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Health insurance terms
Def. 1. Accident or Accidental means an unexpected, unconditioned and uncontrolled event caused by an external and visible means.
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 insured.
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 period.
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 below:
· Well experienced and qualified doctors and nursing staff available in the hospital 24X7.
· 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 inspection
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 insured.
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 in which:
· The management of the illness or injury the insured is suffering from is undertaken
· 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 of nursing 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 sophisticated manner.
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’ medical condition.
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.