Health insurance terms
Def. 1. Accident
or Accidental means
an unexpected, unconditioned and uncontrolled event caused by an external and
Def. 2. Congenital Anomaly can be defined as either:
An external condition(s) in which a structural or positional abnormality in
the accessible or visible parts of the body is present since birth. OR
An internal, invisible condition that the body is born with.
Def. 3. Co-pay is a cost-sharing essential that comes under a
health insurance policy. As per Co-pay a specified percentage of the admissible
cost will be borne by the insured. Co-pay in any way does not affect the sum
Def. 4. Day Care Procedure refers to the surgical assistance and/or medical
treatment which are:
Performed in less than 24 hours under
local or general anesthetic conditions in a hospital/day care center as a result
of the present technological advancement, and
Which otherwise would have required a continuous medical observation of more
than 24 hours. This definition does not include treatment provided normally on
an out-patient basis.
Def. 5. Dependents means the family members as listed below:
Legally married spouse, who are considered dependent as long as he/she is
married to you;
Children less than 21 years of age, who are unmarried, do not have their own
independent households and are financially dependent on you;
Def. 6. Diagnostic Tests: Examination of symptoms occurring in your body
using procedure such as X-Ray or blood tests to find out the medical condition
resulting from their occurrence.
Def. 7. Domiciliary Treatment: Domiciliary treatment means a medical treatment
provided at home for more than 3 days for an illness/disease/injury which in
normally would require hospitalization and intense care. Domiciliary treatment
is provided to a patient under following circumstances:
When the patient is not mobile and cannot be moved to a hospital, or
When no rooms are vacant in the hospital
Def. 8. Doctor is a medical practitioner who holds the highest
valid degree from the medical council of any state of India and has legal rights
to treat people who suffer from health conditions and are staying within the
jurisdiction of his/her license.
Def. 9. Emergency means an unexpected medical condition or sudden
occurrence of certain symptoms that require immediate attention of doctor to
prevent further serious ailment or death.
Def. 10. Family Floater Policy is a policy in which as at the date of commencement, the patient
and the dependents listed in the schedule are insured.
Def. 11. Grace Period means a definite period of time coming
immediately after the premium due date during which the payment should be made
in order to avoid discontinuity of benefits viz. coverage of pre-existing
conditions and waiting period or to renew a policy . If there is no premium
received for a certain period then, no Coverage will be available for that
Def. 12. Hospital an institution established and registered with
the local authorities for providing medical & surgical treatments and nursing
care for sick or injured patients. It should be in supervision of a registered
and qualified medical practitioner and must meet all minimum criteria as listed
Well experienced and qualified doctors and nursing staff available in the
At least have 10 in-patient beds in a town where the population is below
10,00,000 and should have minimum15
inpatient beds in other regions;
It should have a well stocked operation theatre with all the medical and
surgical facilities required to smoothly carry out the surgical procedures
Must maintain regular accessible records of patients that should be made
available to the insurance company’s authorized personnel at the time of
Def. 13. Hospitalisation or Hospitalised means the admission of a person suffering from an
illness that requires continuous medical supervision and treatment for a minimum
period of 24 hours during his/her ailment.
Def. 14. Information Summary Sheet means a complete record of the information
provided to the insurance company representative through a telephonic
conversation for application and implementation of policy.
Def. 15. Intensive Care Unit means a specialized ward or section of a
hospital where higher levels of care and more
sophisticated treatment is provided to the patients who are in critical
condition and/or on life support. This unit is specially designed and equipped
for the continuous monitoring of the patients’ medical condition and is
constantly under intense supervision of a dedicated doctor.
Def. 16. Illness means a condition in the regular wellbeing of
the insured person’s general health (sickness) or a disorder in the insured
person’s organs that shows a particular pattern of symptoms (disease) or any
deceleration in the normal functioning of the body leading to pathological
trouble and that occurs during the Policy Period and demands medical attention.
Neither illness means mental sickness nor does the policy cover it even if it is
caused as a result of an accident.
Def. 17. In-patient: A condition in which the insured who is unwell
has to stay in the hospital for more than 24 hours for constant medical
observation and treatment.
Def. 18. Insured Person means You and the person named in the Schedule as
Def. 19. Medical Expenses means expenses actually incurred for the medical
treatment of the insured as advised by the doctor in-charge to cure the insured
from the illness or poor medical condition caused as a result of an accident or
illness during the policy period.
Def. 20. Medically Necessary: Medically necessary treatment is defined as any
process involved to treat, test, provide medication or admission in the hospital
· The management of the illness or injury the insured is suffering from is
· The intensity of care required to
provide adequate medicals need in a particular duration should not be exceeded.
· A valid prescription for the same from a qualified licensed doctor is must;
It must follow the International medical standards widely accepted around the
globe or by the medical community in India.
Def. 21. Network means a series
homes, hospitals, and day care centers which are mutually collaborated with us
to provide necessary cashless medical services to
policyholders. The list of such hospitals is available with us and is subject to
amendment from time to time.
Def. 22. Out-Of-Network means any Hospital, nursing home or other
provider that is not part of the Network.
Def. 23. Out-patient Treatment means a shorter treatment given at a hospital, or
clinic or doctors' consulting room, office etc where you are not required to
stay for a period of 24 hours or more.
Def. 24. Policy means these terms and conditions, any annexure
thereto and the Schedule (as amended from time to time), the statements included
in a proposal form and the Information Summary Sheet and the policy wording.
Def. 25. Policy Period means the time period between the date of
commencement and the date of expiry of a policy as mentioned in the schedule.
Def. 26. Pre-existing Condition means any condition, ailment or illness for which
the Insured Person had symptoms, and / or was diagnosed, and / or received
medical advice/ treatment, within 4 years before the first Policy issued by Us.
Def. 27. Product Benefits Table means the table issued by us showing the product
benefits which accompanies this Policy and annexures thereto.
Def. 28. Qualified Nurse is a trained person who holds a valid
registration from the Nursing Council of India or the Nursing Council of any
state in India and is in-charge of taking care of the patient in the most
Def. 29. Rehabilitation: Treatment that has a goal to bring back the
patient to their normal and independent self by restoring their health in the
best possible condition.
Def. 30. Reasonable and Customary charges means the standard charges payable for services
provided by a service provider. Keeping in mind the nature of illness involved,
these charges are constant in the geographical area with the current charge for
similar services between the providers.
Def. 31. Schedule means the schedule which is issued from our end,
and, in case multiple, then the recently updated.
Def. 32. Specialist Doctor means a Doctor who has a specialized knowledge or
expertise in a particular field of medicine and is registered and licensed by
the Medical Council of India to treat the patients suffering from illness or
disorder in that particular part of the body respectively. This does not include
a general physician. E.g. Doctor who treats dental problems is a specialized
dentist and a general physician cannot treat such cases.
Def. 33. Sum Insured means the sum which represents Our maximum total
and cumulative liability for any and all claims under the Policy during the
Policy Period as mentioned in the schedule.
Def. 34. Surgical Operation means manual and / or operative procedure (s)
performed in a hospital to treat an illness, correction of deformities and
defects, internal surgical cure of diseases for the betterment of the patients’
Def. 35. We/Our/Us means Max Bupa Health Insurance Company Limited
Def. 36. You/Your/Policyholder means the insured or person named in the Schedule
who has holds this Policy with Us.