GoActive™ – Family Health Insurance Plan

Investigation & Evaluation

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

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

Rest Cure, rehabilitation and respite care

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

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.

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

Obesity/ Weight Control

• Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:
• Surgery to be conducted is upon the advice of the Doctor.
• The surgery/Procedure conducted should be supported by clinical protocols.
• The member has to be 18 years of age or older and;
• Body Mass Index (BMI);
• greater than or equal to 40 or
• 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:
• Obesity-related cardiomyopathy
• Coronary heart disease
• Severe Sleep Apnea
• Uncontrolled Type2 Diabetes

Change-of-Gender treatments

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

Cosmetic or plastic Surgery

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.

Hazardous or Adventure sports

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.

Breach of law

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

Excluded Providers

Expenses incurred towards treatment in any Hospital or by any Medical Practitioner or any other provider specifically excluded by Us and disclosed in Our 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.

The complete list of excluded providers can be referred to on our website.

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

Treatments received in heath 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.

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

Refractive Error

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

Unproven Treatments

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.

Sterility and Infertility

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

Maternity

Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during Hospitalization) except ectopic pregnancy;

Expenses towards miscarriage (unless due to an Accident) and lawful medical termination of pregnancy during the Policy Period.

Ancillary Hospital Charges

Charges related to a Hospital stay not expressly mentioned as being covered. This will include RMO charges, surcharges and service charges levied by the Hospital.

Circumcision:

Circumcision unless necessary for the treatment of a disease or necessitated by an Accident.

Conflict & Disaster:

Treatment for any Injury or Illness resulting directly or indirectly from nuclear, radiological emissions, war or war like situations (whether war is declared or not), rebellion (act of armed resistance to an established government or leader), acts of terrorism.

External Congenital Anomaly:

Screening, counseling or treatment related to external Congenital Anomaly.

Dental/oral treatment:

Treatment, procedures and preventive, diagnostic, restorative, cosmetic services related to disease, disorder and conditions related to natural teeth and gingiva except if required by an Insured Person while Hospitalized due to an Accident.

Hormone Replacement Therapy:

Treatment for any condition / illness which requires hormone replacement therapy.

Multifocal Lens and ambulatory devices such as walkers, crutches, splints, stockings of any kind and also any medical equipment which is subsequently used at home.

Sexually transmitted Infections & diseases (other than HIV / AIDS):

Screening, prevention and treatment for sexually related infection or disease (other than HIV / AIDS).

Sleep disorders:

Treatment for any conditions related to disturbance of normal sleep patterns or behaviors.

Any treatment or medical services received outside the geographical limits of India.

Unrecognized Physician or Hospital:

• Treatment or Medical Advice  provided by a Medical Practitioner not recognized by the Medical Council of India or by Central Council of Indian Medicine or by Central council of Homeopathy.
• Treatment provided by anyone with the same residence as an Insured Person or who is a member of the Insured Person’s immediate family or relatives.
• Treatment provided by Hospital or health facility that is not recognized by the relevant authorities in India. 
• Artificial life maintenance for the Insured Person who has been declared brain dead or in vegetative state as demonstrated by:
• Deep coma and unresponsiveness to all forms of stimulation; or
• Absent pupillary light reaction; or
• Absent oculovestibular and corneal reflexes; or
• Complete apnea.

AYUSH Treatment

Any form of AYUSH Treatments, except as mentioned in policy document