subsequent “Policy Period” shall mean a period of 12 consecutive months commencing from the date following the end of the previous Policy Period and ending before Renewable Date.
Policy Period End Date: The date on which the Policy expires, as specifically appearing in the Policy Schedule.
Policy Period Start Date: The date on which the Policy commences, as specifically appearing in the Policy Schedule.
Post Hospitalization Medical Expenses means medical expenses incurred immediately after the Insured Person is discharged from the Hospital provided that:
- Such medical expenses are incurred for the same condition for which the Insured Person's hospitalization was required and
- The inpatient hospitalization claim for such Hospitalization is admissible by the Company
Portability: Portability means transfer by an individual health insurance policyholder (including floater) of the credit gained of pre-existing conditions and time-bound exclusions if he/she chooses to switch from one insurer to another
Pre-existing Disease: Any condition, ailment or Injury or related condition(s) for which the Insured Person had signs or symptoms, and / or were diagnosed, and / or received medical advice / treatment within 48 months prior to the first Policy issued by the Company under which he was covered. Pre-hospitalization Medical Expenses means medical expenses incurred immediately before the Insured Person is hospitalized provided that:
- Such medical expenses are incurred for the same condition for which the Insured Person's hospitalization was required and
- The inpatient hospitalization claim for such Hospitalization is admissible by the Company
Qualified Nurse: A person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India.
Reasonable & 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 / injury involved
Rehabilitation: Assisting an Insured Person who, following a medical condition, requires assistance in physical, vocational, independent living and educational pursuits to restore him to the position in which he was in, prior to such medical condition occurring.
Room Rent means the amount charged by a Hospital for the occupancy of a bed on per day (24 hrs) basis and shall include associated medical expenses
Surgery / Surgical Procedure / Surgical Operation means manual and/or operative procedure(s) 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.
Unproven/ Experimental Treatments: Treatment including drug experimental therapy which is not based on established medical practice in India, is treatment experimental or unproven.
