Comprehensive Surgical Hospitalisation & Follow up Medical Trip Cover

In-patient Hospitalisation

If during the policy year, the policyholder suffers an injury due to an accident caused by an event covered under the policy and directly results in hospitalization, the reasonable and customary charges will be paid. The payout is for hospitalization to avail medically necessary treatment of the policyholder, and the admission date is within the policy year.

1. Room charges up to the category specified in the policy schedule
2. Charges for accommodation in ICU/CCU/HDU
3. Operation theatre cost
4. Medical practitioner’s fees
5. Specialist’s fee 
6. Surgeon’s fee
7.  Anaesthetist’s fee
8. Radiologist’s fee
9. Pathologist’s fee
10. Assistant surgeon’s fee
11. Qualified nurses’ fee
12.  Medication
13. Cost of diagnostic tests as an in-patient
14. Surgical appliance or medical appliance

If the policyholder is admitted in a room where the room rent incurred is higher than that which is specified in the policy schedule, then the policyholder shall bear a ratable proportion of the total associated medical expenses (including surcharge or taxes thereon). The expenses should be in proportion to the difference between the room rent of the entitled or eligible room rent to the room rent actually incurred unless specified otherwise. 

Artificial life maintenance will be covered, including life support machine use, where such treatment will not result in recovery or restoration of the previous state of health under any circumstances unless in a vegetative state as certified by the treating medical practitioner.

Day Care will be covered under the cover if opted and as specified under the policy schedule.

The cover is payable up to the limit as specified in the policy schedule.

Surgical Pre-hospitalization (5 days)

The pre-hospitalization Medical Expenses will be paid immediately before the policyholder's date of hospitalization or daycare (if opted) up to the limits as specified in the policy schedule. The claim must be admissible under ‘surgical hospitalization cover,’ and the pre-hospitalization medical expenses are related to the same injury. The date of admission to the hospital for this cover shall be the date of the policyholder's first admission in relation to any injury.

Surgical Post-hospitalization (10 days)

The post-hospitalization medical expenses will be paid post-discharge of the policyholder immediately from the hospital or daycare (if opted) up to the limits as specified in the policy schedule. The payout is eligible provided that a claim is admissible under ‘surgical hospitalization cover’ and the post-hospitalization medical expenses are related to the same injury. 

The date of discharge from the hospital for this cover shall be the date of the policyholder's last discharge from the hospital concerning any one injury.

Surgery Follow up Medical Trip

If during the policy year, the policyholder suffers an illness or injury due to an accident and needs to undergo a surgical procedure, covered under the policy, that results in a severe trauma or advised amputation that requires follow up treatment to be taken outside the territorial limits of the city of residence within the territorial boundaries of India, the cost of travelling (return trip) and cost pertaining to boarding and lodging during the duration of such treatment will be paid.

The insurer shall further pay the travel and boarding expenses of one immediate family member who will accompany him during the period of such treatment.

The coverage is payable up to the limit as specified in the policy schedule.

Room Rent Caping
For SI, 1Lakh and 2 Lakhs, the room rent limit is capped at Rs. 2000 per day for a normal room and Rs. 4000 per day for ICU. For SI, 5 Lacs, the room rent is limited to a single private room and there is no limit for ICU.

Waiting Period
The initial waiting period for this cover is 30 days, whereas the waiting period for specific illness is 24 months. 

Specified disease or procedure waiting period 

Since the inception date of the cover, a waiting period specified in the policy schedule shall apply to all treatments. The following treatments, medical or surgical, for all medical expenses along with their complications, are not covered: 

1. a) Cataract.
2. b) Hysterectomy for Menorrhagia or Fibromyoma or prolapse of uterus unless necessitated by malignancy myomectomy for fibroids.
3. c) Knee replacement surgery (other than caused by accident), non-infectious Arthritis, Gout, Rheumatism, Osteoarthritis and Osteoporosis, Joint Replacement Surgery (other than caused by accident), prolapse of intervertebral discs (other than caused by accident), all Vertebrae Disorders, including but not limited to Spondylitis, Spondylosis, Spondylolisthesis, Congenital Internal. 
4. d) Varicose Veins and Varicose Ulcers.
5. e) Stones in the urinary urogenital and biliary systems, including calculus diseases. 
6. f) Benign Prostate Hypertrophy, all types of Hydrocele. 
7. g) Fissure, Fistula in the anus, Piles, all types of Hernia, Pilonidal sinus, Hemorrhoids, and an abscess related to the anal region. 
8. h) Chronic Suppurative Otitis Media (CSOM), Deviated Nasal Septum, Sinusitis, and related disorders, surgery on tonsils/Adenoids, Tympanoplasty, and any other benign ear, nose, and throat disorder or surgery.
9. i) Gastric and duodenal ulcer, any Cysts/Nodules/Polyps/internal tumors/ 

skin tumors, and any Breast lumps (unless malignant), Polycystic Ovarian diseases. 

1. j) Any Surgery of the Genito-urinary system unless necessitated by malignancy.

If these diseases are pre-existing diseases at the time of proposal or subsequently found to be pre-existing, the waiting periods mentioned in the policy schedule shall apply.