1) Hospital Daily Cash Benefit

A)We will pay the Daily Cash Amount, subject to Deductible, as specified in the Certificate of Insurance under this Benefit for each and every completed day of the Insured Person's Hospitalization for Inpatient Care during this Policy Period. We shall be liable to make payment only for the maximum number of days per policy year per Insured Person as specified in the Certificate of Insurance for this Cover.

2) Day Care Procedure Benefit

A)We will pay the Sum Insured specified in the of Policy Schedule/Certificate Insurance for this Benefit if an Insured Person undergoes a Day Care Procedure as an inpatient for less than 24 hours in a Hospital or Day Care Centre during the Policy Period.. The complete list of Day Care Treatments covered is also available on www.kotakgeneral.com. The payment under this benefit is over and above the Base Cover, subject to limits specified, if any.

3) Terms

Deductible (Days)	Nil
Policy Type	Individual
Pre-existing Disease Waiting Period	Applicable
30 days Waiting Period	Applicable
First year Waiting Period	Applicable

4) Pre-Existing Disease Waiting Period

A)Expenses related to the treatment of 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. If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health Insurance) Regulations, then waiting period for the same would be reduced to the extent of prior coverage.

5) 30 Days Waiting Period

A)Expenses related 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, provided the same are covered. This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve months.

6) Specified disease/ procedure waiting Period

A)Expenses related 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. 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. If the Insured Person is continuously covered without any break as defined under the applicable norms on portability stipulated by IRDAI, then waiting period for the same would be reduced to the extent of prior coverage.

   List of specific diseases/procedures

    (a) Cataract;

    (b) Benign Prostatic Hypertrophy;

    (c) Myomectomy, Hysterectomy unless because of malignancy;

    (d) All types of Hernia, Hydrocele;

    (e) Fissures and/or Fistula in anus, haemorrhoids/piles;

    (f) Arthritis, gout, rheumatism and spinal disorders;

    (g) Joint replacements unless due to Accident;

    (h) Sinusitis and related disorders;

    (i) Stones in the urinary and biliary systems;

    (j) Dilatation and curettage, Endometriosis;

    (k) All types of skin and internal tumors / cysts / nodules /polyps of any kind including breast lumps unless malignant;

    (l) Dialysis required for chronic renal failure;

    (m) Tonsillitis, adenoids and sinuses;

    (n) Gastric and duodenal erosions and ulcers;

    (o) Deviated nasal septum;

    (p) Varicose Veins/ Varicose Ulcers.

7) What is not covered in the Policy? (Permanent Exclusions)

   (a)Investigation & Evaluation(Code- Excl04)

     (a) Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.

     (b) Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded

  (b) Rest Cure, rehabilitation and respite care (Code – Excl05)

   a) Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:

    i. 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.

    ii. Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.

  (c) Obesity/ Weight Control (Code – Excl06)

 Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:

 1) Surgery to be conducted is upon the advice of the Doctor

 2) The surgery/Procedure conducted should be supported by clinical protocols

 3) The member has to be 18 years of age or older and

 4) Body Mass Index (BMI);

  a) greater than or equal to 40 or

  b) greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive methods of weight loss:

    i. Obesity-related cardiomyopathy

    ii. Coronary heart disease

    iii. Severe Sleep Apnea

    iv. Uncontrolled Type2 Diabetes

  (d) Change-of- Gender treatments (Code – Excl07)

Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.

  (e) Cosmetic or plastic Surgery (Code – Excl08)

Expenses for 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 and immediate health risk to the insured. For this to be considered a medical necessity, it must be certified by the attending Medical Practitioner.

  (f) Hazardous or Adventure sports: (Code- Excl09)

Expenses related to any treatment 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.

  (g) Breach of law (Code – Excl10)

Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with criminal intent.

  (h) Excluded Providers: (Code- Excl11)

Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website / notified to the policyholders are not admissible. However, in case of life threatening situations or following an accident, expenses up to the stage of stabilization are payable but not the complete claim.

  (i) Code- Excl12

Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof

  (j) Code- Excl13

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.

  (k) Code- Excl14

Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals and organic substances unless prescribed by a medical practitioner as part of hospitalization claim or day care procedure.

  (l) Refractive Error (Code- Excl15)

Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres.

  (m) Unproven Treatments (Code – Excl16)

Expenses related 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.

  (n) Sterility and Infertility (Code- Excl17)

Expenses related to sterility and infertility. This includes: i. Any type of contraception, sterilization ii. Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI iii. Gestational Surrogacy iv. Reversal of sterilization

  (o) Maternity (Code- Excl18)

    i. Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalisation) except ectopic pregnancy

    ii. Expenses towards miscarriage (unless due to an accident) and lawful medical termination of pregnancy during the policy period.

  (p) Costs of routine medical, eye or ear examinations preventive health check-ups, spectacles, laser surgery for correction of refractory errors, contact lenses, hearing aids, dentures or artificial teeth;

  (q) Any expenses incurred on prosthesis, corrective devices, external durable medical equipment of any kind, like wheelchairs, crutches, instruments used in treatment of sleep apnoea syndrome or continuous ambulatory peritoneal dialysis (C.A.P.D.) and oxygen concentrator for bronchial asthmatic condition, cost of cochlear implant(s) unless necessitated by an Accident or required intra-operatively;

  (r) Expenses incurred on all dental treatment unless necessitated due to an Accident and treated as an in-patient;

  (s) Any expenses incurred on personal comfort, cosmetics, convenience and hygiene related items and services;

  (t) Any acupressure, acupuncture, magnetic and such other therapies;

  (u) Circumcision unless necessary for treatment of an Illness or necessitated due to an Accident;

  (v) Vaccination or inoculation of any kind, unless it is post animal bite and treated as an in-patient;

  w) Intentional self-injury (whether arising from an attempt to commit suicide or otherwise);

  (x) Treatment relating to Congenital external Anomalies;

  (y) any treatment related to sleep disorder or sleep apnoea syndrome, general debility, convalescence, run-down condition or rest cures;

  (z) Costs incurred for any health check-up or for the purpose of issuance of medical certificates and examinations required for employment or travel or any other such purpose;

   (aa) Any treatment taken outside India;

   (bb) Any treatment taken from anyone not falling within the scope of definition of Medical Practitioner. Any treatment charges or fees charged by any Medical Practitioner acting outside the scope of licence or registration granted to him by any medical council;

   (cc) AYUSH treatment

   (dd) Domiciliary Hospitalisation

   (ee) Any consequential or indirect loss arising out of or related to Hospitalization;

   (ff) Any Injury or Illness directly or indirectly caused by or arising from or attributable to war, invasion, acts of foreign enemies, hostilities (whether war be declared or not), civil war, commotion, unrest, rebellion, revolution, insurrection, military or usurped power or confiscation or nationalisation or requisition of or damage by or under the order of any government or public local authority;

   (gg) Any Illness or Injury directly or indirectly caused by or contributed to by nuclear weapons/materials or contributed to by or arising from ionising radiation or contamination by radioactivity by any nuclear fuel or from any nuclear waste or from the combustion of nuclear fuel;

   (hh) Any OPD treatment will not be covered

   (ii) Medical supplies including elastic stockings, diabetic test strips, and similar products.

   (jj) Treatment and supplies for analysis and adjustments of spinal subluxation, diagnosis and treatment by manipulation of the skeletal structure; muscle stimulation by any means except treatment of fractures (excluding hairline fractures) and dislocations of the mandible and extremities.

   (kk) External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy will not be covered unless it forms a part of in-patient treatment in case of hospitalisation or part of discharge advice upto the Post hospitalisation period as specified in the policy Schedule/ Certificate of Insurance.

   (ll) Any physical, medical condition or treatment that is specifically excluded in the Policy Schedule under Important Conditions

8) Claims process

A)Claim Administration - The fulfilment of the terms and conditions of this Policy (including payment of premium by the due dates mentioned in the Policy Schedule/ Certificate of Insurance) insofar as they relate to anything to be done or complied with by You or any Insured Person, including complying with the following in relation to claims, shall be Condition Precedent to admission of Our liability under this Policy:

    a) On the occurrence or discovery of any Illness or Injury that may give rise to a Claim under this Policy, the Claims Procedure set out below shall be followed;

    b) If requested by Us and at Our cost, We may conduct Medical examination by any Medical Practitioner for this purpose when and so often as We may reasonably require. Such medical examination will be carried out only in case of reimbursement claims with prior consent of the Insured Person and We/Our representatives must be permitted to inspect the medical and Hospitalisation records pertaining to the Insured Person's treatment and to investigate the facts surrounding the Claim;

    c) We/Our representatives must be given all reasonable cooperation in investigating the Claim in order to assess Our liability and quantum in respect of such Claim;

    d) If the Insured Person suffers a relapse within 45 days of the date of discharge from Hospital for a Claim that has been made, then such relapse shall be deemed to be part of the same Claim and all limits for Any One Illness under this Policy shall be applied as if they were part of a single claim.

Claims Intimation - In the event of a Hospitalization claim under the Policy, We must be notified either at our call center or in writing within 48 hours of the Hospitalization but not later than discharge from the Hospital. In case of an Accidental Death or Permanent Total Disablement/ Critical Illness claim under Benefit 2.10 and 2.11 of the Policy, We must be notified either at our call center or in writing within 10 days from the date of occurrence of the Accident.

We shall be provided the following necessary information and documentation in respect of the Claims is within 30 days of the Insured Person's occurred Injury/ Hospitalization:

(a) Policy Number

(b) Name of the Policyholder

(c) Name of the Insured Person in whose relation the Claim is being lodged

(d) Nature of Accident (if Accident Case)

(e) Name and address of the attending Medical Practitioner and Hospital (if Admission has taken place)

(f) Date of Admission if applicable

(g) Any other information, documentation as requested by us at:

In Case of Claim, Contact us at:

24x7 Toll Free number : 1800 266 4545 or may write an e-mail at [email protected] In the event of claims, please send the relevant documents to:

Claims Manager

Kotak Mahindra General Insurance Company Ltd.

8th Floor, Zone IV, Kotak Infiniti, Bldg. 21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E), Mumbai 400097.India.

If the Claim is not notified to us within the time period specified above, then We shall be provided the reasons for the delay in writing. We will condone such delay on merits where the delay has been proved to be for reasons beyond the claimant's control.