Def. 1. Accident or Accidental means a sudden, unforeseen and involuntary event caused by external and visible means

Def. 2. Congenital Anomaly refers to either:

• an external condition(s) which is present since birth, in the visible and accessible parts of the body, and which is abnormal with reference to form, structure or position, OR
• a condition(s) which is present since birth, but is internal and not visible.

Def. 3. Co-pay is a cost-sharing requirement under a health insurance policy that provides that the insured will bear a specified percentage of the admissible costs. A co-pay does not reduce the sum insured.

Def. 4. Day Care Procedure refers to medical treatment, and/or surgical procedure which is:

• undertaken under General or Local Anaesthesia in a hospital/day care centre in less than 24 hrs because of technological advancement, and
• which would have otherwise required a hospitalization of more than 24 hours. Treatment normally taken on an out-patient basis is not included in the scope of this definition.

Def. 5. Dependents means those of Your family members as listed below:

• Legally married spouse as long as he or she continues to be married to You;
• Unmarried children aged less than 21 years, who are financially dependant on You and do not have their own independent households;

Def. 6. Diagnostic Tests: Investigations, such as X-Ray or blood tests, to find the cause of your symptoms and medical condition.

Def. 7. Domiciliary Treatment: Domiciliary treatment means medical treatment for a period exceeding 3 days, 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:

• the condition of the patient is such that he/she is not in a condition to be removed to a hospital, or
• the patient takes treatment at home on account of non availability of room in a hospital.

Def. 8. Doctor is a medical practitioner who holds a valid registration from the medical council of any state of India and is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of his licence.

Def. 9. Emergency means a severe illness or injury which results in symptoms which occur suddenly and unexpectedly, and requires immediate care by a Doctor to prevent death or serious long term impairment of the Insured Person’s health.

Def. 10. Family Floater Policy means a policy in terms of which You and Your Dependents named in the Schedule are insured as at the date of commencement.

Def. 11. 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 conditions. Coverage is not available for the period for which no premium is received.

Def. 12. Hospital means any institution established for in-patient care and day care treatment of sickness and / or injuries and which has been registered as a hospital 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 at least 10 inpatient beds, in those towns having a population of less than 10,00,000 and 15 inpatient beds in all other places;
• has qualified nursing staff under its employment round the clock;
• has qualified Doctor (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 will make these accessible to the Insurance company’s authorized personnel.

Def. 13. Hospitalisation or Hospitalised means the admission as an In-patient into a Hospital for necessary medical treatment for a continuous minimum period of 24 hours as a consequence of an Illness or Accident occurring during the Policy Period.

Def. 14. Information Summary Sheet means the record and confirmation of information provided to Us or Our representatives over the telephone for the purposes of applying for this Policy.

Def. 15. Intensive Care Unit means an identified section, ward or wing of a hospital which is under the constant supervision of a dedicated Doctor(s), 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.

Def. 16. Illness means sickness (which is a condition or an ailment that impacts on the general soundness and health of the body of the Insured Person) or a disease (which is an affliction of the Insured Person’s bodily organs that has a distinct and recognised pattern of symptoms) or a pathological condition which results in detriment to normal physiological function and which shows itself during the Policy Period and necessitates medical Treatment. 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, disorganisation of personality or mind, or emotions or behaviour) even if caused by or aggravated by or related to an Accident or Illness.

Def. 17. In-patient: Treatment for which the Insured Person has to stay in a hospital for more than 24 hours for a covered event.

Def. 18. Insured Person means You and the person named as insured in the Schedule.

Def. 19. Medical Expenses means expenses necessarily and actually incurred for medical treatment during the Policy Period on the advice of a Doctor due to Illness or Accident, by an Insured Person, which are Reasonable and Customary.

Def. 20. Medically Necessary: Medically necessary treatment is defined as any treatment, tests, medication, or stay in Hospital or part of a stay in Hospital which:

• is required for the medical management of the illness or injury suffered by the insured;
• 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 Doctor;
• must conform to the professional standards widely accepted in international medical practice or by the medical community in India.

Def. 21. Network means all such Hospitals, day care centres or other providers that We have mutually agreed with, to provide services like cashless access to Policyholders. The list is available with Us and subject to amendment from time to time.

Def. 22. Out-Of-Network means any Hospital, day care centre or other provider that is not part of the Network.

Def. 23. Out-patient Treatment means treatment given at a hospital, doctors' consulting room, office or Out-patient clinic where You are not admitted for Day-Care Procedures or In-patient treatment.

Def. 24. Policy means these terms and conditions, any annexure thereto and the Schedule (as amended from time to time), Your statements in the proposal form and the Information Summary Sheet and the policy wording (including endorsements, if any).

Def. 25. Policy Period means the period between the date of commencement and the expiry date specified shown in the Schedule.

Def. 26. Pre-existing Condition means 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 Us.

Def. 27. Product Benefits Table means the Product Benefits Table issued by Us and accompanying this Policy and annexures thereto.

Def. 28. Qualified Nurse is a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India.

Def. 29. Rehabilitation: Treatment aimed at restoring health or mobility, or to allow a person to live an independent life, such as after a stroke.

Def. 30. Reasonable and 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 among comparable providers, taking into account the nature of the illness / injury involved.

Def. 31. Schedule means the schedule issued by Us, and, if more than one, then the latest in time.

Def. 32. Specialist Doctor means a Doctor who is registered and licensed by a state council, governed by the Medical Council of India, and having specialized qualification in the field of, or expertise in, the treatment of the Illness or injury being treated but does not include a general practitioner.

Def. 33. Sum Insured means the sum shown in the Schedule which represents Our maximum total and cumulative liability for any and all claims under the Policy during the Policy Period.

Def. 34. 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 Doctor.

Def. 35. We/Our/Us means Max Bupa Health Insurance Company Limited

Def. 36. You/Your/Policyholder means the person named in the Schedule who has concluded this Policy with Us.