Surgery - Permanent Total Disablement Cash

Surgery Permanent Total Disablement Cash

This policy provides a cover of up to Rs. 20,000 per month for 90 days.

If the policyholder suffers from an injury due to an accident covered under the policy and directly results in undergoing a surgical procedure covered under the policy and suffers permanent total disablement of the nature specified below, the cash coverage will be payable. The illness or accident must occur within the policy year. The cash benefit is payable as per the policy schedule within 365 days from the date of the injury if caused due to an accident.

For this cover, limb means a hand at or above the wrist or a foot below the ankle. Physical separation of one hand or foot stands for separation at or above the wrist and/or above the ankle, respectively.

The cover will be payable if: 

1. The permanent total disablement is proved. A disability certificate issued by a civil surgeon or the equivalent appointed by the District, State, or Government Board needs to be submitted. 
2. For disablement other than physical separation of limb/s, digit/s, the permanent total disablement continues for at least 180 days from its commencement. If at the expiry of the 180 days there is no reasonable medical hope of improvement, such disability is considered permanent at the end of this period. 
3. If the policyholder passes away before the claim is admitted, no amount will be payable under this cover. However, coverage under Accidental Death shall become payable instead of this cover if opted. 
4. If the policyholder suffers a loss that is not of the nature of permanent total disablement specified above, then a disability certificate issued by a civil surgeon or the equivalent appointed by the District, State, or Government Board will determine the degree of disablement and the amount payable, if any.
5. If the policyholder passes away before a claim has been admitted under this cover, then no amount will be payable under this cover. However, the cover under accidental death shall become payable in lieu of this benefit, if opted.
6. Once a claim has been accepted and paid under this coverage then the policyholder’s insurance cover under this section will lapse.

Waiting Period

The initial waiting period for this cover is 30 days, whereas the waiting period for a 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 tumours/ 

skin tumours, 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.