MANIPALCIGNA PROHEALTH PRIME

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

A. Preamble

This is a legal contract between You and Us subject to the receipt of full

premium, Disclosure to Information Norm including the information

provided by You in the Proposal Form and the terms, conditions and

exclusions of this Policy.

If any Claim arising as a result of a Disease/Illness or Injury that

occurred during the Policy Period becomes payable, then We shall

 paythebenetsinaccordancewithterms,conditionsandexclusions

of the Policy subject to availability of Sum Insured and Cumulative

Bonus (if any). All limits mentioned in the Policy Schedule are

applicable for each Policy Year of coverage.

B Denitions

B.I StandardDenitions

1. Accidentmeans a sudden, unforeseen and involuntary event caused

by external, visible and violent means.

2. AnyoneIllness means continuous Period of illness and it includes

relapse within 45 days from the date of last consultation with the

Hospital/Nursing Home where the treatment was taken.

3. AYUSH Hospital is a healthcare facility wherein medical/ surgical/

para-surgical treatment procedures and interventions are carried out

by AYUSH Medical Practitioner(s) comprising any of the following:

1. Central or State Government AYUSH Hospital; or

2. Teaching hospitals attached to AYUSH College recognized by the

Central Government / Central Council of Indian Medicine / Central

Council for Homeopathy; or

3. AYUSH Hospital, standalone or co-located with In-patient

healthcare facility of any recognized system of medicine, registered

with the local authorities, wherever applicable, and is under the

  supervisionofaqualiedregistered AYUSH Medical Practitioner

and must comply with all the following criterion:

  i) HavingatleastveIn-patientbeds;

  ii) HavingqualiedAYUSHMedicalPractitionerinchargeroundthe

clock;

iii) Having dedicated AYUSH therapy sections as required and/or

has equipped operation theatre where surgical procedures are

to be carried out;

iv) Maintaining daily record of the patients and making them

accessible to the insurance company’s authorized

representative.

4. Cashless Facility means a facility extended by the insurer to the

insured where the payments, of the costs of treatment undergone by

the insured in accordance with the Policy terms and conditions, are

directly made to the network provider by the insurer to the extent pre-

authorization approved.

5. Co-payment means a cost-sharing requirement under a health

insurance policy that provides that the policyholder/insured will bear a

 specied percentage of the admissible claim amount. A co-payment

does not reduce the Sum Insured.

6. ConditionPrecedent means a policy term or condition upon which the

Insurer’s Liability under the Policy is conditional upon.

7. CongenitalAnomaly refers to a condition(s) which is present since

birth, and which is abnormal with reference to form, structure or

position.

a. Internal Congenital Anomaly - which is not in the visible and

accessible parts of the body is called Internal Congenital Anomaly

b. ExternalCongenitalAnomaly- Congenital Anomaly which is in the

visible and accessible parts of the body.

8. CriticalIllnessmeans the following:

a) CancerofSpeciedSeverity

A malignant tumor characterized by the uncontrolled growth &

spread of malignant cells with invasion & destruction of normal

tissues. This diagnosis must be supported by histological evidence

of malignancy. The term cancer includes leukemia, lymphoma and

sarcoma.

The following are excluded –

i. All tumors which are histologically described as carcinoma in

situ, benign, pre-malignant, borderline malignant, low malignant

potential, neoplasm of unknown behavior, or non-invasive,

including but not limited to: Carcinoma in situ of breasts, Cervical

dysplasia CIN-1, CIN -2 and CIN-3.

ii. Any non-melanoma skin carcinoma unless there is evidence of

metastases to lymph nodes or beyond;

iii. Malignant melanoma that has not caused invasion beyond the

epidermis;

 iv. Alltumorsoftheprostateunlesshistologicallyclassiedashaving

a Gleason score greater than 6 or having progressed to at least

  clinicalTNMclassicationT2N0M0

 v. All Thyroid cancers histologically classied as T1N0M0 (TNM

  Classication)orbelow;

vi. Chronic lymphocytic leukemia less than RAI stage 3

vii. Non-invasive papillary cancer of the bladder histologically

  describedasTaN0M0orofalesserclassication,

 viii.All Gastro-Intestinal Stromal Tumors histologically classied as

  T1N0M0 (TNM Classication) or below and with mitotic count of

  lessthanorequalto5/50HPFs;

ix. All tumors in the presence of HIV infection.

 b) MyocardialInfarction(FirstHeartAttackofSpecicSeverity)

 I Therstoccurrenceofheartattackormyocardialinfarction,which

means the death of a portion of the heart muscle as a result of

inadequate blood supply to the relevant area. The diagnosis for

this will be evidenced by all of the following criteria:

i. a history of typical clinical symptoms consistent with the diagnosis

of Acute Myocardial Infarction (for e.g. typical chest pain)

ii. new characteristic electrocardiogram changes

  iii. elevation of infarction specic enzymes, Troponins or other

   specicbiochemicalmarkers.

II The following are excluded:

i. Other acute Coronary Syndromes

ii. Any type of angina pectoris.

iii. A rise in cardiac biomarkers or Troponin T or I in absence

of overt ischemic heart disease OR following an intra-arterial

cardiac procedure.

 c) OpenChestCABG

I The actual undergoing of heart surgery to correct blockage or

narrowing in one or more coronary artery (s), by coronary artery

bypass grafting done via a sternotomy (cutting through the breast

bone) or minimally invasive keyhole coronary artery bypass

procedures. The diagnosis must be supported by a coronary

  angiographyandtherealizationofsurgeryhastobeconrmedby

a cardiologist.

II The following are excluded:

a. Angioplasty and/or any other intra-arterial procedures

 d) OpenHeartReplacementorRepairofHeartValves

The actual undergoing of open-heart valve surgery is to replace or repair

one or more heart valves, as a consequence of defects in,

abnormalities of, or disease-affected cardiac valve(s). The diagnosis

of the valve abnormality must be supported by an echocardiography

 and the realization of surgery has to be conrmed by a specialist

medical practitioner. Catheter based techniques including but not

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ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

limited to, balloon valvotomy/ valvuloplasty are excluded.

 e) ComaofSpeciedSeverity

1. A state of unconsciousness with no reaction or response to

external stimuli or internal needs.

This diagnosis must be supported by evidence of all of the following:

i. no response to external stimuli continuously for at least 96 hours;

ii. life support measures are necessary to sustain life; and

 iii. permanentneurologicaldecitwhichmustbeassessedatleast30

days after the onset of the coma.

 2. The condition has to be conrmed by a specialist medical

practitioner. Coma resulting directly from alcohol or drug abuse is

excluded.

 f) KidneyFailureRequiringRegularDialysis

End stage renal disease presenting as chronic irreversible failure

of both kidneys to function, as a result of which either regular

renal dialysis (hemodialysis or peritoneal dialysis) is instituted or

  renaltransplantationiscarriedout.Diagnosishastobeconrmed

by a specialist medical practitioner.

 g) StrokeResultinginPermanentSymptoms

Any cerebrovascular incident producing permanent neurological

sequelae. This includes infarction of brain tissue, thrombosis in

an intracranial vessel, hemorrhage and embolization from an

  extracranialsource.Diagnosishastobeconrmedbyaspecialist

medical practitioner and evidenced by typical clinical symptoms

  aswellastypicalndingsinCTscanorMRIofthebrain.Evidence

  ofpermanentneurologicaldecitlastingforatleast3monthshas

to be produced.

The following are excluded:

1. Transient ischemic attacks (TIA)

2. Traumatic injury of the brain

3. Vascular disease affecting only the eye or optic nerve or

vestibular functions.

 h) MajorOrgan/BoneMarrowTransplant

The actual undergoing of a transplant of:

1. One of the following human organs: heart, lung, liver, kidney,

pancreas, that resulted from irreversible end-stage failure of the

relevant organ, or

2. Human bone marrow using hematopoietic stem cells. The

  undergoing of a transplant has to be conrmed by a specialist

medical practitioner.

The following are excluded:

i. Other stem-cell transplants

ii. Where only islets of langerhans are transplanted

 i) PermanentParalysisofLimbs

Total and irreversible loss of use of two or more limbs as a result of

injury or disease of the brain or spinal cord. A specialist medical

practitioner must be of the opinion that the paralysis will be permanent

with no hope of recovery and must be present for more than 3 months.

j) MotorNeuronDiseasewithPermanentSymptoms

Motor neuron disease diagnosed by a specialist medical practitioner

as spinal muscular atrophy, progressive bulbar palsy, amyotrophic

lateral sclerosis or primary lateral sclerosis. There must be progressive

degeneration of corticospinal tracts and anterior horn cells or bulbar

 efferent neurons. There must be current signicant and permanent

functional neurological impairment with objective evidence of motor

dysfunction that has persisted for a continuous period of at least 3

months.

 k)MultipleSclerosiswithPersistingSymptoms

 I. TheunequivocaldiagnosisofDeniteMultipleSclerosisconrmed

and evidenced by all of the following:

  i. investigationsincludingtypicalMRIndingswhichunequivocally

   conrmthediagnosistobemultiplesclerosisand

ii. there must be current clinical impairment of motor or sensory

function, which must have persisted for a continuous period of

at least 6 months.

II. Other causes of neurological damage such as SLE and HIV are

excluded.

9. CumulativeBonus

Cumulative Bonus means any increase in the Sum Insured granted by

the insurer without an associated increase in premium.

10. DayCareCentre - A day care centre means any institution established

for day care treatment of illness and / or injuries or a medical set -up

within a hospital and which has been registered with the local authorities,

wherever applicable, and is under the supervision of a registered and

 qualied medical practitioner AND must comply with all minimum

criteria as under:-

 a. hasqualiednursingstaffunderitsemployment

 b. hasqualiedmedicalpractitioner(s)incharge

c. has a fully equipped operation theatre of its own where surgical

procedures are carried out

d. maintains daily records of patients and will make these accessible

to the Insurance Company’s authorized personnel.

11. Day Care Treatment means medical treatment, and/or surgical

procedure which is:

i) Undertaken under General or Local Anesthesia in a hospital/day

care centre in less than 24 hours because of technological

advancement, and

ii) Which would have otherwise required a Hospitalization of more

than 24 hours.

Treatment normally taken on an out-patient basis is not included in the

 scopeofthisdenition.

12. Deductible means a cost-sharing requirement under a health

insurance policy that provides that the Insurer will not be liable for a

 specied rupee amount in case of indemnity policies and for a

 speciednumberofdays/hoursincaseofhospitalcashpolicies,which

 willapplybeforeanybenetsarepayablebytheinsurer.Adeductible

does not reduce the sum insured.

13. Dental Treatment - Dental treatment means a treatment related to

 teeth or structures supporting teeth including examinations, llings

(where appropriate), crowns, extractions and surgery excluding any

form of cosmetic surgery/implants.

14. DisclosuretoInformationNorm means the Policy shall be void and

all premium paid hereon shall be forfeited to the Company, in the event

of misrepresentation, mis-description or non-disclosure of any material

fact.

15. DomiciliaryHospitalization means medical treatment for an illness/

disease/injury which in the normal course would require care and

 treatment at a hospital but is actually taken while conned at home

under any of the following circumstances:

a) the condition of the patient is such that he/she is not in a condition

to be removed to a hospital, or

b) the patient takes treatment at home on account of non-availability

of room in a hospital.

16. Emergency Care means management for a severe illness or injury

which results in symptoms which occur suddenly and unexpectedly,

and requires immediate care by a medical practitioner to prevent death

or serious long term impairment of the insured person’s health

17. GracePeriodmeansthespeciedperiodoftimeimmediatelyfollowing

the premium due date during which a payment can be made to renew

 or continue a policy in force without loss of continuity benets such

as waiting periods and coverage of pre-existing diseases. Coverage is

not available for the period for which no premium is received.

18. Hospitalmeans any institution established for In-patient care and day

care treatment of illness and/or injuries and which has been registered

as a hospital with the local authorities, under the Clinical Establishments

 (Registration and Regulation) Act, 2010 or under the enactments

 specied under the Schedule of Section 56 (1) of the said Act OR

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

complies with all minimum criteria as under:

 i. hasqualiednursingstaffunderitsemploymentroundtheclock;

 ii. has at least 10 In-patient beds, in towns having a population of

  less than 10,00,000 and at least 15 In-patient beds in all other

places;

 iii. hasqualiedmedicalpractitioner(s)inchargeroundtheclock;

iv. has a fully equipped operation theatre of its own where surgical

procedures are carried out

v. maintains daily records of patients and makes these accessible to

the Insurance company’s authorized personnel.

19. Hospitalization or Hospitalized means admission in a hospital for

a minimum period of 24 consecutive In-patient Care hours except for

 speciedprocedures/treatments,wheresuchadmissioncouldbefora

period of less than 24 consecutive hours.

20. Illness means a sickness or disease or pathological condition leading

to the impairment of normal physiological function and requires medical

treatment.

a) Acutecondition- Acute condition is a disease, illness or injury that

is likely to respond quickly to treatment which aims to return the

person to his or her state of health immediately before suffering

the disease/illness/injury which leads to full recovery

b) Chroniccondition-Achronic condition isdenedasa disease,

illness, or injury that has one or more of the following characteristics:

1. it needs ongoing or long-term monitoring through consultations,

examinations, check-ups, and /or tests

2. it needs ongoing or long-term control or relief of symptoms

3. it requires rehabilitation for the patient or for the patient to be

specially trained to cope with it

  4. itcontinuesindenitely

5. it recurs or is likely to recur

21. Injury means accidental physical bodily harm excluding illness or

disease solely and directly caused by external, violent and visible and

 evidentmeanswhichisveriedandcertiedbyaMedicalPractitioner.

22. In-patientCare means treatment for which the Insured Person has to

stay in a hospital for more than 24 hours for a covered event.

23. IntensiveCare Unit means an identied section, ward or wing of a

Hospital which is under the constant supervision of a dedicated

medical practitioner (s), and which is specially equipped for the

continuous monitoring and treatment of patients who are in a critical

condition, or require life support facilities and where the level of care

and supervision is considerably more sophisticated and intensive than

in the ordinary and other wards.

24. Maternityexpenses means:

i. Medical treatment expenses traceable to childbirth (including

complicated deliveries and caesarean sections incurred during

Hospitalization);

ii. Expenses towards lawful medical termination of pregnancy during

the Policy Period

25. Medical Advice means any consultation or advice from a Medical

Practitioner including the issue of any prescription or follow-up

prescription.

26. Medical Expenses means those expenses that an Insured Person

has necessarily and actually incurred for medical treatment on account

of Illness or Accident on the advice of a Medical Practitioner, as long as

these are no more than would have been payable if the Insured Person

had not been insured and no more than other hospitals or doctors in

the same locality would have charged for the same medical treatment.

27. Medically Necessary Treatment means any treatment, tests,

medication, or stay in Hospital or part of a stay in Hospital which

i. Is required for the medical management of the Illness or injury

suffered by the Insured;

ii. Must not exceed the level of care necessary to provide safe,

adequate and appropriate medical care in scope, duration or

intensity.

iii. Must have been prescribed by a Medical Practitioner.

iv. Must conform to the professional standards widely accepted in

international medical practice or by the medical community in

India.

28. Medical Practitioner A Medical practitioner means a person who

holds a valid registration from the medical council of any state or

Medical Council of India or Council for Indian Medicine or for

Homeopathy set up by Government of India or a State Government

and is and is thereby entitled to practice medicine within its jurisdiction;

and is acting within the scope and jurisdiction of license.

29. NewBornBaby means baby born during the Policy Period and is Aged

 upto90days

30. NetworkProvider means hospitals or health care provider enlisted by

an insurer, TPA or jointly by an insurer and TPA to provide medical

services to an insured by a cashless facility.

31. Non-NetworkProviderAny hospital, day care centre or other provider

that is not part of the network.

32. Notication of Claim Notication of claim means the process of

intimating a claim to the insurer or TPA through any of the recognized

modes of communication.

33. Migration means, the right accorded to health insurance policyholders

(including all members under family cover and members of group

Health insurance policy), to transfer the credit gained for pre-existing

conditions and time bound exclusions, with the same insurer.

34. OPDTreatment is one in which the Insured visits a clinic / hospital

or associated facility like a consultation room for diagnosis and

treatment based on the advice of a Medical Practitioner. The Insured is

not admitted as a day care or In-patient.

35. Pre-existingDisease means any condition, ailment, injury or disease

a. That is/are diagnosed by a physician within 48 months prior to the

effective date of the policy issued by the insurer or

b. For which medical advice or treatment was recommended by, or

received from, a physician within 48 months prior to the effective

date of the policy issued by the insurer or its reinstatement.

36. Pre-hospitalizationMedicalExpenses

Pre-hospitalization Medical Expenses means medical expenses

 incurredduringpredenednumberofdaysprecedingtheHospitalization

of the Insured Person, provided that:

- Such Medical Expenses are incurred for the same condition for

which the Insured Person’s Hospitalization was required, and

- The In-patient Hospitalization claim for such Hospitalization is

admissible by the Insurance Company.

37. Post-hospitalizationMedicalExpenses

Post-hospitalization Medical Expenses means medical expenses

 incurred during predened number of days immediately after the

insured person is discharged from the hospital provided that:

i. Such Medical Expenses are for the same condition for which the

insured person’s Hospitalization was required, and

ii. The In-patient Hospitalization claim for such Hospitalization is

admissible by the insurance company.

38. Portability means the right accorded to an individual health insurance

policyholder (including all members under family cover), to transfer the

credit gained for pre-existing conditions and time bound exclusions,

from one insurer to another insurer.

39. QualiedNurse means a person who holds a valid registration from

the Nursing Council of India or the Nursing Council of any state in

India.

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

40. ReasonableandCustomaryChargesmeans the charges for services

 orsupplies,whicharethestandardchargesforthespecic provider

and consistent with the prevailing charges in the geographical area for

identical or similar services, taking into account the nature of the illness

/ injury involved.

41. Renewal means the terms on which the contract of insurance can be

renewed on mutual consent with a provision of grace period for treating

the renewal continuous for the purpose of gaining credit for pre-existing

diseases, time-bound exclusions and for all waiting periods.

42. Room Rent - Room Rent means the amount charged by a Hospital

towards Room and Boarding expenses and shall include the associated

medical expenses.

43. Surgery or Surgical Procedure means manual and / or operative

procedure (s) required for treatment of an illness or injury, correction

of deformities and defects, diagnosis and cure of diseases, relief from

suffering and prolongation of life, performed in a hospital or day care

centre by a medical practitioner

44. Unproven/Experimental treatment means the treatment including

drug experimental therapy which is not based on established medical

practice in India, is treatment experimental or unproven.

B.II SpecicDenitions

1. Age or Aged is the age at last birthday, and which means completed

years as at the date of Inception of the Policy.

2. Ambulance means a road vehicle operated by a licensed/authorized

service provider and equipped for the transport and paramedical

treatment of the person requiring medical attention.

3. Annexure means a document attached and marked as Annexure to

this Policy

4. Associated Medical Expenses. shall include Room Rent, nursing

charges, operation theatre charges, fees of Medical Practitioner/

surgeon/ anesthetist/ Specialist, excluding cost of pharmacy and

consumables, cost of implants and medical devices, cost of diagnostics

conducted within the same Hospital where the Insured Person has

been admitted. It shall not be applicable for Hospitalization in ICU.

Associated Medical Expenses shall be applicable for covered

expenses, incurred in Hospitals which follow differential billing based

on the room category.

5. AYUSH treatment refers to the medical and /or hospitalization

treatments given under Ayurveda, Yoga and Naturopathy, Unani,

Siddha and Homeopathy Systems.

6. InceptionDatemeanstheInceptiondateofthisPolicyasspeciedin

the Policy Schedule

7. CosmeticSurgerymeansSurgeryorMedicalTreatmentthatmodies,

improves, restores or maintains normal appearance of a physical

feature, irregularity, or defect.

8. CoveredRelationshipsshallinclude spouse, children, brother and

sister of the Policyholder who are children of same parents, father,

mother, grandparents, grandchildren, parent in laws, son in law,

daughter in law, uncle, aunt, niece and nephew.

9. DependentChild A dependent child refers to a child (natural or legally

 adopted),whoisnanciallydependentonthePolicyHolder,doesnot

have his / her independent source of income, is up to the age of 25

years.

10. Emergency shall mean a serious medical condition or symptom

resulting from injury or sickness which arises suddenly and

unexpectedly, and requires immediate care and treatment by a medical

practitioner, generally received within 24 hours of onset to avoid

jeopardy to life or serious long term impairment of the insured person’s

health, until stabilization at which time this medical condition or

symptom is not considered an emergency anymore.

11. Family Floater means a Policy described as such in the Policy

Schedule where under You and Your Dependents named in the Policy

Schedule are insured under this Policy as at the Inception Date. The

Sum Insured for a Family Floater means the sum shown in the Policy

Schedule which represents Our maximum liability for any and all claims

made by You and/or all of Your Dependents during each Policy Period.

12. HighDependencyUnit/ward is a specially staffed and equipped area

of a hospital that provides a level of care intermediate between

intensive care and the general ward care

13. Indian Resident - An individual will be considered to be resident of

India, if he is in India for a period or periods amounting in all to one

hundred and eighty-two days or more, in the immediate preceding 365

days.

14. In-patientmeans an Insured Person who is admitted to hospital and

stays for at least 24 consecutive hours for the sole purpose of receiving

treatment.

15. InsuredPerson means the person(s) named in the Policy Schedule,

who is / are covered under this Policy, for whom the insurance is

proposed and the appropriate premium paid.

16. IUI - Intrauterine insemination (IUI) is a fertility treatment where sperm

are placed directly into a woman’s uterus

17. IVF - In vitro fertilization (IVF) is a type of assistive reproductive

technology (ART). It involves retrieving eggs from a woman’s ovaries

and fertilizing them with sperm.

18. MaternitySumInsuredmeansthesumspeciedinthePolicySchedule

 againstthebenet

19. Policymeans this Terms & Conditions document, the Proposal Form,

 PolicySchedule,Add-OnBenetDetails(ifapplicable)andAnnexures

which form part of the Policy contract including endorsements, as

amended from time to time which form part of the Policy Contract and

shall be read together.

20. PolicyPeriod means the period between the inception date and the

 expirydateofthepolicyasspeciedinthePolicyScheduleorthedate

of cancellation of this policy, whichever is earlier.

21. PolicyYear means a period of 12 consecutive months within the Policy

Period commencing from the Policy Anniversary/Commencement

Date.

22. PolicySchedule means Schedule attached to and forming part of this

Policy mentioning the details of the Policy Holder, Insured Persons, the

 Sum Insured, the period and the limits to which benets under

the Policy are subject to, Premium Paid (including taxes), including any

annexures and/or endorsements, made to or on it from time to time,

and if more than one, then the latest in time.

23. Restored Sum Insured means the amount restored in accordance

with Section D.I.8 of this Policy

24. SinglePrivateRoommeans a single Hospital room with any rating

and of most economical category available at the time of hospitalization

with/without air-conditioning facility where a single patient is

accommodated and which has an attached toilet (lavatory and bath).

The room should have the provision for accommodating an attendant.

This excludes a suite or higher category.

25. Sum Insured means, subject to terms, conditions and exclusions of

this Policy, the amount representing Our maximum liability for any or all

 claimsduringthePolicyPeriodspeciedinthePolicySchedule

separately in respect of that Insured Person.

i. In case where the Policy Period is 2/3 years, the Sum Insured

  speciedonthePolicyisthelimitfortherstPolicyYear.These

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

  limitswilllapseattheendoftherstyearandthefreshlimitsupto

the full Sum Insured as opted will be available for the second/third

year.

ii. In the event of a claim being admitted under this Policy, the Sum

Insured for the remaining Policy Period shall stand correspondingly

reduced by the amount of claim paid (including ’taxes’) or admitted

and shall be reckoned accordingly.

26. ThirdPartyAdministrator(TPA) means a company registered with

the Authority, and engaged by Us, for a fee or, by whatever name called

and as may be mentioned in the health services agreement, for

providing health services as mentioned under TPA Regulations.

27. We/Our/Us/Insurer means ManipalCigna Health Insurance Company

Limited

28. You/Your/Policy Holder means the person named in the Policy

Schedule as the policyholder and who has concluded this Policy with

Us.

C Benetscoveredunderthepolicy

C.I Basiccovers

C.I.1 In-patientHospitalization

We will cover Medical Expenses of an Insured Person in case of

Medically Necessary Hospitalization arising from a Disease/ Illness

or Injury provided such Medically Necessary Hospitalization is for

more than 24 consecutive hours provided that the admission date of

the Hospitalization due to Disease/ Illness or Injury is within the Policy

Year. We will pay Medical Expenses as shown in the Policy Schedule

for:

a. Reasonable and Customary Charges for Room Rent for

  accommodation in Hospital room up to Category as specied in

the Policy Schedule.

b. Intensive Care Unit charges for accommodation in ICU ,

c. Operation theatre charges,

d. Fees of Medical Practitioner/ Surgeon ,

e. Anesthetist,

 f. QualiedNurses,

g. Specialists,

h. Cost of diagnostic tests,

i. Medicines,

j. Drugs and consumables, blood, oxygen, surgical appliances and

prosthetic devices recommended by the attending Medical

Practitioner and that are used intra operatively during a Surgical

Procedure.

Room category coverage under each plan will be covered up to

 SinglePrivateACRoomorasspeciedinthePolicySchedule,subject

to maximum of Sum Insured Opted. For ICU accommodation, we will

 coveruptoSumInsuredoptedorasspeciedinthePolicySchedule.

If the Insured Person is admitted in a room category that is higher

 than the one that is specied in the Policy Schedule, then the

Policyholder/Insured Person shall bear a ratable proportion of the total

Associated Medical Expenses (including surcharge or taxes thereon)

in the proportion of the difference between the room rent of the entitled

room category to the room rent actually incurred.

Under In-patient Hospitalization expenses, when availed under In-

 patient care, we will cover the expenses towards articial life

maintenance, including life support machine use, even 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

 certiedbythetreatingMedicalPractitioner.

The following procedures will be covered (wherever medically

indicated) either as In-patient or as part of Day Care Treatment in

a hospital up to the limit as per the plan and sum insured opted and as

 speciedinthePolicyScheduleinaPolicyYear.:

a. Uterine Artery Embolization and HIFU (High intensity focused

ultrasound)

b. Balloon Sinuplasty

c. Deep Brain stimulation

d. Oral chemotherapy

e. Immunotherapy - Monoclonal Antibody to be given as injection

f. Intra vitreal injections

g. Robotic surgeries

h. Stereotactic radio surgeries

i. Bronchial Thermoplasty

j. Vaporization of the prostrate (Green laser treatment or holmium

laser treatment)

k. IONM - (Intra Operative Neuro Monitoring)

l. Stem cell therapy: Hematopoietic stem cells for bone marrow

transplant for hematological conditions to be covered.

Medical Expenses incurred towards Medically Necessary Treatment of

the Insured Person for In-patient Hospitalization due to a condition

 caused by or associated with Human Immunodeciency Virus (HIV)

 or HIV related Illnesses, including Acquired Immune Deciency

Syndrome (AIDS) or AIDS Related Complex (ARC) and/or any mutant

derivative or variations thereof, sexually transmitted diseases (STD), in

respect of an Insured Person, will be covered up to the Sum Insured

 optedandasspecied in thePolicySchedulein a PolicyYear.The

 necessity of the Hospitalization is to be certied by an authorized

Medical Practitioner.

Medical Expenses incurred towards Medically Necessary treatment

taken during In-patient Hospitalization of the Insured Person, arising

out of a condition caused by or associated to a Mental illness, or a

medical condition impacting mental health will be covered up to the

 suminsuredoptedandasspeciedinthePolicyScheduleinaPolicy

Year. For the below mentioned ICD Codes, the Insured Person should

have been continuously covered under this Policy for at least 24

 monthsbeforeavailingthisbenet.

ICD 10

CODES

DISEASES

F05 Delirium due to known physiological condition

F06 Other mental disorders due to known physiological

condition

F07 Personality and behavioural disorders due to known

physiological condition

F10 Alcohol related disorders

F20 Schizophrenia

F23 Brief psychotic disorders

F25 Schizoaffective disorders

F29 Unspeciedpsychosisnotduetoasubstanceorknown

physiological condition

F31 Bipolar disorder

F32 Depressive episode

F39 Unspeciedmood[affective]disorder

F40 Phobic Anxiety disorders

F41 Other Anxiety disorders

F42 Obsessive-compulsive disorder

F44 Dissociative and conversion disorders

F45 Somatoform disorders

F48 Other nonpsychotic mental disorders

F60 Specicpersonalitydisorders

F84 Pervasive developmental disorders

F90 Attention-decithyperactivitydisorders

F99 Mentaldisorder,nototherwisespecied

AllClaimsunderthisbenetcanbemadeasper theprocessdenedunder

Section G.I.4 and G.I.5.

C.I.2 Pre-hospitalization

We will, on a reimbursement basis cover Medical Expenses of an

Insured Person which are incurred due to a Disease/ Illness or Injury

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

that occurs during the Policy Year immediately prior to the Insured

 Person’s date of Hospitalization up to the limits as specied in the

Policy Schedule, provided that a Claim has been admitted under

 In-patientbenetunderSectionD.I.1andisrelatedtothesameillness/

condition.

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.5 and G.I.9.

C.I.3 Post-hospitalization

We will, on a reimbursement basis cover Medical Expenses of an

Insured Person which are incurred due to a Disease/ Illness or Injury

that occurs during the Policy Year immediately post discharge of the

 InsuredPersonfromthe Hospital uptothelimits as speciedinthe

Policy Schedule, provided that a Claim has been admitted under

 In-patientbenetunderSectionD.I.1andisrelatedtothesameillness/

condition.

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.5 and G.I.9.

C.I.4 DayCareTreatment

We will cover payment of Medical Expenses of an Insured Person in

case of Medically Necessary Day Care Treatment or Surgery that

requires less than 24 hours of Hospitalization due to advancement in

technology and which is undertaken in a Hospital/ Nursing Home/ Day

Care Centre on the recommendation of a Medical Practitioner, up to

 theSumInsuredasspeciedinthePolicySchedule,providedthat:

a. The Day Care Treatment is Medically Necessary and follows the

written advice of a Medical Practitioner.

b. The Medical Expenses incurred are Reasonable and Customary

Charges for any procedure where such procedure is undertaken

by an Insured Person as Day Care Treatment.

c. We will not cover any OPD Treatment and Diagnostic Service

  underthisbenet.

Coverage will also include pre-post hospitalization expenses as per the

 limitsapplicableandspeciedunderthePlanopted.

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.4 & G.I.5.

C.I.5 DomiciliaryHospitalization

We will cover Medical Expenses of an Insured Person, up to limits

 speciedaspertheoptedplan,whicharetowardsaDisease/Illnessor

Injury which in the normal course would otherwise have been covered

for Hospitalization under the policy but is taken at home on the advice

of the attending Medical Practitioner, under the following circumstances:

i. The condition of the Insured Person does not allow a Hospital

transfer; or

ii. A Hospital bed was unavailable;

Provided that, the treatment of the Insured Person continues for at

least 3 days, in which case the reasonable cost of any Medically

Necessary treatment for the entire period shall be payable.

a) We will pay for Pre-hospitalization, Post-hospitalization Medical

  Expensesupto30dayseach.

b) Restoration of Sum Insured shall not be available under this

  benet

c) We shall not be liable under this Policy for any Claim in connection

with or in respect of the following:

i. Asthma, COPD, bronchitis, tonsillitis and upper and lower

respiratory tract infection including laryngitis and pharyngitis,

   coughandcold,inuenza,

ii. Arthritis, gout and rheumatism including the rheumatism of

bones, joints and also rheumatic heart disease,

iii. Chronic nephritis and nephritic syndrome,

iv. All types of Diarrhea and dysenteries, including gastroenteritis,

v. Diabetes mellitus and Diabetes Insipidus,

vi. Epilepsy / Seizure disorder,

vii. Hypertension,

viii. Pyrexia of unknown origin.

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.5.

C.I.6 RoadAmbulance

We will provide for reimbursement of Reasonable and Customary

 expenses up to Sum Insured as specied in the Policy Schedule

that are incurred towards road transportation of an Insured Person by a

registered Healthcare or Ambulance Service Provider to a nearest

Hospital for treatment of an Illness or Injury covered under the Policy in

case of an Emergency, necessitating the Insured Person’s admission

to the nearest Hospital. The necessity of use of an Ambulance must be

 certiedbythetreatingMedicalPractitioner.

a. Reasonable and Customary expenses shall include:

(i) Costs towards transferring the Insured Person from one

Hospital to another Hospital or diagnostic centre for advanced

diagnostic treatment where such facility is not available at the

existing Hospital; or

(ii) When the Insured Person requires to be moved to a better

Hospital facility due to lack of super specialty treatment in the

existing Hospital.

b. Payment under this cover is subject to a claim being admissible

under Section D.I.1 ‘In-patient Hospitalization’, for the same

Illness/Injury;

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.5.

C.I.7 DonorExpenses

We will cover In-patient Hospitalization Medical Expenses towards the

 donorforharvestingtheorganuptotheSumInsuredasspeciedin

the Policy Schedule, subject to the below mentioned conditions:

a. The organ donor is any person in accordance with the

Transplantation of Human Organs Act 1994 (amended) and other

applicable laws and rules, provided that –

i. The organ donated is for the use of the Insured Person who

has been asked to undergo an organ transplant on Medical

Advice.

b. We have admitted a claim under Section D.I.1 – towards In-patient

Hospitalization

c. We will not cover expenses towards the Donor in respect of:

i. Any Pre or Post-hospitalization Medical Expenses,

ii. Cost towards donor screening,

iii. Cost associated to the acquisition of the organ,

iv. Any other medical treatment or complication in respect of the

donor, consequent to harvesting.

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.4 & G.I.5.

C.I.8 RestorationofSumInsured

 We will provide for a 100% restoration of the Sum Insured for any

number of times in a Policy Year whether the illness/condition is

unrelated or same, provided that:

a. The Sum Insured inclusive of earned Cumulative Bonus (if any) or

  CumulativeBonusBooster(ifopted&earned)isinsufcientasa

result of previous claims in that Policy Year.

b. The Restored Sum Insured will be available only for claims made

by Insured Persons in respect of future claims that become

payable under Section D of the Policy and shall not apply to the

  rstclaiminthePolicyYear.RestorationoftheSumInsuredwillonly

be provided for coverage under Section D.I.1 ‘In-patient

Hospitalization’, Section D.I.2 ‘Pre-Hospitalization’, Section D.I.3

‘Post-Hospitalization’, Section D.I.4 ‘Day Care Treatment’, Section

D.I.6 ‘Road Ambulance’, Section D.I.7 ‘Donor Expenses’, Section

D.I.9 ‘AYUSH Treatment (In-patient Hospitalization)’ Section D.IV.1

‘Non-Medical Items’.

c. The Restored Sum Insured will not be considered while calculating

the Cumulative Bonus/ Cumulative Bonus Booster.

d. Such restoration of Sum Insured will be available for any number

of times, during a Policy Year to each insured in case of an

Individual Policy and can be utilized by Insured Persons who stand

covered under the Policy before the Sum Insured was exhausted.

 e. IfthePolicyisissuedonaoaterbasis,theRestoredSumInsured

  willalsobeavailableonaoaterbasis.

f. If the Restored Sum Insured is not utilized in a Policy Year, it shall

not be carried forward to subsequent Policy Year.

g. For any single claim during a Policy Year the maximum Claim

amount payable shall be sum of:

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

i. The Sum Insured

ii. Cumulative Bonus (if earned) or Cumulative Bonus Booster (if

opted & earned)

iii. Restored Sum Insured

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.4 & G.I.5.

C.I.9 AYUSHTreatment(In-patientHospitalization)

We will pay the Medical Expenses incurred during the Policy Year,

 up to the Sum Insured as specied in the Policy Schedule, of an

Insured Person in case of Medically Necessary Treatment taken during

In-patient Hospitalization for AYUSH Treatment for an Illness or Injury

that occurs during the Policy Year, provided that:

The Insured Person has undergone treatment in an AYUSH Hospital

where AYUSH Hospital is a healthcare facility wherein medical/

surgical/ para-surgical treatment procedures and interventions

are carried out by AYUSH Medical Practitioner(s) comprising any of the

following:

i) Central or State Government AYUSH Hospital; or

ii) Teaching hospitals attached to AYUSH College recognized by

Central Government / Central Council of Indian Medicine and

Central Council of Homeopathy; or

iii) AYUSH Hospital, standalone or co-located with In-patient

healthcare facility of any recognized system of medicine, registered

with the local authorities, wherever applicable, and is under the

  supervisionofaqualiedregistered AYUSH Medical Practitioner

and must comply with all the following criterion:

  a. HavingatleastveIn-patientbeds;

  b. HavingqualiedAYUSHMedicalPractitionerinchargeround

the clock;

c. Having dedicated AYUSH therapy sections as required and/or

has equipped operation theatre where surgical procedures are

to be carried out;

d. Maintaining daily record of the patients and making them

accessible to the insurance company’s authorized

representative.

The following exclusions will be applicable in addition to the other

Policy exclusions:

Facilities and services availed for pleasure or rejuvenation or as

 a preventive aid, like beauty treatments, Panchakarma, purication,

 detoxicationandrejuvenation.

 Allclaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.4 & G.I.5.

C.I.10 AirAmbulanceCover

We will reimburse the Reasonable and Customary expenses

incurred towards transportation of an Insured Person, to the

nearest Hospital or to move the Insured Person to and from

healthcare facilities within India, by an Air Ambulance, provided

that:

i. Air Ambulance is used in case of an Emergency life threatening

health condition of the Insured Person which requires immediate

and rapid ambulance transportation to the hospital or a medical

centre which ground transportation cannot provide;

ii. The Illness/ Injury, causing Emergency, is covered under the

Section D.I.1 In-patient Hospitalization;

iii. The transportation should be provided by medically equipped

  aircraft which can provide medical care in ight and should

have medical equipment to monitor vitals and treat the Insured

Person suffering from an Illness/Injury such as but not limited

to ventilators, ECG’s, monitoring units, CPR equipment and

stretchers;

iv. Restoration of Sum Insured shall not be available under this

  benet.

v. Air Ambulance service is offered by a Registered Ambulance

service provider;

 vi. ThetreatingMedicalPractitionercertiesinwritingthattheseverity

and nature of the Insured Person’s Illness/Injury warrants the

Insured Person’s requirement for Air Ambulance;

vii. Payment under this cover is subject to a claim being admissible

under Section D.I.1 ‘In-patient Hospitalization’ or under Section

D.I.4 ‘Day Care Treatment’, for the same Illness/Injury;

 Benet under this cover is payable Up to the limits as specied in

the Policy Schedule subject to maximum up to `10 Lacs in a

policy year and this is over and above the Sum Insured.

What is not covered: Expenses incurred in return transportation to

Insured Person’s home by air ambulance is excluded.

 All Claims under this benet can be made as per the process

 denedunderSectionG.I.5.

C.I.11 BariatricSurgeryCover

We will cover the Medical Expenses incurred towards Medically

Necessary Hospitalization of the Insured Person for Bariatric

 Surgery and its complications, up to Sum Insured and as specied

in Policy Schedule subject to maximum of `5 Lacs.

The cover is available subject to below conditions:

 i. SurgeryisMedically Necessary andiscertiedby anauthorized

Medical Practitioner;

ii. Hospitalization is within the Policy Year.

 iii. TheInsuredPersonsatisesfollowingcriteriaasdevisedbyNIH

(National Institute of Health):

a. The BMI should be greater than 37.5 without any co-morbidity;

or greater than 32 with co-morbidity and

b. Is unable to lose weight through traditional methods like diet

and exercise.

iv. This cover is available after a Waiting Period of 36 months from the

inception of this Policy with Us, with respect to the Insured Person.

v. Restoration of Sum Insured shall not be available under this

  benet

 vi. ExclusionE.I.6shallnotapplyuptotheextentofthisbenet

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.4 & G.I.5

C.I.12 OutpatientExpenses

We will cover the Reasonable and Customary Charges for below

mentioned expenses incurred by the Insured Person as an Outpatient

when treatment is taken from a Network Medical Practitioner to the

 extentoftheOutpatientSumInsuredoptedandasspeciedinPolicy

 Scheduleforthisbenet.

i. Consultation and Diagnostic tests including Dental and Vision

consultations and diagnostics, wherever prescribed by the Network

  MedicalPractitioner,uptotheOutpatientSumInsuredasspecied

in the Policy Schedule.

ii. Expenses incurred on drugs and medicines prescribed by the

  Network Medical Practitioner up to 20% of the Outpatient Sum

  InsuredandasspeciedinthePolicySchedule.

 Overall payout in a Policy Year should not exceed 100% of the

applicable Outpatient Sum Insured.

Any medical aids such as spectacles and contact lenses, hearing aids,

crutches, wheel chair, walker, walking stick, lumbo-sacral belt shall not

 becoveredunderthisbenet.Weshallnotcoveranytreatmentand/or

 procedureunderthisbenetrelatedtoDentalandVision

 Any unutilized amount under this benet shall not be carried

forward to subsequent Policy Year.

 This benet shall be available only on Cashless basis from the

MCHI Network. All Diagnostics and Pharmacy requirements would

need to be prescribed by the Network Medical Practitioner in order

 tomakethemeligibleunderthisbenet.

Restoration of Sum Insured shall not be available under this

 benet.

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.4. and G.I.12

C.I.13 DailyCashforSharedAccommodation

 WewillpayadailycashamountasspeciedinthePolicySchedule

for the Insured Person for each continuous and completed period

of 24 hours of Hospitalization provided that,

a. We have accepted claim under Section D.I.1 In-patient

Hospitalization during the Policy Year

b. The Insured Person has occupied a shared room accommodation

during such Hospitalization

c. The Insured Person has been admitted in a Hospital for a minimum

period of 48 hours continuously.

What is not covered:

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

 This benet will not be payable if the Insured Person stays in an

Intensive Care Unit or High Dependency Units / wards.

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.5

C.II Valueaddedcovers

C.II.1 HealthCheckUp

(a) If the Insured Person, covered as adult (excluding dependent

  children in oater Policy) and has completed 18 years of age,

the Insured Person may avail a comprehensive health check-up

with Our Network Provider as per the eligibility details mentioned in

the table below.

(b) In case of individual policy where more than 1 member are covered

under the same Individual Policy, upon attainment of 18 years of

age, the Insured member shall be eligible for health check-up with

Our Network Provider as per the eligibility details mentioned in the

table below.

Network Providers. Alternatively, the Insured member may choose

to undergo Health Check Ups as per Insured member’s choice on

Cashless basis with Our Network Provider, subject to the maximum

  limitsasspeciedagainsttheapplicableSumInsured.

 (d) This benet is available once in a policy year including the rst

policy year. And all the tests must have been done on the same

date.

(e) Original Copies of all reports will be provided to You.

(f) We shall cover Health Check Up only on cashless basis.

(g) All eligible Insured members under the Policy shall either follow

“Basis A” or “Basis B” while availing Health Check Up cover, within

MCHI Network.

HealthCheckUp

Package

Sum

Insured

Age

group

Basis–A Basis-B

Listoftests–Cashless

Limitsfor

testsof

Insured

member’s

choiceon

Cashless

basis

Compulsory

Tests

Optional

Tests

(Anyone)

Lacs,

`5 Lacs

to40

Years

CBC-ESR,

FBS, Lipid

Prole,Sr.

Creatinine

B1 - Heart

monitoring

– ECG or

B2 - Liver

screening

- SGOT

and SGPT

`1,000

per adult

Insured

member

Above

40

years

CBC-ESR,

FBS, Lipid

Prole,Sr.

Creatinine

B1 - Heart

monitoring

– ECG or

B2 - Liver

screening

- SGOT

and SGPT

B3 -

Thyroid

Screening

- Thyroid

prole

B4 -

Diabetes

screening

- HbA1c

`7.5

Lacs,

`10

Lacs,

to40

Years

ECG,FBS,LipidProle,

Sr. Creatinine, CBC-ESR,

SGOT, SGPT, GGT, TSH,

USG - Abdomen & pelvis

`2,500

per adult

Insured

member

Above

40

years

ECG,FBS,LipidProle,

Sr. Creatinine, CBC-ESR,

SGOT, SGPT, GGT, TSH,

HbA1c, USG Abdomen &

Pelvis, PSA (for Males),

Mammogram/ PAP Smear

(for females)

> `10

Lacs

to40

Years

FBS,KidneyProle,ECG,

CBC-ESR,LipidProle,

LiverProle,Thyroid

Prole,2D-Echo,USGAb-

domen & Pelvis, Vitamin

D3, Vitamin B12

`5,000

per adult

Insured

member

Above

40

years

FBS, ECG, HbA1C,

KidneyProle,CBC-ESR,

LipidProle,LiverProle,

ThyroidProle,2D-Echo,

PSA (for Males)/ Mam-

mogram/ PAP Smear (for

females), USG Abdomen

& Pelvis, Vitamin D3,

Vitamin B12,

 Full explanation of Tests is provided here: FBS – Fasting Blood

Sugar, ECG – Electrocardiogram, CBC-ESR – Complete Blood Count-

Erythrocyte Sedimentation Rate, Sr. Creatinine – Serum Creatinine,

HbA1c – Glycosylated Hemoglobin, SGOT – Serum Glutamate

oxaloacetate transaminase, SGPT – Serum Glutamate Pyruvate

Transaminase, GGT – Gamma Glutamyl Transferase, TMT – Tread

 Mill Test, PSA – Prostate Specic Antigen, USG – Ultrasound

Sonography, TSH – Thyroid Stimulating Hormone, CBC – Complete

Blood Count

(h) This cover is available up to the limits as per Sum Insured opted

  andasspeciedinthePolicySchedule.

 (i) ThisbenetshallbeoverandabovetheSumInsured.

(j) Restoration of Sum Insured shall not be available under this

  benet

 (k) All Claims under this benet can be made as per the process

  denedunderSectionG.I.14&G.I.5

C.II.2 DomesticSecondOpinion

You may choose to secure a second opinion from Our Network of

Medical Practitioners in India, if an Insured Person is diagnosed

 with/ advised a treatment listed and dened under Critical Illness

during the Policy Year. The expert opinion would be directly sent to the

Insured Person.

You understand and agree that You can exercise the option to secure

an expert opinion, provided:

(a) We have received a request from You to exercise this option.

(b) That the expert opinion will be based only on the information and

documentation provided by the Insured Person that will be shared

with the Medical Practitioner

 (c) This benet is only a value added service provided by Us and

does not deem to substitute the Insured Person’s visit or

consultation to an independent Medical Practitioner.

(d) The Insured Person is free to choose whether or not to obtain the

expert opinion, and if obtained then whether or not to act on it.

(e) We shall not, in any event be responsible for any actual or alleged

errors or representations made by any Medical Practitioner or in

any expert opinion or for any consequence of actions taken or not

taken in reliance thereon.

(f) The expert opinion under this Policy shall be limited to covered

Critical Illnesses and not be valid for any medico legal purposes.

(g) We do not assume any liability towards any loss or damage arising

out of or in relation to any opinion, advice, prescription, actual

or alleged errors, omissions and representations made by the

Medical Practitioner.

 (h) This benet can be availed by each Insured Person only once

during a Policy Year for one Critical Illness. However, one can avail

  thisbenetformultiplecriticalillnessesinayear.

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

 (i) AnyclaimunderthisbenetwillnotimpacttheSumInsuredand/or

Cumulative Bonus or Cumulative Bonus Booster.

 (j) For the purpose of this benet covered Critical Illnesses shall

include –

1. CancerofSpeciedSeverity

A malignant tumor characterized by the uncontrolled growth & spread

of malignant cells with invasion & destruction of normal tissues. This

diagnosis must be supported by histological evidence of malignancy.

The term cancer includes leukemia, lymphoma and sarcoma.

The following are excluded –

i. All tumors which are histologically described as carcinoma in

situ, benign, pre-malignant, borderline malignant, low malignant

potential, neoplasm of unknown behavior, or non-invasive,

including but not limited to: Carcinoma in situ of breasts, Cervical

dysplasia CIN-1, CIN -2 and CIN-3.

ii. Any non-melanoma skin carcinoma unless there is evidence of

metastases to lymph nodes or beyond;

iii. Malignant melanoma that has not caused invasion beyond the

epidermis;

 iv. All tumors of the prostate unless histologically classied as

having a Gleason score greater than 6 or having progressed to at least

  clinicalTNMclassicationT2N0M0

 v. All Thyroid cancers histologically classied as T1N0M0 (TNM

  Classication)orbelow;

vi. Chronic lymphocytic leukemia less than RAI stage 3

vii. Non-invasive papillary cancer of the bladder histologically

  describedasTaN0M0orofalesserclassication,

 viii.All Gastro-Intestinal Stromal Tumors histologically classied as

  T1N0M0 (TNM Classication) or below and with mitotic count of

  lessthanorequalto5/50HPFs;

ix. All tumors in the presence of HIV infection.

2. MyocardialInfarction(FirstHeartAttackofSpecicSeverity)

I The rst occurrence of heart attack or myocardial infarction, which

means the death of a portion of the heart muscle as a result of

inadequate blood supply to the relevant area. The diagnosis for this will

be evidenced by all of the following criteria:

i. a history of typical clinical symptoms consistent with the diagnosis

of Acute Myocardial Infarction (for e.g. typical chest pain)

ii. new characteristic electrocardiogram changes

 iii. elevationofinfarctionspecicenzymes,Troponinsorotherspecic

biochemical markers.

II The following are excluded:

1. Other acute Coronary Syndromes

2. Any type of angina pectoris.

3. A rise in cardiac biomarkers or Troponin T or I in absence of overt

ischemic heart disease OR following an intra-arterial cardiac

procedure.

3. OpenChestCABG

I The actual undergoing of heart surgery to correct blockage or

narrowing in one or more coronary artery(s), by coronary artery bypass

grafting done via a sternotomy (cutting through the breast bone) or

minimally invasive keyhole coronary artery bypass procedures. The

diagnosis must be supported by a coronary angiography and the

 realizationofsurgeryhastobeconrmedbyacardiologist.

II The following are excluded:

a. Angioplasty and/or any other intra-arterial procedures

4. OpenHeartReplacementorRepairofHeartValves

The actual undergoing of open-heart valve surgery is to replace or

repair one or more heart valves, as a consequence of defects in,

abnormalities of, or disease-affected cardiac valve (s). The diagnosis

of the valve abnormality must be supported by an echocardiography

 and the realization of surgery has to be conrmed by a specialist

medical practitioner. Catheter based techniques including but not

limited to, balloon valvotomy/valvuloplasty are excluded.

5. ComaofSpeciedSeverity

1. A state of unconsciousness with no reaction or response to external

stimuli or internal needs.

This diagnosis must be supported by evidence of all of the following:

i. no response to external stimuli continuously for at least 96 hours;

ii. life support measures are necessary to sustain life; and

 iii. permanentneurologicaldecitwhichmustbeassessedatleast30

days after the onset of the coma.

 2. The condition has to be conrmed by a specialist medical

practitioner. Coma resulting directly from alcohol or drug abuse is

excluded.

6. KidneyFailureRequiringRegularDialysis

End stage renal disease presenting as chronic irreversible failure of

both kidneys to function, as a result of which either regular renal dialysis

(hemodialysis or peritoneal dialysis) is instituted or renal transplantation

 iscarriedout.Diagnosishastobeconrmedbyaspecialistmedical

practitioner.

7. StrokeResultinginPermanentSymptoms

Any cerebrovascular incident producing permanent neurological

sequelae. This includes infarction of brain tissue, thrombosis in an

intracranial vessel, hemorrhage and embolization from an extra cranial

 source. Diagnosis has to be conrmed by a specialist medical

practitioner and evidenced by typical clinical symptoms as well as

 typicalndingsinCTscanorMRIofthebrain.Evidenceofpermanent

 neurologicaldecitlastingforatleast3monthshastobeproduced.

The following are excluded:

1. Transient ischemic attacks (TIA)

2. Traumatic injury of the brain

3. Vascular disease affecting only the eye or optic nerve or vestibular

functions.

8. MajorOrgan/BoneMarrowTransplant

The actual undergoing of a transplant of:

1. One of the following human organs: heart, lung, liver, kidney,

pancreas, that resulted from irreversible end-stage failure of the

relevant organ, or

2. Human bone marrow using hematopoietic stem cells. The

  undergoing of a transplant has to be conrmed by a specialist

medical practitioner.

The following are excluded:

i. Other stem-cell transplants

ii. Where only islets of langerhans are transplanted

9. PermanentParalysisofLimbs

Total and irreversible loss of use of two or more limbs as a result of

injury or disease of the brain or spinal cord. A specialist medical

practitioner must be of the opinion that the paralysis will be permanent

with no hope of recovery and must be present for more than 3 months.

10. MotorNeuronDiseasewithPermanentSymptoms

Motor neuron disease diagnosed by a specialist medical practitioner

as spinal muscular atrophy, progressive bulbar palsy, amyotrophic

lateral sclerosis or primary lateral sclerosis. There must be progressive

degeneration of corticospinal tracts and anterior horn cells or bulbar

 efferent neurons. There must be current signicant and permanent

functional neurological impairment with objective evidence of motor

dysfunction that has persisted for a continuous period of at least 3

months.

11. MultipleSclerosiswithPersistingSymptoms

I. TheunequivocaldiagnosisofDeniteMultipleSclerosisconrmedand

evidenced by all of the following:

 i. investigationsincluding typicalMRIndings,which unequivocally

  conrmthediagnosistobemultiplesclerosis;

ii. there must be current clinical impairment of motor or sensory

function, which must have persisted for a continuous period of at

least 6 months, and

II. Other causes of neurological damage such as SLE and HIV are

excluded.

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

12. Primary(Idiopathic)PulmonaryHypertension

I. An unequivocal diagnosis of Primary (Idiopathic) Pulmonary

Hypertension by a Cardiologist or specialist in respiratory medicine

with evidence of right ventricular enlargement and the pulmonary

 arterypressureabove30mmofHgonCardiacCauterization.

There must be permanent irreversible physical impairment to the

degree of at least Class IV of the New York Heart Association

 Classicationofcardiacimpairment.

II. TheNYHAClassicationofCardiacImpairmentareasfollows:

i. Class III: Marked limitation of physical activity. Comfortable at rest,

but less than ordinary activity causes symptoms.

ii. Class IV: Unable to engage in any physical activity without

discomfort. Symptoms may be present even at rest.

III. Pulmonary hypertension associated with lung disease, chronic

hypoventilation, pulmonary thromboembolic disease, drugs and toxins,

diseases of the left side of the heart, congenital heart disease and any

 secondarycausearespecicallyexcluded.

13. AortaGraftSurgery

The actual undergoing of major Surgery to repair or correct aneurysm,

narrowing, obstruction or dissection of the Aorta through surgical

opening of the chest or abdomen.

 Forthepurposeofthisbenet,Aortameansthethoracicandabdominal

aorta but not its branches.

You understand and agree that We will not cover:

a. Surgery performed using only minimally invasive or intra-arterial

techniques.

b. Angioplasty and all other intra-arterial, catheter based techniques,

"keyhole" or laser procedures.

c. Congenital narrowing of the aorta and traumatic injury of the aorta

  arespecicallyexcluded.

14. Deafness

Total and irreversible Loss of hearing in both ears as a result of Illness

or accident.

This diagnosis must be supported by pure tone audiogram test and

 certiedbyanEar,NoseandThroat(ENT)specialist.Totalmeans“the

 lossofhearingtotheextentthatthelossisgreaterthan90decibels

across all frequencies of hearing” in both ears.

15. Blindness

I. Total, permanent and irreversible loss of all vision in both eyes as a

result of illness or accident.

II. The Blindness is evidenced by:

 i. correctedvisualacuitybeing3/60orlessinbotheyesor;

 ii. theeldofvisionbeinglessthan10degreesinbotheyes.

III. The diagnosis of blindness must be conrmed and must not be

correctable by aids or surgical procedure.

16. AplasticAnemia

Chronic persistent bone marrow failure which results in anemia,

neutropenia and thrombocytopenia requiring treatment with at least

one of the following:

a. Blood product transfusion;

b. Marrow stimulating agents;

c. Immunosuppressive agents; or

d. Bone marrow transplantation.

 The diagnosis must be conrmed by a hematologist Medical

Practitioner using relevant laboratory investigations including Bone

 MarrowBiopsyresultinginbone marrowcellularityoflessthan 25%

which is evidenced by any two of the following:

 a. Absoluteneutrophilcountoflessthan500/mm³orless;

 b. Plateletscountlessthan20,000/mm³orless;

 c. Reticulocytecountoflessthan20,000/mm³orless.

We will not cover temporary or reversible Aplastic Anemia under this

Section.

17. CoronaryArteryDisease

 Therstevidenceofnarrowingofthelumenofatleastonecoronary

 arterybyaminimumof75%andoftwoothersbyaminimumof60%,

regardless of whether or not any form of coronary artery Surgery

has been performed. Coronary arteries herein refer to left main stem,

 leftanteriordescendingcircumexandrightcoronaryarteryandnotits

branches which is evidenced by the following

a. evidence of ischemia on Stress ECG (NYHA Class III symptoms)

b. coronary arteriography (Hearth Cath)

18. EndStageLungFailure

End Stage Lung Disease, causing chronic respiratory failure, as

 conrmedandevidencedbyallofthefollowing:

i. FEV1 test results consistently less than 1 liter measured on 3

occasions 3 months apart; and

ii. Requiring continuous and permanent supplementary oxygen

therapy for hypoxemia; and

iii. Arterial blood gas analysis with partial oxygen pressure of 55mmHg

or less (PaO2 < 55 mm Hg); and

iv. Dyspnea at rest.

19. EndStageLiverFailure

Permanent and irreversible failure of liver function that has resulted in

all three of the following:

a. Permanent jaundice;

b. Ascites; and

c. Hepatic Encephalopathy.

Liver failure secondary to drug or alcohol abuse is excluded.

20. ThirdDegreeBurns

There must be third-degree burns with scarring that cover at least

 20%ofthebody’ssurfacearea.Thediagnosismustconrmthetotal

area involved using standardized, clinically accepted, body surface

 areachartscovering20%ofthebodysurfacearea.

21. FulminantHepatitis

A sub-massive to massive necrosis of the liver by the Hepatitis virus,

leading precipitously to liver failure. This diagnosis must be supported

by all of the following:

a. Rapid decreasing of liver size;

b. Necrosis involving entire lobules, leaving only a collapsed reticular

framework;

c. Rapid deterioration of liver function tests;

d. Deepening jaundice; and

e. Hepatic encephalopathy.

Acute Hepatitis infection or carrier status alone does not meet the

diagnostic criteria.

22. Alzheimer’sDisease

Alzheimer’s disease is a progressive degenerative Illness of the

brain, characterized by diffuse atrophy throughout the cerebral cortex

with distinctive histopathological changes. Deterioration or loss of

 intellectualcapacity,asconrmedbyclinicalevaluationandimaging

tests, arising from Alzheimer’s disease, resulting in progressive

 signicant reduction in mental and social functioning, requiring the

continuous supervision of the Insured Person. The diagnosis must be

 supported by the clinical conrmation of a Neurologist Medical

Practitioner and supported by Our appointed Medical Practitioner.

The following conditions are however not covered:

a. non-organic diseases;

b. alcohol related brain damage; and

c. any other type of irreversible organic disorder/dementia.

23. BacterialMeningitis

 Bacterialinfectionresultinginsevereinammationofthemembranes

 of the brain or spinal cord resulting in signicant, irreversible and

 permanentneurologicaldecit.Theneurologicaldecitmustpersistfor

 atleast6weeks.Thisdiagnosismustbeconrmedby:

 a. Thepresenceofbacterialinfectionincerebrospinaluidbylumbar

puncture; and

b. A consultant neurologist Medical Practitioner.

We will not cover Bacterial Meningitis in the presence of HIV infection

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under this Section.

24. BenignBrainTumor

 a. Benignbraintumorisdenedasalifethreatening,non-cancerous

tumor in the brain, cranial nerves or meninges within the skull. The

  presenceoftheunderlyingtumormustbeconrmedbyimaging

studies such as CT scan or MRI.

b. This brain tumor must result in at least one of the following and

  mustbeconrmedbytherelevantmedicalspecialist.

  i. Permanent Neurological decit with persisting clinical

   symptoms for a continuous period of at least 90consecutive

days or

ii. Undergone surgical resection or radiation therapy to treat the

brain tumor.

The following conditions are however not covered by Us:

a. cysts;

b. granulomas;

c. malformations in the arteries or veins of the brain;

d. hematoma;

e. Abscesses

f. Pituitary Tumors

g. tumors of skull bones and

h. tumors of the spinal cord

25. ApallicSyndrome

Universal necrosis of the brain cortex with the brainstem remaining

 intact. The diagnosis must be conrmed by a Neurologist Medical

Practitioner acceptable to Us and the condition must be documented

by such Medical Practitioner for at least one month.

26. Parkinson’sDisease

The unequivocal diagnosis of progressive, degenerative idiopathic

Parkinson’s disease by a Neurologist Medical Practitioner acceptable

to Us.

The diagnosis must be supported by all of the following conditions:

a. the disease cannot be controlled with medication;

b. signs of progressive impairment; and

c. inability of the Insured Person to perform at least 3 of the 6

activities of daily living as listed below (either with or without the use

of mechanical equipment, special devices or other aids and

adaptations in use for disabled persons) for a continuous period of

at least 6 months:

Activities of daily living:

i. Washing: the ability to wash in the bath or shower (including getting

into and out of the shower) or wash satisfactorily by other means

and maintain an adequate level of cleanliness and personal

hygiene;

ii. Dressing: the ability to put on, take off, secure and unfasten all

  garmentsand,asappropriate,anybraces,articiallimbsorother

surgical appliances;

iii. Transferring: The ability to move from a lying position in a bed to a

sitting position in an upright chair or wheel chair and vice versa;

iv. Toileting: the ability to use the lavatory or otherwise manage bowel

and bladder functions so as to maintain a satisfactory level of

personal hygiene;

v. Feeding: the ability to feed oneself, food from a plate or bowl to the

mouth once food has been prepared and made available.

vi. Mobility: The ability to move indoors from room to room on level

surfaces at the normal place of residence.

We will not cover Parkinson’s disease secondary to drug and/or alcohol

abuse under this Section.

27. MedullaryCysticDisease

A progressive hereditary disease of the kidneys characterised by the

presence of cysts in the medulla, tubular atrophy and interstitial

 brosiswiththeclinicalmanifestationsofanaemia,polyuriaandrenal

loss of sodium, progressing to chronic renal failure. The diagnosis

must be supported by renal biopsy.

28. MuscularDystrophy

A group of hereditary degenerative diseases of muscle characterized

by progressive and permanent weakness and atrophy of certain

muscle groups. The diagnosis of muscular dystrophy must be

unequivocal and made by a Neurologist Medical Practitioner acceptable

 toUs,withconrmationofatleast3ofthefollowing4conditions:

a. Family history of muscular dystrophy;

b. Clinical presentation including absence of sensory disturbance,

  normalcerebrospinaluidandmildtendonreexreduction;

c. Characteristic electromyogram;

 d. Clinicalsuspicionconrmedbymusclebiopsy.

The condition must result in the inability of the Insured Person to

perform at least 3 of the 6 activities of daily living as listed below (either

with or without the use of mechanical equipment, special devices or

other aids and adaptations in use for disabled persons) for a continuous

period of at least 6 months:

Activities of daily living:

i. Washing: the ability to wash in the bath or shower (including getting

into and out of the shower) or wash satisfactorily by other means

and maintain an adequate level of cleanliness and personal

hygiene;

ii. Dressing: the ability to put on, take off, secure and unfasten all

  garmentsand,asappropriate,anybraces,articiallimbsorother

surgical appliances;

iii. Transferring: The ability to move from a lying position in a bed to a

sitting position in an upright chair or wheel chair and vice versa;

iv. Toileting: the ability to use the lavatory or otherwise manage bowel

and bladder functions so as to maintain a satisfactory level of

personal hygiene;

v. Feeding: the ability to feed oneself, food from a plate or bowl to the

mouth once food has been prepared and made available;

vi. Mobility: The ability to move indoors from room to room on level

surfaces at the normal place of residence.

29. LossofSpeech

a. Total and irrecoverable loss of the ability to speak as a result

of injury or disease to the vocal cords. The inability to speak must

be established for a continuous period of 12 months. This diagnosis

must be supported by medical evidence furnished by an Ear,

Nose, Throat (ENT) specialist.

b. All psychiatric related causes are excluded.

30. SystemicLupusErythematous

A multi-system, multifactorial, autoimmune disorder characterized

by the development of auto-antibodies directed against various self-

antigens. Only those forms of systemic lupus erythematous which

involve the kidneys (Class III to Class V lupus nephritis, established by

renal biopsy, and in accordance with the World Health Organization

 (WHO) classication) will be covered by Us under this Section. The

 naldiagnosismustbeconrmedbyaregisteredMedicalPractitioner

specializing in Rheumatology and Immunology acceptable to Us. Other

forms of systemic lupus erythematous, discoid lupus and those forms

with only hematological and joint involvement are however not covered:

 TheWHOlupusclassicationisasfollows:

• Class I: Minimal change – Negative, normal urine.

• Class II: Mesangial – Moderate proteinuria, active sediment.

• Class III: Focal Segmental – Proteinuria, active sediment.

• Class IV: Diffuse – Acute nephritis with active sediment and/or

nephritic syndrome.

• Class V: Membranous – Nephrotic Syndrome or severe proteinuria.

31. LossofLimbs

a. The physical separation of two or more limbs, at or above the wrist or

ankle level limbs as a result of injury or disease. This will include

medically necessary amputation necessitated by injury or disease.

The separation has to be permanent without any chance of surgical

correction. Loss of Limbs resulting directly or indirectly from self-

  inictedinjury,alcoholordrugabuseisexcluded.

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32. MajorHeadTrauma

 a. AccidentalheadinjuryresultinginpermanentNeurologicaldecit

to be assessed no sooner than 3 months from the date of the

accident. This diagnosis must be supported by unequivocal

  ndings on Magnetic Resonance Imaging, Computerized

Tomography, or other reliable imaging techniques. The accident

must be caused solely and directly by accidental, violent, external

and visible means and independently of all other causes.

b. The Accidental Head injury must result in an inability to perform

at least three (3) of the following Activities of Daily Living either

with or without the use of mechanical equipment, special devices

or other aids and adaptations in use for disabled persons. For the

  purposeofthisbenet,theword“permanent”shallmeanbeyond

the scope of recovery with current medical knowledge and

technology.

c. The Activities of Daily Living are:

i. Washing: the ability to wash in the bath or shower (including

getting into and out of the bath or shower) or wash satisfactorily

by other means;

ii. Dressing: the ability to put on, take off, secure and unfasten all

   garments and, as appropriate, any braces, articial limbs or

other surgical appliances;

iii. Transferring: the ability to move from a bed to an upright chair

or wheelchair and vice versa;

iv. Mobility: the ability to move indoors from room to room on level

surfaces;

v. Toileting: the ability to use the lavatory or otherwise manage

bowel and bladder functions so as to maintain a satisfactory

level of personal hygiene;

vi. Feeding: the ability to feed oneself once food has been

prepared and made available.

d. The following are excluded:

a) Spinal cord injury

33. BrainSurgery

The actual undergoing of surgery to the brain, under general

anesthesia, during which a Craniotomy is performed. Burr hole and

brain surgery as a result of an accident is excluded. The procedure

 mustbeconsiderednecessarybyaqualiedspecialistandthebenet

shall only be payable once corrective surgery has been carried out.

34. Cardiomyopathy

The unequivocal diagnosis by a consultant cardiologist of

Cardiomyopathy causing impaired ventricular function suspected by

 ECGabnormalitiesandconrmedbycardiacechoofvariableetiology

and resulting in permanent physical impairments to the degree of at

 leastClassIV oftheNew YorkAssociation(NYHA) Classicationof

cardiac impairment.

 The NYHA Classication of Cardiac Impairment (Source: “Current

Medical Diagnosis and Treatment – 39th Edition”):

a. Class I: No limitation of physical activity. Ordinary physical activity

does not cause undue fatigue, dyspnoea, or angina pain.

b. Class II: Slight limitation of physical activity. Ordinary physical

activity results in symptoms.

c. Class III: Marked limitation of physical activity. Comfortable at rest,

but less than ordinary activity causes symptoms.

d. Class IV: Unable to engage in any physical activity without

discomfort. Symptoms may be present even at rest.

We will not cover Cardiomyopathy related to alcohol abuse under this

Section.

35. Creutzfeldt-JacobDisease(CJD)

A Diagnosis of Creutzfeldt-Jakob disease must be made by a Specialist

Medical Practitioner (Neurologist). There must be permanent clinical

loss of the ability in mental and social functioning for a minimum period

 of30daystotheextentthatpermanentsupervisionorassistancebya

third party is required.

 Socialfunctioningisdenedastheabilityoftheindividualtointeractin

the normal or usual way in society.

Mental functioning would mean functions /processes which we can do

with our minds.

36. TerminalIllness

An Insured Person shall be regarded as terminally ill only if he/ she

is diagnosed as suffering from a condition which, in the opinion of two

appropriate independent Medical Practitioners, is highly likely to lead

to death within 12 months from the date of the diagnosis and the

Insured Person is not receiving any active treatment for the terminal

illness, other than that of the pain relief. The terminal illness must

 bediagnosedandconrmedbyMedicalPractitionersregisteredwith

the Indian Medical Association and approved by Us.

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.13.

C.II.3 Tele-Consultation

Insured Person may avail tele-consultations with our Medical

Practitioner(s) through our network in India. These consultations would

be available through tele/chat mode.

 Any claim under this benet will not impact theSum Insured and/or

Cumulative Bonus or Cumulative Bonus Booster (if opted).

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.14

C.II.4 CumulativeBonus

a) On Sum Insured

 WewillincreaseYourSumInsuredby25%asspeciedunderPolicy

Schedule at the end of the Policy Year if the Policy is renewed with Us

without any break:

a) No Cumulative Bonus will be added if the Policy is not renewed

with Us by the end of the Grace Period.

b) The Cumulative Bonus will not be accumulated in excess of

  200%oftheSumInsuredunderthecurrentPolicywithUsunder

any circumstances.

c) Any Cumulative Bonus that has accrued for a Policy Year will be

credited at the end of that Policy Year if the policy is renewed with

us within grace period and will be available for any claims made in

the subsequent Policy Year.

d) Merging of policies: If the Insured Persons in the expiring Policy

are covered under multiple policies and such expiring Policy has

been Renewed with Us on a Family Floater basis then the

Cumulative Bonus to be carried forward for credit in such Renewed

Policy shall be the lowest percentage of Cumulative Bonus

applicable on the lowest Sum Insured of the last policy year

amongst all the expiring polices being merged.

e) Splitting of policies: If the Insured Persons in the expiring Policy

are covered on a Family Floater basis and such Insured Persons

Renew their expiring Policy with Us by splitting the Sum Insured

in to two or more Family Floater/Individual policies then the

Cumulative Bonus shall be apportioned to such Renewed Policies

in the proportion of the Sum Insured of each Renewed Policy.

f) Reduction in Sum Insured: If the Sum Insured has been reduced at

the time of Renewal, the applicable Cumulative Bonus shall be

calculated on the revised Sum Insured on pro-rata basis.

g) Increase in Sum Insured: If the Sum Insured under the Policy has

been increased at the time of Renewal, the Cumulative Bonus

shall be calculated on the Sum Insured of the last completed

Policy Year.

h) Cumulative bonus shall not be available for claims made under

Value added cover (Section D.II) and also for D.III.1.i

Maternity & New Born Hospitalization Expenses, D.III.3.i Maternity

& New Born Hospitalization Expenses, D.III.1.iii Health Maintenance

  Benet,D.I.10AirAmbulanceCover,D.I.12OutpatientExpenses,

D.I.13 Daily Cash for Shared Accommodation and D.IV.3 Infertility

Treatment.

i) This clause does not alter Our right to decline a Renewal or

cancellation of the Policy for reasons as mentioned under Section

F.I.6

C.II.5 SwitchOffBenet

 IntheeventofyourtraveloutsideIndiaaftertherstpolicyyear,you

may switch off your insurance cover for a maximum continuous period

 of30daysinapolicyyearandearnapremiumdiscountintheform

of pro-rated premium, based on the total number of days up to which

the cover has been switched off. Such pro-rated premium can be

utilized in the form of premium discount at the time of policy renewal.

When the insurance cover is in Switch Off mode, only the following

cover(s) if opted in the policy, shall remain active:

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

I. Section D.IV.4 Personal Accident Cover and

II. Section D.III.4.ii Worldwide Emergency Hospitalization with

Outpatient Cover under Freedom optional package

III. Section D.IV.6 Critical Illness Add On Cover

a. Premium discount shall be calculated on a pro-rata basis the

number of days the policy has been switched off on a per day

basis and this discount shall be adjusted in the renewal premium

falling due immediately after the expiring Policy Period.

 b. In a Floater Policy, Switch Off Benet can be availed only if all

the Insured Persons travel outside India. However, in case of

an Multi-Individual Policy if any one or more Insured Person(s)

  travel outside India, you can avail this benet and the premium

discount shall be calculated based on the applicable premium for

that/those particular individual(s).

 c. ThisbenetshallnotbeavailableintherstPolicyYear.

 d. This benet cannot be availed in the last 90 days of the Policy

Year.

e. During the Switch-off period, Your cover will be limited only

to Section D.IV.4 Personal Accident, Section D.III.4.ii

Worldwide Emergency Hospitalization with Outpatient Cover and

Section D.IV.6 Critical Illness Add-on, if opted. Any claim under

  the oater policy, arising during the switch off period other than

claim under Section D.IV.4 Personal Accident Cover, Section

D.III.4.ii Worldwide Emergency Hospitalization with Outpatient

Cover and Section D.IV.6 Critical Illness Add-on, shall not be

payable. In case of Multi-Individual policies where members are

covered on individual basis, the switch off period shall apply only to

the respective member for which the request to switch off the

coverage is placed with the Insurer. The coverage shall start once

the cover is switched on either upon the expiry of the Switch Off

  periodor30daysfromtheSwitchOffdate,whicheverisearlier.

f. The date of travel to abroad for all the Insured Members should be

  sameincaseofaoaterpolicyinordertobeeligibletoutilizethis

cover.

 g. InaFloaterPolicy,SwitchOffBenetcanbeavailedonlyifallthe

Insured Persons travel outside India at the same time. The date of

travel to abroad and return to India for all the Insured Members

should be same to be eligible to utilize this cover.

h. In case of a Multi-Individual Policy, You can Switch Off the Policy

for one or more members provided that the date of travel to abroad

and return to India for those Insured Members is same to be

eligible to utilize this cover.

 i. ThisbenetcanbeutilizedonlyonceinaPolicyYearirrespective

of Policy type (Floater or Individual/ Multi-Individual) .

j. You need to intimate Us at least 72 hours prior to the date of travel

to switch off the policy as per process mentioned in G.I.17. We

would require the following details:

a. Date and time of leaving India

b. Date and time of your return to India

k. In case You arrive back to India earlier than the date informed to

Us, then You need to intimate us at least 24 hours prior to the

return travel to India in order to Switch On the Policy. If out of all

members who travelled, only one or few members return to India

earlier than the date informed to Us, then the Policy shall be

switched on from the earliest date of return to India for all the

members.

l. Your coverage shall be switched off and reactivated as per the

details provided in clause (j) above subject to a maximum

  switch off period of 30 days. If the return to India is later than

  30 days from the date of Switch off, the coverage shall be

  reactivatedimmediatelyafter30daysirrespectiveofyourreturn.

m. We may require the following documents to record the date of your

travel in order to Switch-Off and Switch-on the policy for You

a. Flight tickets of the Insured members travelling to abroad

b. Flight tickets of the Insured members travelling back to India

n. Your Policy coverage will be automatically activated based on the

  informationpertainingtodateofreturnprovidedtousor30days

from the Switch Off date, whichever is earlier. In case of policy

  termof2yearsand3years,youcanavailthisbeneteachyear

and the discount shall be accumulated during the policy period

which can be redeemed at the time of policy renewal as per the

below

a. If the policy is renewed with the same policy term or higher,

   then 100% of the earned discount shall be adjusted in the

renewal premium as ‘Discount in renewal premium’.

b. If the policy is renewed with a reduced policy term, then the

earned discount shall be adjusted on a proportionate basis in

   theratioasspeciedbelow:

 RenewalPolicy

Term

DiscounttobeAdjusted=EarnedDiscountX

PreviousPolicy

 Illustration:PreviousPolicyTerm=3years;SwitchOffDiscount

  Earnedover3years=`1,800

If

Renewed

Policy

Termis

Renewal

Premium

(Excluding

optional

covers,Rider

andtaxes)

SwitchOff

discountutilized

Renewal

Premium

Payableafter

adjusting

SwitchOff

discount

1 Year 13,000 600(1,800*1/3as

Insured is renewing

from 3 Year Policy Term

to 1 Year Policy Term)

12,400

2 Years 27,000 1,200(1,800*2/3as

Insured is renewing

from 3 Year Policy Term

to 2 Year Policy Term)

25,800

3 Years 42,000 1,800(Insuredis

renewing with the same

Policy Term of 3 years)

40,200

Illustration2:SwitchOffPeriod

TravelPeriod

From:15/01/2022 To:20/01/2022

Time:16:00hrs. Time:15:00hrs.

RequestedDateofSwitch

Off

15/01/2022

RequestedDateofSwitch

20/01/2022

Inthiscase,SwitchOffshallhappenon15/01/2022at23:59:59hrsand

SwitchOnshallhappenon20/01/2022at00:00:00hrs.

 Forthepurposeofthisbenet,

Switch Off – means to deactivate all the covers in the Policy, except

coverage under Section D.IV.4 Personal Accident Cover and Section

D.III.4.ii Worldwide Emergency Hospitalization with Outpatient Cover

Section D.IV.6 Critical Illness Add-on, from the requested Switch Off

date.

C.II.6. WellnessProgram

You can earn reward points by opting for Our Healthy Life

Management Program wherein you need to complete number of steps

per day as per the table given below, that will help You in improving

Your well-being.

HealthyLifeManagementProgram-RewardsStructure

No.ofdays

inaPolicy

Year

No.ofsteps

10,000

steps and

above per

day

8,000-

9,999 steps

per day

6,000-

7,999 steps

per day

Less than

6,000steps

per day

240days

and above

20% 15% 10% Nil

180-239

days

15% 10% 5% Nil

120-179

days

10% 5% Nil Nil

 Conditionsunderthisbenet:

 i. Thenumberofdaysspeciedinthetableaboveshouldfallunder

  the rst 9 (nine) months of every Policy Year. The activities

  undertakentowardsthisbenetduringthelast3(three)monthsof

the Policy Year shall not be considered for reward calculation.

ii. This wellness program is available only for the adult members with

age 18 years and above. However, in a Floater policy, this program

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

shall be available only to the independent adult members and shall

not be available to dependent children.

iii. In an Individual Policy with one or more members, earning of

reward points will be at member level wherein each member can

  earnUpto20%ofhis/herrespectiveexpiringbasepremiumasper

  theapplicabletermsandconditionsbutinaoaterpolicy,earning

of reward points will be at policy level wherein all eligible members

  cumulativelycanearnamaximumUpto20%oftheexpiringbase

premium as per the applicable terms and conditions.

 iv. Inaoaterpolicytheaboverewardpercentagewouldbedivided

as per the number of eligible Adult Insured members as per the

below illustration.

Inaoaterpolicy,therewardpercentagewouldbedividedasperthe

number of eligible Adults covered.

For Example

In a 2A+2C policy, the Healthy Life Management Program shall be

applicablefor2Aonly.AssumingAdult1attainsascoreof10,000steps

perdayforaperiodof240daysandAdult2attainsascoreof6000

stepsperdayforaperiodof240days.

The reward points shall be calculated as per the below:

Adult1:20%/2=10%

Adult2:10%/2=5%

Hence,thetotalearnedrewardpointswouldbe10%+5%=15%ofthe

existing Policy premium (Excluding optional cover/ Rider and taxes).

v. No reward points will be allocated for any count of steps per day,

  foraperiodoflessthan120days.

vi. Maximum reward points that can be earned in a single Policy Year

  willbelimitedto20%ofthepremiumpaid(excludingpremiumfor

Optional covers, Riders and taxes) in the existing Policy. In case

of 2 or 3 year policies, maximum reward points that can be earned

  shallnotexceed20%ofthetotalpremiumpaid(excludingpremium

for Optional covers, Riders and taxes) for 2 years or 3 years as

applicable.

vii. Each earned reward point will be valued at 1 Rupee. Accrued

rewards can be redeemed against payable premium (excluding

premium for Optional covers, Riders and Taxes) from 1st Renewal

of the Policy.

viii. The earned reward points can be utilized as Discount in the

renewal premium falling due immediately after the accrual. Carry

forward of earned reward points shall not be allowed.

ix. Redemption against renewal premium will be available only at the

time such renewal is due. Any earned rewards will lapse at the end

of the grace period if the policy is not renewed with us.

Refer Annexure- A below on the Illustration of Reward Points.

Annexure - A - Illustration of Healthy Life Management Program

Rewards

ReductionofRenewalPolicyYear

PolicyTerm-3years

(Premium indicated here is just for illustration purposes in case of 1

Adult policy and may not be the actual premium.)

Each earned reward point will be valued at 1 Rupee

Year Premium

(Excluding

optional

covers/

Riderand

taxes)

Activity No.of

Days

Reward

Points

Earned

Year 1 10000 10,000

and

above

steps/

day

240

days

and

above

20% 2000

Year 2 11000 8,000

- 9,999

steps/

day

240

days

and

above

15% 1650

Year 3 12000 6,000

- 7,999

steps/

day

240

days

and

above

10% 1200

Total 33000 4850

The earned reward points could be redeemed as discount as per

the below process to pay a portion of the renewal premium

RenewalofPolicyasperbelowtable

If

Renewed

Policy

Termis

Renewal

Premium

(Excluding

optional

covers,

Riderand

taxes)

Reward

discountutilized

RenewalPremium

Payableafter

adjustingReward

discount

1 Year

Policy

13000 1617(4850*1/3

as Insured is

renewing 3 Year

policy to 1 Year

Policy)

11383

2 Years

Policy

27000 3233(4850*2/3

as Insured

renewing 3 Year

policy to 2 Year

Policy)

23767

3 Years

Policy

42000 4850(Insured

renewing to the

same policy

tenure of 3 years)

37150

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

Increase of Renewal Policy Year

PolicyTerm-1years

(Premium indicated here is just for illustration purposes and may not

be the actual premium.)

Each earned reward point will be valued at 1 Rupee

Year Premium

paid

(Excluding

optional

cover,

Riderand

taxes)

Activity No.

of

Days

Rewards

Points

Earned

Year 1 10000 6,000

- 7,999

steps /

day

180

- 239

days

5% 500

Total 10000 500

The earned reward points could be redeemed as discount as per the

below process to pay a portion of the renewal premium

RenewalofPolicyasperbelowtable

If

Renewed

Policy

Termis

Renewal

Premium

(Excluding

optional

cover,

Riderand

taxes)

Rewards

discount

utilized

RenewalPremiumPayable

afteradjustingRewards

discount

1 Year

Policy

11000 500(as

Insured is

renewing

1 Year

policy to

1 Year

Policy)

10500

2 Year

Policy

21000 500(as

Insured is

renewing

1 Year

policy to

2 Year

Policy)

20500

3 Year

Policy

33000 500(as

Insured is

renewing

1 Year

policy to

3 Year

Policy)

32500

The notications related to wellness program will be communicated

 via SMS, email and the program specic phone/ web application.

Details about reward points will be available on the program app (if

any) or would be shared through SMS and/or Renewal Notice which

would be sent to customers.

C.II.7 DiscountfromNetworkProviders

The Insured Person can avail discounts on Diagnostics, Pharmacy

and Health Supplements offered through our Network Providers.

C.II.8 PremiumWaiverBenet

In case, the Policyholder who is also an Insured Person under the

Policy suffers Death due to an injury caused by an Accident within

365 days from the date of the event or he/she is diagnosed with a

Critical Illness, listed under this section, We will pay the next one full

Policy Year’s Renewal Premium (including Optional covers, Riders and

Taxes) of the Policy, for a policy tenure of 1 year. The premium shall be

paid towards existing Insured Persons covered under the same policy,

 withbenetssameastheexpiringPolicy.

 IncaseofanychangeinPolicybenets,completepremiumwillbepaid

by the Policyholder.

The cover is available subject to below conditions:

• If only one person is covered under the Policy, policy will not be

renewed in case of death of the Policyholder.

• The Policyholder is not added in the Policy in the middle of the

  PolicyYear.There is nochangeincovers, SumInsured,benet

structure, limits and conditions applicable under the Policy, at the

time of renewal.

• No new member is being added under the renewed Policy.

• In case of a policy with existing tenure of 2 or 3 years, it will be

renewed only for one year, provided all the terms and conditions,

  benetsandpolicylimitsremainsame.

 Forthepurposeofthisbenet,CriticalIllnessesshallinclude–

 a) CancerofSpeciedSeverity

 b) MyocardialInfarction(FirstHeartAttackofSpecicSeverity)

c) Open Chest CABG

d) Open Heart Replacement or Repair of Heart Valves

 e) ComaofSpeciedSeverity

f) Kidney Failure Requiring Regular Dialysis

g) Stroke Resulting in Permanent Symptoms

h) Major Organ/Bone Marrow Transplant

i) Permanent Paralysis of Limbs

j) Motor Neuron Disease with Permanent Symptoms

k) Multiple Sclerosis with Persisting Symptoms

 Onceaclaimhasbeenacceptedandpaidunderthisbenet,thiscover

will automatically terminate in respect of that Insured Person.

 Any claim under this benet will not impact the Sum Insured and/or

Cumulative Bonus and/or Cumulative Bonus Booster.

C.III. OptionalPackages

These optional packages shall be available to all eligible Insured

Persons covered under the Policy. Selection of this package is allowed

at Policy level only.

 The limits specied under below optional package shall override

the applicable limits mentioned as part of base cover for the respective

coverages.

The Insured Person can opt for any one of the below packages.

C.III.1 EnhancePlus

(Applicable for Protect Plan)

C.III.1.i Maternity&NewBornHospitalizationExpenses

A. MaternityExpenses

We will cover Maternity Expenses up to Maternity Sum insured and as

 perPlanoptedandasspeciedinthePolicyScheduleforthedelivery

of a child and/ or Maternity Expenses incurred during the Policy Year,

related to a Medically Necessary and lawful termination of pregnancy

up to maximum 2 deliveries or terminations during the lifetime of an

Insured Person.

You understand and agree that:

(a) Our maximum liability per delivery or termination is subject to the

  MaternitySumInsuredspeciedinthePolicySchedule.

(b) The female adult Insured Person should have been continuously

covered under this Policy for at least 36 months before availing this

  benet.

 (c)Thecoverunderthisbenetshallberestrictedtotwochildrenonly.

 (d)Thepaymenttowardsanyadmittedclaimunderthisbenetforany

complication arising out of or as a consequence of maternity or

  childbirthwillberestrictedtoMaternitySumInsuredspeciedin

the Policy Schedule however any restored amount will not be

available for coverage under this section.

(e) Pre or post natal Maternity Expenses will be covered within the

  Maternity Sum Insured under this benet however; any Pre or

Post-hospitalization Expenses under Section D.I.2 and D.I.3,

  abovewillnotbeapplicableforthisbenet.

(f) Maternity Sum Insured available under Maternity Expenses will be

in addition to Sum Insured.

(g) Applicable Deductible under the applicable plan shall also apply to

  thisbenet.

 (h) WewillnotcoverthefollowingexpensesunderMaternityBenet:

i) Medical Expenses in respect of the harvesting and storage

of stem cells when carried out as a preventive measure against

possible future Illnesses.

ii) Medical Expenses for ectopic pregnancy. However, these

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

expenses will be covered under the In-patient Hospitalization

under Section D.I.1.

(i) Exclusion E.I.18 shall not apply to this cover subject to terms and

  conditionsunderthisbenet

B. NewBornBabyExpenses:

Subject to a claim being admitted under Maternity Expenses under

Section D.III.1.i.A, We will cover.

(a) Medical Expenses towards treatment of the New Born Baby while

the Insured Person is hospitalized as an In-patient for delivery.

(b) The Reasonable and Customary Charges incurred on the New

  Born Baby during and post birth up to 90 days from the date of

  delivery, within the limits specied in the Policy Schedule under

Maternity Expenses without payment of any additional premium.

this section

(d) Subject to the underwriting and to the terms and conditions of the

  Policy, We will cover the New Born Baby beyond 90 days on

payment of requisite premium for the New Born Baby into the

Policy by way of an endorsement or at the next Renewal, whichever

is earlier.

Applicable Deductible under the applicable plan shall also apply to

  thisbenet.

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.4 & G.I.5.

C. FirstYearVaccinations

We will cover Reasonable and Customary charges for vaccination

expenses for the New Born Baby as per National Immunization

Scheme (India) listed below, till the baby completes 1 year (12 months)

 within the limits specied in the Policy Schedule under Maternity

Expenses without payment of any additional premium. In case the

Policy ends before the New Born Baby has completed 1 year (12

 months),thecoverageunderthisbenetshallcontinuesubjecttothe

Policy being renewed in the subsequent year. Any restored Sum

Insured will not be available for coverage under this section.

Time Interval Vaccinations to be done (Age) Frequency

0–3months

BCG (Birth to 2 weeks) 1

OPV(0‚6‚10weeks)OROPV+IPV1

(6,10weeks)

3 OR 4

DPT(6&10week) 2

Hepatitis-B(0&6week) 2

Hib(6&10week) 2

3 – 6 months

OPV (14 week) OR OPV + IPV2 1 or 2

DPT (14 week) 1

Hepatitis-B (14 week) 1

Hib (14 week) 1

9 months Measles (+9 months) 1

12 months Chicken Pox (12 months) 1

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.5.

C.III.1.ii RoomAccommodationUpgrade

We will upgrade the Room category coverage under Section D.I.1 In-

patient hospitalization up to ‘Any Room Category’ subject to maximum

 ofSumInsuredOptedandasspeciedinthePolicySchedule.

C.III.1.iii HealthMaintenanceBenet

 We will cover, up to limits specied in the Policy Schedule, by way

of reimbursement of the Reasonable and Customary Charges for

below mentioned expenses incurred by the Insured Person for

Medically Necessary charges incurred during the Policy Year on an

Out Patient basis.

i. Consultation with Medical Practitioner, Diagnostic tests, preventive

tests, drugs, prosthetics, medical aids (spectacles and contact

lenses, hearing aids, crutches, wheel chair, walker, walking stick,

lumbo-sacral belt), prescribed by the specialist Medical Practitioner

  uptothelimitsspeciedinthePolicySchedule.

ii. Towards Dental Treatments and AYUSH forms of Medicines

wherever prescribed by a Medical Practitioner.

Insured can use Our application or contact Us for scheduling an

 appointment for availing services covered under this benet at our

Network provider.

 Any unutilised Health Maintenance Benet limit shall lapse at the

 end of the Policy Year. Fresh limits will be available as specied in

the Policy Schedule for the new Policy Year.

All Waiting Periods and Permanent Exclusions including Co-pay’s

applicable on the Policy under Section E shall not apply to this section.

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

 underSectionsG.I.14andG.I.18.Further,allclaimsunderthisbenet

 will be subject to the any one claim limits specied under Section

G.I.18 of the Policy.

C.III.2 Assure

(Applicable for Sum Insured `3Lacs, `4 Lacs and `5 Lacs under

Protect Plan)

C.III.2.i RoomAccommodationLimit

We will limit the Room category coverage under Section D.I.1 In-

 patienthospitalizationupto1%oftheoptedSumInsuredperdayand

 asspeciedinthePolicySchedule.ForICUaccommodation,wewill

 coverupto2%oftheoptedSumInsuredperdayandasspeciedin

the Policy Schedule.

If the Insured Person is admitted in a room category/ limit that is higher

 than the one that is specied in the Policy Schedule, then the

Policyholder/Insured Person shall bear a ratable proportion of the total

Associated Medical Expenses (including surcharge or taxes thereon)

in the proportion of the difference between the room rent of the entitled

room category to the room rent actually incurred.

C.III.2.iiDiseaseSpecicSub-limits

We will indemnify the Medical Expenses under Section D.I.1 In-patient

hospitalization incurred by an Insured Person in respect of the below

listed ailments / procedures (refer the table below) up to the limits

 speciedagainsteachandeveryailment/procedurefortheapplicable

Sum Insured options:

Sum Insured (in `) `3 & `4

Lacs

`5 Lacs

Treatment for each Ailment / Procedure

mentioned below:

1. Surgery for treatment of all

types of Hernia

2. Hysterectomy

3. Surgeries for benign Prostate

Hypertrophy

4. Surgical treatment of stones of renal

system

`50,000 `65,000

Treatment of Cataract (Per Eye)

`20,000 `30,000

Treatment of Total Knee replacement

(Per knee)

`80,000 `1,00,000

Treatment for breakage of bones

`2,00,000 `2,50,000

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.4 and G.I.5.

C.III.2.iii ModernandAdvancedTreatments

We will cover the following procedures (wherever medically indicated)

either as In-patient or as part of Day Care Treatment in a hospital up

 to10%oftheSumInsuredasspeciedinthePolicySchedule,during

the Policy Year:

a. Uterine Artery Embolization and HIFU (High intensity focused

ultrasound)

b. Balloon Sinuplasty

c. Deep Brain stimulation

d. Oral chemotherapy

e. Immunotherapy - Monoclonal Antibody to be given as injection

f. Intra vitreal injections

g. Robotic surgeries

h. Stereotactic radio surgeries

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

i. Bronchial Thermoplasty

j. Vaporization of the prostrate (Green laser treatment or holmium

laser treatment)

k. IONM - (Intra Operative Neuro Monitoring)

l. Stem cell therapy: Hematopoietic stem cells for bone marrow

transplant for hematological conditions to be covered.

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.4 and G.I.5.

C.III.3 Enhance

(Applicable for Advantage Plan)

C.III.3.i Maternity&NewBornHospitalizationExpenses

A. MaternityExpenses

We will cover Maternity Expenses up to Maternity Sum insured and as

 perPlanoptedandasspeciedinthePolicyScheduleforthedelivery

of a child and/ or Maternity Expenses incurred during the Policy Year,

related to a Medically Necessary and lawful termination of pregnancy

up to maximum 2 deliveries or terminations during the lifetime of an

Insured Person.

You understand and agree that:

(a) Our maximum liability per delivery or termination is subject to the

  MaternitySumInsuredspeciedinthePolicySchedule.

(b) The female adult Insured Person should have been continuously

covered under this Policy for at least 36 months before availing this

  benet.

 (c)Thecoverunderthisbenetshallberestrictedtotwochildrenonly.

 (d) Thepaymenttowardsanyadmittedclaimunderthisbenetforany

complication arising out of or as a consequence of maternity or

  childbirthwillberestrictedtoMaternitySumInsuredspeciedin

the Policy Schedule however any restored amount will not be

available for coverage under this section.

(e) Pre or post-natal Maternity Expenses will be covered within the

  Maternity Sum Insured under this benet however; any Pre or

Post-hospitalization Expenses under Section D.I.2 and D.I.3,

  abovewillnotbeapplicableforthisbenet.

(f) Maternity Sum Insured available under Maternity Expenses will be

in addition to Sum Insured.

(g) Applicable Deductible under the applicable plan shall also apply to

  thisbenet.

 (h)WewillnotcoverthefollowingexpensesunderMaternityBenet:

i) Medical Expenses in respect of the harvesting and storage

of stem cells when carried out as a preventive measure against

possible future Illnesses.

ii) Medical Expenses for ectopic pregnancy. However, these

expenses will be covered under the In-patient Hospitalization

under Section D.I.1.

Exclusion E.I.18 shall not apply to this cover subject to terms and

 conditionsunderthisbenet

B. NewBornBabyExpenses

Subject to a claim being admitted under Maternity Expenses under

Section D.III.3.i.A, We will cover.

(a) Medical Expenses towards treatment of the New Born Baby while

the Insured Person is hospitalized as an In-patient for delivery.

(b) The Reasonable and Customary Charges incurred on the New

  Born Baby during and post birth up to 90 days from the date of

  delivery, within the limits specied in the Policy Schedule under

Maternity Expenses without payment of any additional premium.

this section

(d) Subject to the underwriting and to the terms and conditions of

  thePolicy,WewillcovertheNewBornBabybeyond90dayson

payment of requisite premium for the New Born Baby into the

Policy by way of an endorsement or at the next Renewal, whichever

is earlier.

Applicable Deductible under the applicable plan shall also apply to this

 benet.

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.4 & G.I.5.

C. FirstYearVaccinations

We will cover Reasonable and Customary charges for vaccination

expenses for the New Born Baby as per National Immunization

Scheme (India) listed below, till the baby completes 1 year (12 months)

 within the limits specied in the Policy Schedule under Maternity

Expenses without payment of any additional premium. In case the

Policy ends before the New Born Baby has completed 1 year (12

 months),thecoverageunderthisbenetshallcontinuesubjecttothe

Policy being renewed in the subsequent year. Any restored Sum

Insured will not be available for coverage under this section.

Time Interval Vaccinations to be done (Age) Frequency

0–3months

BCG (Birth to 2 weeks) 1

OPV(0‚6‚10weeks)OROPV+IPV1

(6,10weeks)

3 OR 4

DPT(6&10week) 2

Hepatitis-B(0&6week) 2

Hib(6&10week) 2

3 – 6 months

OPV (14 week) OR OPV + IPV2 1 or 2

DPT (14 week) 1

Hepatitis-B (14 week) 1

Hib (14 week) 1

9 months Measles (+9 months) 1

12 months Chicken Pox (12 months) 1

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.5.

C.III.3.iiRoomAccommodationUpgrade

We will upgrade the Room category coverage under Section D.I.1

In-patient hospitalization up to ‘Any Room Category’ subject to

 maximum of Sum Insured Opted and as specied in the Policy

Schedule.

C.III.4 Freedom

(Applicable for Protect and Advantage Plans)

This package is available to all Insured Persons provided they are

Indian resident at inception of the Policy and at subsequent renewals

of this policy.

C.III.4.i RoomAccommodationUpgrade

We will upgrade the Room category coverage under Section D.I.1

In-patient hospitalization up to ‘Any Room Category’ subject to

 maximum of Sum Insured Opted and as specied in the Policy

Schedule.

C.III.4.iiWorldwideEmergencyHospitalizationwithOutpatientCover

We will cover Medical Expenses incurred during the Policy Year, for

Emergency In-patient Hospitalization Treatments or Emergency

Outpatient Treatment of the Insured Person incurred outside India,

 covered up to Sum Insured as specied in the Policy Schedule,

provided that:

 (a)The treatment is Medically Necessary and has been certied as

an Emergency by a Medical Practitioner, where such treatment

cannot be postponed until the Insured Person has returned to India

and is payable under Section D.I.1 ‘In-patient Hospitalization’ and/

or D.I.12 ‘Outpatient Expenses’ of the Policy.

(b) The Medical Expenses payable shall be limited to Emergency

In-patient Hospitalization and Emergency Outpatient only.

 (c) AnypaymentunderthisbenetwillonlybemadeinIndia,inIndian

rupees on a reimbursement basis and subject to maximum of Sum

Insured. Insured Person can contact Us at the numbers provided

on the Health Card for any claim assistance. In case where

Cumulative Bonus accumulated is used for payment of claim

  underthisbenet,themaximumliabilityunderasinglePolicyyear

shall not exceed the Opted Sum Insured including Cumulative

Bonus or Cumulative Bonus Booster as applicable.

 (d)Thepaymentofanyclaimunderthisbenetwillbebasedonthe

rate of exchange as on the date of payment to the Hospital

published by Reserve Bank of India (RBI) and shall be used for

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

conversion of foreign currency into Indian rupees for payment

of claim. You further understand and agree that where on the

date of discharge, if RBI rates are not published, the exchange rate

next published by RBI shall be considered for conversion.

(e) You have given Us, intimation of such hospitalization within 48

hours of admission.

 (f) Any claim made under this benet will be as per the claims

procedure provided under Clause G.1.5 and G.I.15 of this Policy.

 (g)Anyclaim payableunderthisbenetis overandabovetheSum

Insured.

(h) Restoration of Sum Insured shall not be available under this

  benet.

 (i) ExclusionE.II.13doesnotapplytothisbenet.

C.IV Optionalcovers

The following optional covers shall apply under the Policy for an

 Insured Person if specically mentioned on the Policy Schedule

and shall apply to all Insured Persons under a single policy without any

individual selection.

C.IV.1 Non-MedicalItems

We will cover the cost of Non-Medical items, listed under Annexure III

List 1 of the Policy, incurred towards Medically Necessary

Hospitalization of the insured person, arising out of Disease/ Illness or

Injury.

The cover is available subject to the claim being admissible under

Section D.I.1 ‘In-patient Hospitalization’ and/ or Section D.I.4 Day Care

Treatment cover under this policy and the expenses on Non-medical

items are related to the same Illness/ Injury.

 ExclusionE.II.18shallnotbeapplicableforthisbenet.

 AnyclaimmadeunderthisoptionalbenetwillreducetheSumInsured.

 Allclaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.4 & G.I.5.

C.IV.2 Deductible

You can opt for a Deductible of `10,000 or `25,000 in the Policy.

Wherever a Deductible is selected such amount will be applied for each

Policy Year on the aggregate of all Claims in that Policy Year other than

 forclaimsunderxedbenetcoversandHealthCheckUps.Deductible

shall apply to all sections other than D.IV.4 Personal Accident Cover,

D.I.13 Daily Cash for Shared Accommodation, D.I.12 Outpatient

Expenses, D.II. Value added covers and Add On Riders if opted.

For the purpose of calculating the deductible and assessment of

admissibility all claims must be submitted in accordance with Section

G.I.16 of Claims Process.

 ForDeductibleofRs10,000,thecovercanbeoptedeitheratinception

or can be opted or removed at the time of Policy Renewal.

 ForDeductibleofRs.25,000,thecovercanbeoptedeitheratinception

or at the time of Policy Renewal. However once opted, the Insured

 Person can remove the Deductible of Rs 25,000 onlyat the time of

renewal falling immediately due after 4 continuous Policy Years or any

 subsequent renewals thereon, from the year of opting Rs 25,000

Deductible

This benet shall not be available if D.III.2 Assure optional package is

opted.

All other terms, conditions, waiting periods and exclusions shall apply.

C.IV.3 InfertilityTreatment

We will cover the Medical Expenses of the eligible Insured Person

if hospitalized on the advice of the Medical Practitioner for Infertility

Treatments up to maximum of `2.5 lacs as per Sum Insured opted

 andasspeciedinPolicyScheduleprovidedthat,

a. D.III.1 ‘Enhance Plus’ or D.III.3 ‘Enhance’ Optional Package is

opted and Sum Insured opted under the Policy and mentioned in

Policy Schedule is `7.5 lacs and above.

b. This cover is limited to IVF and/or IUI treatments.

c. The Insured Person should have been continuously covered under

  thisPolicyforatleast36monthsbeforeavailingthisbenet.

 d. The benet shall be restricted to two successful procedures

leading to conception during the lifetime of the eligible Insured

Person and the coverage shall terminate thereafter

e. Sum Insured available under this section will be in addition to

Maternity Sum Insured under Section D.III.1.i Maternity & New Born

Hospitalization Expenses or D.III.3.i Maternity & New Born

Hospitalization Expenses

f. Restoration of Sum Insured shall not be available under this

  benet.

g. Exclusion E.I.17 shall not apply to this cover subject to terms and

  conditionsunderthisbenet

h. The cover shall automatically cease upon the eligible Insured

  Personattaining60yearsofage.

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.4 & G.I.5.

C.IV.4 PersonalAccidentCover

We will pay two times of the Sum Insured opted subject to maximum of

`50 Lacs, as specied in the Policy Schedule, in case the Insured

Person suffers an Injury solely and directly due to an Accident that

occurs during the Policy Period and such Injury solely and directly

results in the Insured Person’s Death or Permanent Total Disablement

 whichisofthenaturespeciedbelowwithin365daysoftheAccident.

TableofBenets Percentage

oftheSum

Insured

payable

a. Type of Permanent Total Disablement

i) Total and irrecoverable loss of sight of both eyes 100%

ii) Loss by physical separation or total and permanent

loss of use of both hands or both feet

100%

iii) Loss by physical separation or total and

permanent loss of use of one hand and one foot

100%

iv) Total and irrecoverable loss of sight of one eye and

loss of a Limb

100%

v) Total and irrecoverable loss of hearing of both ears

and loss of one Limb/loss of sight of one eye

100%

vi) Total and irrecoverable loss of hearing of both ears

and loss of speech

100%

vii) Total and irrecoverable loss of speech and loss of

one Limb/loss of sight of one eye

100%

viii) Permanent total and absolute disablement (not

falling under the above) disabling the Insured

Person from engaging in any employment or

occupationorbusinessforremunerationorprot,

of any description whatsoever which results in

“Loss of Independent Living”

100%

Forthepurposeofthisbenet,

- Limb means a hand at or above the wrist or a foot above the ankle;

- Physical separation of one hand or foot means separation at or

above wrist and/or at or above ankle, respectively.

 Thebenetsasspeciedabovewillbepayableprovidedthat:

a. The Permanent Total Disablement is proved to Our satisfaction;

  and a disability certicate issued by a Civil Surgeon or the

equivalent appointed by the District/State or Government Board;

and

b. The Permanent Total Disablement continues for a period of at least

  180 days from the commencement of the Permanent Total

  Disablement;providedthatWemustbe satisedatthe expiryof

  the 180 days that there is no reasonable medical hope of

improvement.

c. If We have admitted a claim for Permanent Total Disablement

  inaccordancewiththisbenet,thenWeshallnotbeliabletomake

  anypaymentunderthisbenetonthedeathoftheInsuredPerson,

if the Insured Person subsequently dies.

 d. Onceaclaimhasbeenacceptedandpaidunderthisbenetincase

of Death then cover under this Policy shall immediately and

automatically cease in respect of that Insured Person.

e. Restoration of Sum Insured shall not be available under this

  benet.

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.5

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

C.IV.5 CumulativeBonusBooster

 WewillprovideanoptiontoincreasetheSumInsuredby50%foreach

 policyyearuptoamaximumof200%ofSumInsuredprovidedthatthe

Policy is renewed with Us without a break.

a. No cumulative bonus will be added if the Policy is not renewed

with Us by the end of the Grace Period. The Cumulative Bonus

  will not be accumulated in excess of 200% of the Sum Insured

under the current Policy with Us.

b. Any earned Cumulative Bonus will not be reduced for claims made

in the future, wherever the earned Cumulative Bonus is used for

payment of a claim during a particular Policy Year.

c. In case of opting for Cumulative Bonus Booster, the Cumulative

Bonus under section D.II.4 shall not be available, however all

terms and conditions of the said section shall apply.

d. This Cumulative bonus shall not be available for claims made for

Value added cover (Section D.II) and also for D.III.1.i Maternity

& New Born Hospitalization Expenses, D.III.3.i Maternity & New

Born Hospitalization Expenses, D.III.1.iii Health Maintenance

  Benet,D.I.10AirAmbulanceCover,D.I.12OutpatientExpenses,

D.I.13 Daily Cash for Shared Accommodation and D.IV.3 Infertility

Treatment

C.IV.6 Addon-CriticalIllnessRider

Along with this Product You can also avail the ManipalCigna Critical

 IllnessAddOnCover(UIN:MCIHLIP21128V022021)oritssubsequent

revisions. Please ask for the Prospectus and Proposal Form of the

same at the time of purchase. All waiting periods, exclusions and terms

and conditions of applicable rider including medical check-up

requirement will apply.

 ForthepurposeofthisBenet,CriticalIllnesswillbeaslistedunderthe

ManipalCigna Critical Illness Add on Cover Policy documents.

D. Exclusions

We shall not be liable to make any payment under this Policy caused

by, based on, arising out of or howsoever attributable to any of the

 following unless otherwise covered or specied under the Policy or

any Cover opted under the Policy. All the waiting period shall be

applicable individually for each Insured Person and claims shall be

assessed accordingly.

D.I StandardExclusions

D.I.1 Pre-existingDisease-Code-Excl.01

a. Expenses related to the treatment of a Pre-existing Disease

(PED) and its direct complications shall be excluded until the

expiry of the applicable waiting period

a. 24 months of continuous coverage from the date of

commencement of coverage for Sum Insured `7.5 Lacs and

above

b. 36 months of continuous coverage from the date of

commencement of coverage for Sum Insured Up to `5 Lacs.

b. In case of enhancement of sum insured, the exclusion shall apply

afresh to the extent of sum insured increase.

c. If the Insured Person is continuously covered without any break as

  dened under the portability norms of the extant IRDAI (Health

Insurance) Regulations then waiting period for the same would be

reduced to the extent of prior coverage.

d. Coverage under the policy after the expiry of Pre-existing disease

waiting period for any pre-existing disease is subject to the same

being declared at the time of application and accepted by us.

D.I.2 Specieddisease/procedureWaitingPeriod-Code-Excl.02

a. Expenses related to the treatment of the listed Conditions,

surgeries/treatments shall be excluded until the expiry of 24 months

  ofcontinuouscoverageafterthedateofinceptionoftherstpolicy

with us. This exclusion shall not be applicable for claims arising

due to an accident.

b. In case of enhancement of sum insured the exclusion shall apply

afresh to the extent of sum insured increase.

 c. If any of the specied disease/procedure falls under the waiting

  periodspeciedforpre-Existingdiseases,thenthelongerofthe

two waiting periods shall apply.

d. The waiting period for listed conditions shall apply even if

contracted after the policy or declared and accepted without a

  specicexclusion.

e. If the Insured Person is continuously covered without any break

  asdenedundertheapplicablenormsonportabilitystipulatedby

IRDAI, then waiting period for the same would be reduced to the

extent of prior coverage.

 f. Listofspecicdiseases/procedures:

i. Cataract,

ii. Hysterectomy for Menorrhagia or Fibromyoma or prolapse of

   Uterus or myomectomy for broids unless necessitated by

malignancy,

iii. Knee Replacement Surgery (other than caused by an

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,

iv. Varicose Veins and Varicose Ulcers,

v. Stones in the urinary uro-genital and biliary systems including

calculus diseases and complications thereof,

vi. Benign Prostate Hypertrophy, all types of Hydrocele,

vii. Fissure, Fistula in anus, Piles, all types of Hernia, Pilonidal

sinus, Hemorrhoids and any abscess related to the anal region.

viii. 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.

ix. gastric and duodenal ulcer, any type of Cysts/Nodules/

Polyps/internal tumors/skin tumors, and any type of Breast

lumps(unless malignant), Polycystic Ovarian Diseases,

x. Any surgery of the genito-urinary system unless necessitated

by malignancy.

If these diseases are pre-existing at the time of proposal or

subsequently found to be pre-existing the pre-existing waiting

periods as mentioned in the Policy Schedule shall apply.

D.I.3 30daysWaitingPeriod-Code-Excl.03

 a) Expenses related to the treatment of any illness within 30 days

  ofcontinuouscoveragefromtherstpolicycommencementdate

shall be excluded except claims arising due to an accident,

provided the same are covered.

b) This exclusion shall not, however, apply if the Insured Person has

Continuous Coverage for more than twelve months.

c) The within referred waiting period is made applicable to the

enhanced sum insured in the event of granting higher sum insured

subsequently

D.I.4 Investigation&Evaluation-Code-Excl04

a. Expenses related to any admission primarily for diagnostics and

evaluation purposes only are excluded.

b. Any diagnostic expenses which are not related or not incidental to

the current diagnosis and treatment are excluded.

D.I.5 RestCure,rehabilitationandrespitecare-Code-Excl05

a) Expenses related to any admission primarily for enforced bed rest

and not for receiving treatment. This also includes:

i. 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.

ii. Any services for people who are terminally ill to address

physical, social, emotional and spiritual needs.

D.I.6 Obesity/WeightControl:Code-Excl06

 Expensesrelatedtothesurgicaltreatmentofobesitythatdoesnotfull

all the below conditions:

1. Surgery to be conducted is upon the advice of the Doctor

2. The surgery/Procedure conducted should be supported by clinical

protocols

3. The member has to be 18 years of age or older and

4. Body Mass Index (BMI);

  a. greaterthanorequalto40or

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

b. greater than or equal to 35 in conjunction with any of the

following severe comorbidities following failure of less invasive

methods of weight loss:

i. Obesity-related cardiomyopathy

ii. Coronary heart disease

iii. Severe Sleep Apnea

iv. Uncontrolled Type2 Diabetes

D.I.7 Change-of-Gendertreatments:Code-Excl07

Expenses related to any treatment, including surgical management, to

change characteristics of the body to those of the opposite sex.

D.I.8 CosmeticorPlasticSurgery:Code-Excl08

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 certied by the attending Medical

Practitioner

D.I.9 HazardousorAdventuresports:Code-Excl09

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.

D.I.10 Breachoflaw:Code-Excl10

Expenses for treatment directly arising from or consequent upon any

Insured Person committing or attempting to commit a breach of law

with criminal intent

D.I.11 ExcludedProviders:Code-Excl11

Expenses incurred towards treatment in any hospital or by any Medical

 Practitioner or any other provider specically excluded by the

 Insureranddisclosedinitswebsite/notied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.

D.I.12 Treatment for Alcoholism, drug or substance abuse or any

addictive condition and consequences thereof. Code-Excl12

D.I.13 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. Code- Excl13

D.I.14 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. Code-Excl14

D.I.15 RefractiveError:Code-Excl15

Expenses related to the treatment for correction of eye sight due to

refractive error less than 7.5 diopters

D.I.16 UnprovenTreatments:Code-Excl16

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 signicant medical

documentation to support their effectiveness.

D.I.17 SterilityandInfertility:Code-Excl17

Expenses related to sterility and infertility. This includes:

i. Any type of contraception, sterilization

 ii. Assisted Reproduction services including articial insemination

and advanced reproductive technologies such as IVF, ZIFT, GIFT,

ICSI

iii. Gestational Surrogacy

iv. Reversal of sterilization

D.I.18 Maternity:CodeExcl18

i. Medical treatment expenses traceable to childbirth (including

complicated deliveries and caesarean sections incurred during

hospitalization) except ectopic pregnancy;

ii. Expense towards miscarriage (unless due to an accident) and

lawful medical termination of pregnancy during the policy period.

D.II  SpecicExclusions

D.II.1 MaternityWaitingPeriod

Any treatment arising from or traceable to pregnancy, childbirth

including caesarean section until 36 months of continuous coverage

has elapsed for the particular Insured Person since the inception of the

 rst Policy with Us. However, this exclusion / waiting period will not

 applytoEctopicPregnancyprovedbydiagnosticmeansandcertied

to be life threatening by the attending Medical Practitioner.

D.II.2 PersonalWaitingperiod:

A special Waiting Period not exceeding 48 months, may be applied to

individual Insured Persons for the list of acceptable Medical Ailments

listed under the Underwriting Manual of the Product, depending upon

declarations on the proposal form and existing health conditions. Such

 waitingperiodsshallbespecicallystatedintheScheduleandwillbe

 appliedonlyafterreceivingYourspecicconsent.

D.II.3 90 day waiting period for Critical Illness Add On Cover (if

 opted)

Any critical illness contracted and/or the disease incepts or manifests

 duringtherst90daysfromtheInceptionDateofthepolicywillnotbe

 coveredunderthecriticalillnessbenetwhereveropted.

D.II.4 MentalIllnessCoverWaitingPeriod

Any treatment arising out of a condition caused by or associated to a

Mental illness or a medical condition under below mentioned ICD

Codes impacting mental health, shall not be covered until 24 months

of continuous coverage has elapsed for the particular Insured Person

 sincetheinceptionoftherstPolicywithUs.

ICD 10 CODES DISEASES

F05 Delirium due to known physiological condition

F06 Other mental disorders due to known physiological

condition

F07 Personality and behavioural disorders due to known

physiological condition

F10 Alcohol related disorders

F20 Schizophrenia

F23 Brief psychotic disorders

F25 Schizoaffective disorders

F29 Unspeciedpsychosisnotduetoasubstanceor

known physiological condition

F31 Bipolar disorder

F32 Depressive episode

F39 Unspeciedmood[affective]disorder

F40 Phobic Anxiety disorders

F41 Other Anxiety disorders

F42 Obsessive-compulsive disorder

F44 Dissociative and conversion disorders

F45 Somatoform disorders

F48 Other nonpsychotic mental disorders

F60 Specicpersonalitydisorders

F84 Pervasive developmental disorders

F90 Attention-decithyperactivitydisorders

F99 Mentaldisorder,nototherwisespecied

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

D.II.5 BariatricSurgeryWaitingPeriod

Bariatric Surgery shall not be covered until 36 months of continuous

coverage has elapsed for the particular Insured Person since the

 inceptionoftherstPolicywithUs

D.II.6 InfertilityTreatmentWaitingPeriod

Any treatment taken for Infertility Treatment until 36 months of

continuous coverage has elapsed for the particular Insured Person

 sincetheinceptionoftherstPolicywithUs.

D.II.7 Dental Treatment, orthodontic treatment, dentures or Surgery of

any kind unless necessitated due to an Accident and requiring minimum

24 hours Hospitalization. Treatment related to gum disease or tooth

disease or damage unless related to irreversible bone disease involving

 thejawwhichcannotbetreatedinanyotherway,unlessspecically

covered under the Policy.

D.II.8 Circumcision unless necessary for treatment of a disease, illness

or injury not excluded hereunder or due to an accident.

D.II.9 Instrument used in treatment of Sleep Apnea Syndrome (C.P.A.P.)

and Continuous Peritoneal Ambulatory Dialysis (C.P.A.D.) and Oxygen

Concentrator for Bronchial Asthmatic condition, Infusion pump or any

other external devices used during or after treatment.

D.II.10 External Congenital Anomaly or defects or any complications or

conditions arising therefrom.

D.II.11 Prostheses, corrective devices and medical appliances, which are

not required intra-operatively for the disease/ illness/ injury for which

the Insured Person was Hospitalized.

D.II.12 Any stay in Hospital without undertaking any treatment or any

other purpose other than for receiving eligible treatment of a type that

normally requires a stay in the hospital

D.II.13 Treatment received outside India other than for coverage under

D.III.4.ii Worldwide Emergency Hospitalization with Outpatient Cover

under Freedom optional package if opted.

D.II.14 Costs of donor screening or costs incurred in an organ transplant

surgery involving organs not harvested from a human body.

D.II.15 Any form of Non-Allopathic treatment (except AYUSH Treatment

 (In-patient Treatment)), Hydrotherapy, Acupuncture, Reexology,

Chiropractic treatment or any other form of indigenous system of

medicine.

D.II.16 All Illness/expenses caused by ionizing radiation or contamination

by radioactivity from any nuclear fuel (explosive or hazardous form)

or from any nuclear waste from the combustion of nuclear fuel nuclear,

chemical or biological attack or in any other sequence to the loss.

D.II.17 All expenses caused by or arising from or attributable to foreign

invasion, act of foreign enemies, hostilities, warlike operations (whether

war be declared or not or while performing duties in the armed forces

of any country), participation in any naval, military or air-force operation,

civil war, public defense, rebellion, revolution, insurrection, military or

 usurped power, active participation in riots, conscation or

nationalization or requisition of or destruction of or damage to property

by or under the order of any government or local authority.

D.II.18 All non-medical expenses including convenience items for personal

comfort not consistent with or incidental to the diagnosis and treatment

of the disease/illness/injury for which the Insured Person was

hospitalized - belts, collars, splints, slings, braces, stockings of any

kind, diabetic footwear, thermometer and any medical equipment

that is subsequently used at home except when they form part of room

expenses, procedure charges and cost of treatment. For complete list

of Non-medical expenses, please refer to the Annexure III List – I

“Items for which Coverage is not available in the Policy”

D.II.19 Any deductible amount or percentage of admissible claim under

 co-payifapplicableandasspeciedinthePolicySchedule.

D.II.20 Existing diseases disclosed by the Insured Person (limited to

the extent of the ICD codes mentioned in line with Chapter IV,

Guidelines on Standardization of Exclusions in Health Insurance

 Contracts,2019),providedthesameisappliedattheunderwritingand

consented by You/ Insured Person.

E.  GeneralTermsandClauses

E.I  StandardGeneralTermsandClauses

E.I.1 DisclosureofInformation

The Policy shall be null and void and all premium paid thereon shall be

forfeited to the Company in the event of misrepresentation, mis-

description or non-disclosure of any material fact by the policyholder.

(“ Material facts” for the purpose of this policy shall mean all relevant

information sought by the company in the proposal form and other

connected documents to enable it to take informed decision in the

context of underwriting the risk)

E.I.2 ConditionPrecedenttoAdmissionofLiability

 ThetermsandconditionsofthePolicymustbefullledbytheInsured

Person for the Company to make any payment for claim(s) arising

under the policy.

E.I.3 ClaimSettlement(provisionforPenalInterest)

i. The Company shall settle or reject the claim, as the case may be,

  within30daysfromthedateofreceiptoflastnecessarydocument.

ii. In the case of delay in the payment of a claim, the Company shall

be liable to pay interest to the policyholder from the date of receipt

of last necessary document to the date of payment of claim at a

  rate2%abovethebankrate.

iii. However, where the circumstances of a claim warrant an

investigation in the opinion of the Company, it shall initiate and

complete such investigation at the earliest, in any case not later

  than30daysfromthedateofreceiptoflastnecessarydocument.

In such cases, the Company shall settle or reject the claim within

45 days from the date of receipt of last necessary document.

iv. In case of delay beyond stipulated 45 days, the Company shall be

  liable to pay interest to the policyholder at a rate 2% above the

bank rate from the date of receipt of last necessary document to

the date of payment of claim.

 "Bank rate" shall mean the rate xed by the Reserve Bank of India

 (RBl)atthe beginningofthenancial yearinwhichclaim hasfallen

due.

E.I.4 CompleteDischarge

Any payment to the policyholder, insured person or his/her nominees

or his/her legal representative or assignee or to the Hospital, as the

 casemaybe,foranybenetunderthepolicyshallbeavaliddischarge

towards payment of claim by the Company to the extent of that amount

for the particular claim.

E.I.5 MultiplePolicies

- In case of multiple policies taken by an insured person during a

period from one or more insurers to indemnify treatment costs, the

insured person shall have the right to require a settlement of his/her

claim in terms of any of his/her policies. In all such cases, the insurer

chosen by the insured person shall be obliged to settle the claim as

long as the claim is within the limits of and according to the terms of the

chosen policy.

- Insured person having multiple policies shall also have the right to

prefer claims under this policy for the amounts disallowed under any

other policy / policies even if the sum insured is not exhausted. Then

the insurer shall independently settle the claim subject to the terms and

conditions of this policy.

- If the amount to be claimed exceeds the sum insured under a

single policy, the insured person shall have right to choose insurer from

whom he/she wants to claim the balance amount.

- Where an insured person has policies from more than one insurer

to cover the same risk on indemnity basis, the insured person shall

 onlybeindemniedthetreatmentcostsinaccordancewiththeterms

and conditions of the chosen policy.

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

E.I.6 Fraud

If any claim made by the insured person, is in any respect fraudulent,

or if any false statement, or declaration is made or used in support

thereof, or if any fraudulent means or devices are used by the insured

 personoranyoneactingonhis/herbehalftoobtainanybenetunder

 thispolicy,allbenetsunderthispolicyshallbeforfeited.

Any amount already paid against claims made under this policy which

are found fraudulent later shall be repaid by all recipients(s)/

Policyholder(s), who has made that particular claim, who shall be

jointly and severally liable for such repayment to the Insurer.

For the purpose of this clause, the expression "fraud" means any of

the following acts committed by the Insured Person or by his agent or

the hospital/doctor/any other party acting on behalf of the insured

person, with intent to deceive the insurer or to induce the insurer to

issue an insurance Policy: -

a) the suggestion, as a fact of that which is not true and which the

Insured Person does not believe to be true;

b) the active concealment of a fact by the Insured Person having

knowledge or belief of the fact;

 c) anyotheractttedtodeceive;and

d) any such act or omission as the law specially declares to be

fraudulent

The company shall not repudiate the claim and/or forfeit the policy

 benetsonthegroundsofFraud,iftheinsuredperson/beneciarycan

prove that the misstatement was true to the best of his knowledge

and there was no deliberate intention to suppress the fact or that

such misstatement of or suppression of such material fact are within

the knowledge of the Insurer.

E.I.7. Cancellation

i. The policyholder may cancel this policy by giving 15 days written notice

and in such an event, the Company shall refund premium for the

unexpired policy period as detailed below.

RefundGridas%ofPremium

Policy

Cancelation

Within (Days)

Policy Year-1 Policy Year-2 Policy Year-3

0-30Days 85.00% 87.50% 89.00%

31-90Days 75.00% 80.00% 82.50%

91 - 181 Days 50.00% 70.00% 75.00%

182 - 272 Days 30.00% 60.00% 70.00%

273 - 365 Days 0.00% 50.00% 60.00%

366 - 456 Days

NIL

35.00% 55.00%

457 - 547 Days 25.00% 45.00%

548 - 638 Days 15.00% 40.00%

639-730Days 0.00% 30.00%

731 - 821 Days

NIL

25.00%

822 - 912 Days 15.00%

913-1003

Days

5.00%

1004andmore

Days

0.00%

No refund will be processed for cancellation of policies with Premium

Payment Mode as Half-yearly, Quarterly or Monthly.

Notwithstanding anything contained herein or otherwise, no refunds of

premium shall be made in respect of Cancellation where, any claim has

 beenadmittedorhasbeenlodgedoranybenethasbeenavailedby

the insured person under the policy.

ii. The Company may cancel the policy at any time on grounds of

misrepresentation, non - disclosure of material facts, fraud by the

insured person by giving 15 days written notice. There would be no

refund of premium on cancellation on grounds of misrepresentation,

non-disclosure of material facts or fraud.

E.I.8. Migration

The Insured Person will have the option to migrate the Policy to other

health insurance products/plans offered by the company by applying

 for migration of the policy at least 30 days before the policy

renewal date as per IRDAI guidelines on Migration. If such person is

presently covered and has been continuously covered without any

lapses under any health insurance product/plan offered by the

 company,theInsuredPersonwillgettheaccruedcontinuitybenetsin

waiting periods as per IRDAI guidelines on migration.

For Detailed Guidelines on Migration, kindly refer IRDAI Guidelines

 RefNo:IRDAI/HLT/REG/CIR/003/01/2020

E.I.9. Portability

The insured person will have the option to port the policy to other

insurers by applying to such insurer to port the entire policy along with

all the members of the family, if any, at least 45 days before, but not

 earlier than 60 days from the policy renewal date as per IRDAI

guidelines related to portability. If such person is presently covered and

has been continuously covered without any lapses under any health

insurance policy with an Indian General/Health insurer, the proposed

 insured person will get the accrued continuity benets in waiting

periods as per IRDAI guidelines on portability.

For detailed Guidelines on Portability, kindly refer IRDAI Guidelines Ref

 No:IRDAI/HLT/REG/CIR/003/01/2020andScheduleIofIRDAI(Health

 Insurance)Regulations2016forthePortabilitynorms

E.I.10. RenewalofPolicy

The policy shall ordinarily be renewable except on grounds of fraud,

misrepresentation by the insured person.

i. The Company shall endeavour to give notice for renewal. However,

the Company is not under obligation to give any notice for renewal.

ii. Renewal shall not be denied on the ground that the insured person

had made a claim or claims in the preceding policy years.

iii. Request for renewal along with requisite premium shall be received

by the Company before the end of the policy period.

iv. At the end of the policy period, the policy shall terminate and can

  be renewed within the Grace Period of 30/15 days, to maintain

  continuity of benets without break in policy. Coverage is not

available during the grace period.

v. No loading shall apply on renewals based on individual claims

experience.

E.I.11. WithdrawalofPolicy

i. In the likelihood of this product being withdrawn in future, the

  Companywillintimatetheinsuredpersonaboutthesame90days

prior to expiry of the policy.

ii. Insured person will have the option to migrate to similar health

insurance product available with the Company at the time of renewal

  withalltheaccruedcontinuitybenetssuchascumulativebonus,

waiver of waiting period, as per IRDAI guidelines, provided the

policy has been maintained without a break.

E.I.12. MoratoriumPeriod

After completion of eight continuous years under the policy no look

back to be applied. This period of eight years is called as moratorium

period. The moratorium would be applicable for the sums insured of the

 rstpolicyandsubsequentlycompletionof8continuousyearswould

be applicable from date of enhancement of sums insured only on the

enhanced limits. After the expiry of Moratorium Period no health

insurance claim shall be contestable except for proven fraud and

 permanent exclusions specied in the policy contract. The policies

would however be subject to all limits, sub limits, co-payments,

deductibles as per the policy contract.

E.I.13. PremiumPaymentinInstalments(Whereverapplicable)

If the insured person has opted for Payment of Premium on an

Instalment basis i.e. Half Yearly, Quarterly or Monthly, as mentioned in

 thePolicySchedule/CerticateofInsurance,thefollowingConditions

shall apply (notwithstanding any terms contrary elsewhere in the

policy).

 i. Grace Period of 30 days would be given for Half-yearly and

Quarterly mode of payment and grace period of 15 days for

monthly mode of payment would be given to pay the instalment

premium due for the Policy.

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

ii. During such grace period, coverage will not be available from the

due date of instalment premium till the date of receipt of premium

by Company.

 iii. The insured person will get the accrued continuity benet in

  respectofthe“WaitingPeriods”,“SpecicWaitingPeriods”inthe

event of payment of premium within the stipulated grace Period.

iv. No interest will be charged if the instalment premium is not paid on

due date.

v. In case of instalment premium due not received within the grace

period, the policy will get cancelled.

vi. In the event of a claim, all subsequent premium instalments shall

immediately become due and payable.

vii. The company has the right to recover and deduct all the pending

instalments, from the claim amount due under the policy.

E.I.14. Possibility of Revision of Terms of the Policy Including the

  PremiumRates

The Company, with prior approval of IRDAI, may revise or modify the

terms of the policy including the premium rates. The insured person

 shallbenotiedthreemonthsbeforethechangesareeffected.

E.I.15. FreeLookperiod

The Free Look period shall be applicable on new individual health

insurance policies and not on renewals or at the time of porting/

migrating the policy.

 Theinsuredpersonshallbeallowedafreelookperiodoffteendays

from date of receipt of the policy document to review the terms and

conditions of the policy and to return the same if not acceptable.

If the insured has not made any claim during the Free Look Period, the

insured shall be entitled to

a. a refund of the premium paid less any expenses incurred by the

Company on medical examination of the insured person and the

stamp duty charges or;

b. where the risk has already commenced and the option of return

of the policy is exercised by the insured person, a deduction

towards the proportionate risk premium for period of cover or;

c. Where only a part of the insurance coverage has commenced,

such proportionate premium commensurate with the insurance

coverage during such period.

E.I.16. RedressalofGrievance

If you have a grievance that you wish us to redress, you may contact us

with the details of the grievance through:

Our website: www.manipalcigna.com

Email: [email protected],

Senior Citizens may write to us at -

[email protected]

 TollFree:1800-102-4462

 ContactNo.:+912261703600

 Courier:AnyofOurBranchofceorcorporateofceduringbusiness

hours.

Insured Person may also approach the grievance cell at any of

company’s branches with the details of the grievance.

 IfInsuredPersonisnotsatisedwiththeredressalofgrievancethrough

one of the above methods, insured person may contact the grievance

 ofcer at, ‘The Grievance Cell, ManipalCigna Health Insurance

 Company Limited, 401/402, Raheja Titanium, Western Express

 Highway, Goregaon East, Mumbai - 400063, India or email -

[email protected].

 For updated details of grievance ofcer, kindly refer link -

https://www.manipalcigna.com/grievance-redressal

 IfInsuredpersonisnotsatisedwiththeredressalofgrievancethrough

 above methods, the Insured Person may approach the ofce of

Insurance Ombudsman of the respective area/region for redressal of

 grievance as per Insurance Ombudsman Rules 2017. The contact

 details of Ombudsman ofces attached as Annexure I to this Policy

document.

Grievance may also be lodged at IRDAI Integrated Grievance

Management System - https://igms.irda.gov.in/

You may also approach the Insurance Ombudsman if your complaint is

 openformorethan30daysfromthedateoflingthecomplaint.

E.I.17. Nomination

The policyholder is required at the inception of the policy to make a

nomination for the purpose of payment of claims under the policy in

the event of death of the policyholder. Any change of nomination shall

be communicated to the company in writing and such change shall be

effective only when an endorsement on the policy is made. In the event

of death of the policyholder, the Company will pay the nominee {as

 namedinthePolicySchedule/PolicyCerticate/Endorsement(ifany)}

and in case there is no subsisting nominee, to the legal heirs or legal

representatives of the Policyholder whose discharge shall be treated as

 fullandnaldischargeofitsliabilityunderthePolicy.

E.II. SpecicTermsandClauses

E.II.1. MaterialChange

Material information to be disclosed includes every matter that You are

aware of, that relates to questions in the Proposal Form and which is

relevant to Us in order to accept the risk of insurance and if so on what

terms. You must exercise the same duty to disclose those matters to Us

before the Renewal, extension, variation, endorsement or reinstatement

of the contract.

E.II.2. AlterationsinthePolicy

This Policy constitutes the complete contract of insurance. No change

or alteration will be effective or valid unless approved in writing which

will be evidenced by a written endorsement, signed and stamped by

Us.

E.II.3. ChangeofPolicyholder

The policyholder may be changed only at the time of Renewal of the

Policy. The new policyholder must be a member of the Insured Person’s

immediate family. Such change would be solely subject to Our

discretion and payment of premium by You. The renewed Policy shall

be treated as having been renewed without break.

The policyholder may be changed upon request in case of his demise,

his moving out of India or in case of divorce during the Policy Period.

E.II.4. NoConstructiveNotice

Any knowledge or information of any circumstance or condition in

relation to the Policyholder/ Insured Person which is in Our possession

 andnotspecicallyinformedbythePolicyholder/InsuredPersonshall

not be held to bind or prejudicially affect Us notwithstanding

subsequent acceptance of any premium.

E.II.5. Geography

The geographical scope of this policy applies to events within India

other than for D.III.4.ii Worldwide Emergency Hospitalization with

Outpatient Cover under Freedom optional package (if opted) and

 which are specically covered in the Policy Schedule. However all

admitted or payable claims shall be settled in India in Indian rupees.

E.II.6. Recordstobemaintained

You or the Insured Person, as the case may be shall keep an accurate

record containing all medical records pertaining to claim and shall allow

Us or our representative (s) to inspect such records. You or the Insured

Person as the case may be, shall furnish such information as may be

required by Us under this Policy at any time during the Policy Period

 anduptothreeyearsafterthePolicyexpiration,oruntilnaladjustment

(if any) and resolution of all Claims under this Policy.

E.II.7. GracePeriod

The Policy may be renewed by mutual consent and in such event the

Renewal premium should be paid to Us on or before the date of expiry

 ofthePolicyandinnocaselaterthantheGracePeriodof30daysfrom

the expiry of the Policy. We will not be liable to pay for any claim arising

out of an Injury/ Accident/ Condition that occurred during the Grace

Period. The provisions of Section 64VB of the Insurance Act shall be

applicable. All policies Renewed within the Grace Period shall be

eligible for continuity of cover.

E.II.8. RenewalTerms

a. The Policy is ordinarily renewable on mutual consent for life,

subject to application of Renewal and realization of Renewal

premium.The Policy with Freedom optional package shall be

renewed subject to the Insured Person being an Indian resident at

the time of renewal.

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

b. We shall not be liable for any claim arising out of an ailment

suffered or Hospitalization commencing or disease/illness/condition

contracted during the period between the expiry of previous policy

and date of inception of subsequent policy.

c. Renewals will not be denied except on grounds of misrepresentation,

moral hazard, fraud, non-disclosure of material facts or non-

cooperation by You.

d. Where We have discontinued or withdrawn this product/plan You

will have the option to renewal under the nearest substitute Policy

  being issued by Us, provided however benets payable shall be

subject to the terms contained in such other policy which has been

approved by IRDAI.

e. Insured Person shall disclose to Us in writing of any material

change in the health condition at the time of seeking Renewal of this

Policy, irrespective of any claim arising or made. The terms and

condition of the existing policy will not be altered.

f. We may, revise the Renewal premium payable under the Policy

or the terms of cover, provided that all such changes are approved

by IRDAI and in accordance with the IRDAI rules and regulations

as applicable from time to time. Renewal premium will not alter based

on individual claims experience. We will intimate You of any such

  changes at least 90 days prior to date of such revision or

  modication.

g. Alterations like increase/ decrease in Sum Insured or Change

in Plan/Product, addition/deletion of members, addition deletion

of Medical Condition existing prior to policy inception will be allowed

at the time of Renewal of the Policy. You can submit a request

  forthechangesbyllingtheproposalformbeforetheexpiryofthe

Policy. We reserve Our right to carry out underwriting in relation

to acceptance of request for change of Sum Insured or addition/

deletion of members, addition deletion of Medical Condition

existing prior to policy inception, on renewal. The terms and

conditions of the existing policy will not be altered.

h. Any enhanced Sum Insured during any policy renewals will not

be available for an illness, disease, injury already contracted

under the preceding Policy Periods. All waiting periods as mentioned

below shall apply afresh for this enhanced limit from the effective

date of such enhancement.

i. Wherever the Sum Insured is reduced on any Policy Renewals,

the waiting periods as mentioned below shall be waived only up to

the lowest Sum Insured of the last 36/ 24 consecutive months as

applicable to the relevant waiting periods of the Plan opted.

j. Where an Insured Person is added to this Policy, either by way of

endorsement or at the time of renewal, all waiting periods under

Section E.I.1 to E.I.3 and E.II.1 and E.II.6 will be applicable

  considering such Policy Year as the rst year of Policy with the

Company.

k. Applicable Cumulative Bonus shall be accrued on each renewal as

per eligibility under the plan opted.

 l. Incaseofoaterpolicies,childrenattaining26yearsatthetimeof

  renewal will be moved out of the oater into an individual

  cover, however all continuity benets on the policy will remain

intact. Cumulative Bonus earned on the Policy will stay with the

  oatercover.

III. YoumaypaythepremiumthroughNationalAutomatedClearing

House(NACH)/StandingInstruction(SI)providedthat

 i. NACH/Standing Instruction Mandate form is completely lled &

signed by You.

ii. The Premium amount which would be auto debited & frequency of

  instalmentisdulylledinthemandateform.

 iii. NewMandateFormisrequiredtobelledincaseofanychange

in the Policy Terms and Conditions whether or not leading to

change in Premium.

iv. You need to inform us at least 15 days prior to the due date of

instalment premium if You wish to discontinue with the NACH/

Standing Instruction facility.

Non-payment of premium on due date as opted by You in the mandate

form subject to an additional renewal/ revival period will lead to

termination of the policy.

E.II.9. Premiumcalculation

Premium will be calculated based on the Sum Insured opted, Age,

 gender,riskclassicationandZoneofCover.DefaultZoneofCoverwill

be based on Your City-Location based on Your correspondence

address. All Premiums are age based and will vary as per the change

in age group.

 For premium calculation of oater policies, Age of eldest member

would be considered.

Premium towards D.III.1.i Maternity & New born baby Hospitalization

Expenses, D.III.3.i Maternity & New born baby Hospitalization

Expenses and D.IV.3 Infertility Treatment shall be applied to female

Insured Members covered as adult in the Policy.

Premium can be paid on Single, Half yearly, Quarterly and Monthly

basis. Premium payment mode can only be selected at the inception of

the Policy or at the renewal of the Policy.

In case of premium payment modes other than Single, a loading will be

applied on the premium.

Loading grid applicable for Half-yearly, Quarterly and Monthly payment

mode.

Premium payment mode %Loadingonpremium

Monthly 5.50

Quarterly 3.50

Half yearly 2.50

ZoneClassication

ZoneI: Mumbai, Thane & Navi Mumbai, Gujarat and Delhi & NCR

ZoneII: Bangalore, Hyderabad, Chennai, Chandigarh, Ludhiana, Kolkata,

Pune

ZoneIII: Rest of India excluding the locations mentioned under Zone I &

Zone II

 IdenticationofZonewillbebasedonthelocation-Cityoftheproposed

Insured Persons.

(a) Persons paying Zone I premium can avail treatment all over India wit

out any Co-pay.

(b) Persons paying Zone II premium

i) Can avail treatment in Zone II and Zone III without any Co-pay.

  ii) AvailingtreatmentinZoneIwillhavetobear10%ofeachand

every claim.

i) Can avail treatment in Zone III, without any Co-pay.

  ii) AvailingtreatmentinZoneIIwillhavetobear10%ofeachand

every claim.

  iii)AvailingtreatmentinZoneIwillhavetobear20%ofeachand

every claim.

 ***OptiontoselectZone1iftheactualZoneisZone2orZone3,and

would be available on payment of applicable premium at the time of

buying the First Policy and on subsequent renewals

Aforesaid Co-payments for claims occurring outside of the Zone will

not apply in case of Hospitalization due to Accident.

E.II.10.DiscountsunderthePolicy

You can avail of the following discounts on the premium on Your policy.

i. LifetimeDiscounts

a. EmployeeDiscount:10%discountonthepremium

b. Standing Instruction Discount: 3% discount on the renewal

premium, if the renewal premium is received through standing

instruction.

c. Long Term policy discount - Long term discount of 7.5% for

  selectinga2yearpolicyand10%forselectinga3yearpolicy.This

discount is available only with ‘Single’ Premium Payment mode

d. Familydiscount: (Applicable only with cover on individual basis)

  20%discountonthepremiumisapplicableforcovering2ormore

members under the same individual Policy.

ii. ShortTermDiscounts

a. ManipalCigna Existing Customer Discount: 5% discount will

be applicable to customers of ManipalCigna Insurance who

are already covered under Group / Retail Products. Discount

would be applicable once, only at inception and shall not be offered

to Portability/ Migration related proposals.

b. WorksiteMarketingDiscount–Adiscountof10%willbeavailable

on polices which are sourced through worksite marketing channel.

Discount would be applicable once only at inception of the Policy.

DiscountunderF.II.10.i(d)isapplicableonlytoindividualpolicies.All

other discounts mentioned above are available to both individual

aswellasoaterpolicies.Maximumdiscountinasinglepolicyshallnot

exceed40%.

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

Family Discount, Long Term Discount and Worksite Marketing Discount

is applied on the total Policy premium which is sum total of individual

premium for Family policies.

E.II.11 Loadings&SpecialConditions

We may apply a risk loading on the premium payable (excluding

Statutory Levis and Taxes) or Special Conditions on the Policy

based upon the health status of the persons proposed for insurance

and declarations made in the Proposal Form. These loadings will

 beappliedfrominceptiondateoftherstPolicyincludingsubsequent

Renewal(s) with Us. There will be no loadings based on individual

claims experience.

 We may apply a specic sub-limit on a medical condition/ailment

depending on the past history and declarations or additional waiting

 periods(amaximum of48monthsfrom thedateofinception ofrst

policy) on pre-existing diseases as part of the special conditions on the

Policy.

We shall inform You about the applicable risk loading or special

condition through a counter offer letter or through an electronic mode,

as the case may be and You would need to revert with consent and

 additionalpremium(ifany),withinthedurationspeciedinthecounter

offer letter.

In case, You neither accept the counter offer nor revert to Us within the

 duration specied, We shall cancel Your application and refund the

premium paid. Your Policy will not be issued unless We receive Your

consent.

E.II.12.Communications&Notices

Any communication or notice or instruction under this Policy shall be in

writing and will be sent to:

 a. Thepolicyholder’s,attheaddressasspeciedinPolicySchedule

 b. ToUs,attheaddressspeciedinthePolicySchedule.

c. No insurance agents, brokers, other person or entity is authorised

to receive any notice on the behalf of Us unless explicitly stated in

writing by Us.

 d. Notice and instructions will be deemed served 10 days after

posting or immediately upon receipt in the case of hand delivery,

facsimile or e-mail.

E.II.13.ElectronicTransactions

You agree to comply with all the terms, conditions as We shall

 prescribe from time to time, and conrms that all transactions

effected facilities for conducting remote transactions such as the

internet, World Wide Web, electronic data interchange, call centres,

tele-service operations (whether voice, video, data or combination

thereof) or by means of electronic, computer, automated machines

network or through other means of telecommunication, in respect of

this Policy, or Our other products and services, shall constitute legally

binding when done in compliance with Our terms for such facilities.

Sales through such electronic transactions shall ensure that all

conditions of Section 41 of the Insurance Act, 1938 prescribed for the

proposal form and all necessary disclosures on terms and conditions

and exclusions are made known to You. A voice recording in case of

tele-sales or other evidence for sales through the World Wide Web shall

be maintained and such consent will be subsequently validated /

 conrmedbyYou.

All terms and conditions in respect of Electronic Transactions shall be

within the approved Terms and Conditions of the Policy.

E.II.14.LimitationofLiability

If a claim is rejected or partially settled and is not the subject of any

pending suit or other proceeding or arbitration, as the case may be,

within twelve months from the date of such rejection or settlement, the

claim shall be deemed to have been abandoned and Our liability shall

be extinguished and shall not be recoverable thereafter.

E.II.15.TermsandconditionsofthePolicy

The terms and conditions contained herein and in the Policy Schedule

shall be deemed to form part of the Policy and shall be read together as

one document.

E.II.16.DisputeResolution

Any and all disputes or differences under or in relation to this Policy

shall be determined by the Indian Courts and subject to Indian law

without reference to any principle which would result in the application

of the law of any other jurisdiction.

F.  Othertermsandconditions

F.I. Claimprocess&management

F.I.1. ConditionPreceding

 ThefullmentofthetermsandconditionsofthisPolicy(includingthe

realization of premium by their respective due dates) in so far as they

relate to anything to be done or complied with by You or any Insured

Person, including complying with the following steps, shall be the

condition precedent to the admissibility of the claim.

Completed claim forms and processing documents must be furnished

to Us within the stipulated timelines for all reimbursement claims.

Failure to furnish this documentation within the time required shall not

invalidate nor reduce any claim if You can satisfy Us that it was not

reasonably possible for You to submit / give proof within such time.

The due intimation, submission of documents and compliance with

requirements as provided under the Claims Process under this Section,

by You shall be essential failing which We shall not be bound to accept

a claim.

Cashless and Reimbursement Claim processing and access to

network hospitals is through our service partner/TPA, details of the

same will be available on the Health Card issued by Us as well as on

our website. For the latest list of network hospitals you can log on to

our website. Wherever a TPA is used, the TPA will only work to facilitate

claim processing. All customer contact points will be with Us including

claim intimation, submission, settlement and dispute resolutions.

F.I.2. PolicyHolder’s/InsuredPersonsDutyatthetimeofClaim

You are required to check the applicable list of Network Providers, at

Our website or call center before availing the Cashless services.

On occurrence of an event which may lead to a Claim under this Policy,

You shall:

 (a)Forthwithintimate,leandsubmittheClaiminaccordancetothe

  ClaimProceduredenedunderSectionG.I.3,G.I.4,andG.I.5as

mentioned below.

(b) If so requested by Us, You or the Insured Person must submit

himself/ herself for a medical examination by Our nominated

Medical Practitioner as often as We consider reasonable and

necessary. The cost of such examination will be borne by Us.

inspect the medical and Hospitalization records, investigate the

facts and examine the Insured Person.

(d) Assist and not hinder or prevent Our representatives in pursuance

of their duties for ascertaining the admissibility of the claim, its

circumstances and its quantum under the provisions of the Policy.

F.I.3. ClaimIntimation

Upon the discovery or occurrence of any Illness / Injury that may give

rise to a Claim under this Policy, You / Insured Person shall undertake

the following:

In the event of any Illness or Injury or occurrence of any other

contingency which has resulted in a Claim or may result in a claim

covered under the Policy, You/the Insured Person, must notify Us either

at the call center or in writing, in the event of:

• Planned Hospitalization, You/the Insured Person will intimate such

admission at least 3 days prior to the planned date of admission.

• Emergency Hospitalization, You /the Insured Person will intimate

such admission within 48 hours of such admission.

The following details are to be provided to Us at the time of intimation

of Claim:

• Policy Number

• Name of the Policyholder

• Name of the Insured Person in whose relation the Claim is being

lodged

• Nature of Illness / Injury

• Name and address of the attending Medical Practitioner and

Hospital

• Date of Admission

• Any other information as requested by Us

F.I.4.CashlessFacility

Cashless facility is available only at our Network Hospital. The Insured

Person can avail Cashless facility at the time of admission into any

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

Network Hospital, by presenting the health card as provided by Us with

 thisPolicy,alongwithavalidphotoidenticationproof(VoterIDcard/

Driving License / Passport / PAN Card / any other identity proof as

approved by Us).

(a) ForPlannedHospitalization:

i. The Insured Person should at least 3 days prior to admission to

the Hospital approach the Network Provider for Hospitalization for

medical treatment.

ii. The Network Provider will issue the request for authorization letter

for Hospitalization in the pre-authorization form prescribed by the

IRDA.

iii. The Network Provider shall electronically send the pre-

authorization form along with all the relevant details to the 24

(twenty four) hour authorization/cashless department along with

contact details of the treating Medical Practitioner and the Insured

Person.

iv. Upon receiving the pre-authorization form and all related medical

information from the Network Provider, We will verify the eligibility

of cover under the Policy.

 v. Wherever the information provided in the request is sufcient to

ascertain the authorisation We shall issue the authorisation Letter

to the Network Provider. Wherever additional information or

documents are required We will call for the same from the Network

provider and upon satisfactory receipt of last necessary

documents the authorisation will be issued. All authorisations will

be issued within a period of 4 hours from the receipt of last

complete documents.

vi. The Authorisation letter will include details of sanctioned amount,

  anyspeciclimitationontheclaim,anyco-paysordeductiblesand

non-payable items if applicable.

vii. The authorisation letter shall be valid only for a period of 15 days

from the date of issuance of authorization.

In the event that the cost of Hospitalization exceeds the authorized limit

as mentioned in the authorization letter:

i. The Network Provider shall request Us for an enhancement of

authorisation limit as described under Section G.I.4 (a) including

  detailsofthespeciccircumstanceswhichhaveledtotheneedfor

increase in the previously authorized limit. We will verify the

eligibility and evaluate the request for enhancement on the

availability of further limits.

ii. We shall accept or decline such additional expenses within 24

(twenty-four) hours of receiving the request for enhancement from

You.

In the event of a change in the treatment during Hospitalization to the

Insured Person, the Network Provider shall obtain a fresh authorization

letter from Us in accordance with the process described under G.I.4 (a)

above.

At the time of discharge:

 i. theNetworkProvidermayforwardanalrequestforauthorization

for any residual amount to us along with the discharge summary

and the billing format in accordance with the process described at

G.I.4 (a)above.

 ii. Uponreceiptofthenalauthorisationletterfromus,Youmaybe

discharged by the Network Provider.

(b) IncaseofEmergencyHospitalization

i. The Insured Person may approach the Network Provider for

Hospitalization for medical treatment.

ii. The Network Provider shall forward the request for authorization

within 48 hours of admission to the Hospital as per the process

under Section G.I.4 (a).

iii. It is agreed and understood that we may continue to discuss the

Insured Person’s condition with the treating Medical Practitioner till

Our recommendations on eligibility of coverage for the Insured

  Personarenalised.

iv. In the interim, the Network Provider may either consider treating

the Insured Person by taking a token deposit or treating him as per

their norms in the event of any lifesaving, limb saving, sight saving,

Emergency medical attention requiring situation.

v. The Network Provider shall refund the deposit amount to You

barring a token amount to take care of non-covered expenses

once the pre-authorization is issued.

Note: Cashless facility for Hospitalization Expenses shall be limited

exclusively to Medical Expenses incurred for treatment undertaken in

a Network Hospital for Illness or Injury which are covered under

the Policy and shall not be available to the Insured Person for coverage

under Daily Cash for Shared Accommodation (Section D.1.13),

Worldwide Emergency with Outpatient Cover under Freedom optional

package (Section D.III.4.ii). For all Cashless authorizations, You will, in

any event, be required to settle all non-admissible expenses, Co-

payment and / or Deductibles (if applicable), directly with the Hospital.

The Network Provider will send the claim documents along with the

invoice and discharge voucher, duly signed by the Insured Person

directly to us. The following claim documents should be submitted to

Us within 15 days from the date of discharge from Hospital -

• Claim Form Duly Filled and Signed

• Original pre-authorisation request

• Copy of pre-authorisation approval letter (s)

 • CopyofPhotoIDofPatientVeriedbytheHospital

• Original Discharge/Death Summary

• Operation Theatre Notes (if any)

• Original Hospital Main Bill and break up Bill

• Original Investigation Reports, X Ray, MRI, CT Films, HPE

• Doctors Reference Slips for Investigations/Pharmacy

• Original Pharmacy Bills

• MLC/FIR Report/Post Mortem Report (if applicable and conducted)

We may call for any additional documents as required based on the

circumstances of the claim

There can be instances where We may deny Cashless facility for

 Hospitalization due to insufcient Sum Insured or insufcient

information to determine admissibility in which case You/ Insured

Person may be required to pay for the treatment and submit the claim

for reimbursement to Us which will be considered subject to the Policy

Terms & Conditions.

We in our sole discretion, reserves the right to modify, add or restrict

any Network Hospital for Cashless services available under the Policy.

Before availing the Cashless service, the Policyholder / Insured Person

is required to check the applicable/latest list of Network Hospital on the

Company’s website or by calling our call centre.

F.I.5. ClaimReimbursementProcess

 (a)CollectionofClaimDocuments

i. Wherever You have opted for a reimbursement of expenses, You

may submit the following documents for reimbursement of the

  claimtoOurbranchorheadofceatyourownexpensenotlater

than 15 days from the date of discharge from the Hospital. You can

  obtainaClaimFormfromanyofourBranchOfcesordownloada

copy from our website www.manipalcigna.com

ii. List of necessary claim documents to be submitted for

reimbursement are as following:

Claim form duly signed

Copy of photo ID of patient

Hospital Discharge summary

Operation Theatre notes

Hospital Main Bill

Hospital Break up bill

Investigation reports

Originalinvestigationreports,XRay,MRI,CTlms,HPE,ECG

Doctors reference slip for investigation

Pharmacy Bills

MLC/ FIR report, Post Mortem Report if applicable and conducted

KYC documents (Photo ID proof, address proof, recent passport

size photograph)

Cancelled cheque for NEFT payment

Payment receipt.

We may call for any additional documents/information as required

based on the circumstances of the claim.

 iii. Our branch ofces shall give due acknowledgement of collected

documents to You.

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

In case You/ Insured Person delay submission of claim documents

  asspeciedinG.I.5.(a)above,theninadditiontothedocuments

mentioned in G.I.5.(a) above, You are also required to provide Us

the reason for such delay in writing. In case You delay submission

of claim documents, then in addition to the documents mentioned

above, You are also required to provide Us the reason for such

delay in writing. We will accept such requests for delay up to an

  additional period of 30 days from the stipulated time for such

submission. We will condone delay on merit for delayed Claims

where the delay has been proved to be for reasons beyond Your

Insured Persons control.

where the delay has been proved to be for reasons beyond Your/

Insured Persons control.

F.I.6. ScrutinyofClaimDocuments

a. We shall scrutinize the claim and accompanying documents. Any

  deciencyofdocumentsshallbeintimatedtoYouandtheNetwork

Provider, as the case may be within 5 days of their receipt.

 b. Ifthedeciencyinthenecessaryclaimdocumentsisnotmetorare

  partiallymetin10workingdaysoftherstintimation,Weshallremind

  Youofthesameandevery10(ten)daysthereafter.

c. We will send a maximum of 3 (three) reminders.

d. We shall settle the claim payable amount arrived post scrutinizing the

  claimdocumentsexcludingthedeciencyintimatedtoYou.

e. In case a reimbursement claim is received when a Pre-Authorization

letter has been issued, before approving such claim a check will be

made with the provider whether the Pre-authorization has been utilized

as well as whether the Policyholder has settled all the dues with the

provider. Once such check and declaration is received from the

Provider, the case will be processed.

F.I.7. ClaimAssessment

We will assess all admissible claims under the Policy in the following

progressive order -

(a) For Plans without Deductible Option

i) Where a room accommodation is opted for higher than the

eligible room category under the plan, the room rent for the

applicable accommodation will be apportioned on pro rata

basis. Such apportioned amount will apply to all “Associated

   Medical Expenses”. [(a). Cost of Pharmacy & consumables,

(b). Cost of implant and medical device, (c). Cost of diagnostic

   test,willnotbepartofAssociatedMedicalExpenses)]

ii) Any Sub-limits or Zonal Co-payment shall be applicable on the

amount payable after applying the Section G.I.7 a (i)

(b) For Plans with Deductible Option

i) Where a room accommodation is opted for higher than the

eligible room category under the plan, the room rent for the

applicable accommodation will be apportioned on pro rata

basis. Such apportioned amount will apply to all “Associated

   Medical Expenses”. [(a). Cost of Pharmacy & consumables,

(b). Cost of implant and medical device, (c). Cost of diagnostic

   test,willnotbepartofassociatedmedicalexpenses)]

ii) Arrived payable claim amount will be assessed against the

deductible.

iii) Any Sub-limits or Zonal Co-payment shall be applicable on the

amount payable after applying the Section G.I.7 b (i), (ii)

deducted from the following amounts in the following progressive

order –

i) Deductible (if opted)

ii) Zonal Co-payment (if applicable)

iii) Sum Insured

iv) Cumulative Bonus or Cumulative Bonus Booster

v) Restored Sum Insured

 ClaimAssessmentforBenetPlans:

 WewillpayxedbenetamountsasspeciedinthePolicySchedule

in accordance with the terms of this Policy. We are not liable to make

any reimbursements of Medical Expenses or pay any other amounts

 notspeciedinthePolicy.

ClaimassessmentforpolicieswithMonthly,QuarterlyandHalf-

YearlyPremiumPaymentMode:

In case of a claim (Cashless/Re-imbursement), an amount equivalent

to the balance of the instalment premiums payable, in that policy year,

would be recoverable from the admissible claim amount payable in

respect of the Insured person.

F.I.8. ClaimsInvestigation

We may investigate claims at Our own discretion to determine the

validity of claim. Such investigation shall be concluded within 15 days

from the date of assigning the claim for investigation and not later than

 30 days from the date of receipt of last necessary document.

 Verication carried out, if any, will be done by individuals or entities

 authorisedbyUstocarryoutsuchverication/investigation(s)andthe

 costsforsuchverication/investigationshallbebornebytheUs.

F.I.9. PreandPost-hospitalizationclaims

You should submit the Post-hospitalization claim documents at Your

own expense within 15 days of completion of Post-hospitalization

treatment or eligible post hospitalization period of cover, whichever is

earlier.

We shall receive Pre and Post- hospitalization claim documents either

along with the inpatient Hospitalization papers or separately and

process the same based on merit of the claim subject to Policy terms

and conditions, derived on the basis of documents received.

F.I.10. RepresentationagainstRejection:

Where a rejection is communicated by Us, You may if so desired within

15 days represent to Us for reconsideration of the decision.

F.I.11 PaymentTerms

The Sum Insured opted under the Plan shall be reduced by the amount

 payable/paidundertheBenet(s)andthebalanceshallbeavailable

as the Sum Insured for the unexpired Policy Year.

If You/ Insured Person suffers a relapse within 45 days of the date of

discharge from the Hospital for which a claim has been made, then

such relapse shall be deemed to be part of the same claim and all the

limits for “Any One Illness” under this Policy shall be applied as if they

were under a single claim.

For Cashless Claims, the payment shall be made to the Network

 Hospitalwhosedischargewouldbecompleteandnal.

For Reimbursement Claims, the payment will be made to you. In the

unfortunate event of Your death, We will pay the nominee (as named

in the Policy Schedule) and in case of no nominee to the Legal Heir who

 holds a succession certicate or Indemnity Bond to that effect,

whichever is available and whose discharge shall be treated as full and

 naldischargeofitsliabilityunderthePolicy.

ClaimprocessApplicabletothefollowingSections:

F.I.12 OutpatientExpenses

(a) Assessment of Claim Documents

We shall assess the claim documents and assess the admissibility

of claim subject to terms and conditions of the Policy.

(b) Settlement & Repudiation of a claim

  Weshallsettleclaims,includingitsrejection,within5(ve)working

days of the receipt of the last ‘necessary’ document but not later

  than30days.

 ThisbenetshallbesettledonCashlessBasisonlyasmentionedin

G.I.4

F.I.13 DomesticSecondOpinion

(a) Receive Request for Expert Opinion on Critical Illness

You can submit Your request for an expert opinion by calling Our

call centre or register request through email.

(b) Facilitating the Process

We will schedule an appointment or facilitate delivery of Medical

Records of the Insured Person to a Medical Practitioner in India.

The expert opinion is available only in the event of the Insured

Person being diagnosed with covered Critical Illness.

F.I.14 HealthCheckupandTele-Consultation

(a) You or The Insured Person shall seek appointment by calling Our

call centre.

(b) We will facilitate Your appointment and We will guide You to the

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

nearest Network Provider for conducting the medical examination.

centre.

F.I.15 WorldwideEmergencyHospitalizationwithOutpatientCover

a) In an unlikely event of You or the Insured Person requires

Emergency medical treatment outside India, You or Insured Person,

must notify Us either at Our call centre or in writing within 48 hours

of such admission.

 b) YoushallleaclaimforreimbursementinaccordancewithSection

G.I.5 of the Policy.

F.I.16 Deductible

a) Any claim towards hospitalization during the Policy Period must

be submitted to Us for assessment in accordance with the claim

process laid down under Section G.I.4 and Section G.I.5 towards

cashless or reimbursement respectively in order to assess and

determine the applicability of the Deductible on such claim. Once

the claim has been assessed, if any amount becomes payable after

applying the deductible, We will assess and pay such claim in

accordance with Section G.I.6. and G.I.7.

b) Wherever such hospitalization claims as stated under G.I.16. a)

above is being covered under another Policy held by You, We will

assess the claim on available photocopies duly attested by Your

Insurer / TPA as the case may be.

F.I.17 SwitchOffandOnBenet

To Switch Off/On the Policy and other related documentation, You

can e-mail to - [email protected] and/or contact

 our customer care centre at 1800-102-4462 as mentioned in Your

Policy Schedule.

F.I.18 HealthMaintenanceBenet

(a) Submission of claim

  You can send the Health Maintenance Benet claim form along

with the invoices, treating Medical Practitioner’s prescription,

reports, duly signed by You / Insured Person as the case may

  be,toOurbranchofceorHeadOfceatyourownexpense.The

  Health Maintenance Benet under D.III.1 ‘Enhance’ optional

package can be claimed only once during the Policy Period up to

  theextentoflimitunderthisbenet.

(b) Assessment of Claim Documents

We shall assess the claim documents and assess the admissibility

of claim subject to terms and conditions of the Policy .

(b) Settlement & Repudiation of a claim

  Weshallsettleclaims,includingitsrejection,within5(ve)working

days of the receipt of the last ‘necessary’ document but not later

  than30days.

F.I.19 ApplicationofMultiplepoliciesclause

In case this clause is invoked in accordance to the terms and conditions

as provided under this Policy, the Claim will be adjudicated as under:

a) Retail policy of the Company & any other Policy from other

  insurers:

i) Cashless hospitalization: In case the Insured avail

Cashless Facility for Hospitalization then Insured / Hospital will

intimate us of the admission through a pre-authorization request

with all details & estimated amount for the Hospitalization. The

policyholder having multiple policies shall also have the right to

prefer claims from other policy/policies for the amounts

disallowed under the earlier chosen policy/policies, even if the

sum insured is not exhausted.Then the Insurer(s) shall settle

the claim subject to the terms and conditions of the other policy

/ policies so chosen. Post discharge, the hospital will send

   all the original documents to one of the insurer & certied

copies of all documents to other insurers for settlement along

with authorization letter. The Company will evaluate the entire

bill & arrive at the total payable amount & deduct the amount

already settled by the other insurers & settle the difference

payable amount to the hospital as per AL issued.

ii) Reimbursement claim: In case the Insured gets

   admitted&pays theentirebill &thenlesfor reimbursement

claim then he will have to intimate us of the admission 48

hours before admission for planned admissions & within 24

hours post hospitalization for emergency hospitalization but in

no case later than discharge from the Hospital. Insured will

need to submit details of the other insurance policies to the

Company. Post discharge insured will send all the original

documents along with bills & claim form to one of the insurer

   &certiedcopiesofalldocuments&billsalongwithdulylled

claim form to the other insurers. The policyholder having

multiple policies shall also have the right to prefer claims from

other policy / policies for the amounts disallowed under the

earlier chosen policy / policies, even if the sum insured is not

exhausted. Then the Insurer (s) shall settle the claim subject to

the terms and conditions of the other policy / policies so chosen.

b) Retailpolicy&grouppolicyfromtheCompany:

i). Cashless process: In case the insured needs to utilize

cashless facility for hospitalization then the insured / hospital will

intimate the Company about the hospitalization through pre-

authorization process. The policyholder having multiple

policies shall also have the right to prefer claims from other

policy / policies for the amounts disallowed under the earlier

chosen policy / policies, even if the sum insured is not

exhausted. Then the Insurer(s) shall settle the claim subject to

the terms and conditions of the other policy / policies so chosen.

Post discharge hospital will send as many separate claims

as no of policies with the Company with attached authorization

letters & original documents with the 1st claim & copy of

documents with the other claims for settlement to the

Company. The Company will settle all the claims as per policy

terms & conditions & authorization letter issued.

ii). Reimbursement Claim process: In case the Insured gets

   admitted&pays theentirebill &thenlesfor reimbursement

claim then he will have to intimate the Company of the

admission 48 hours before admission for planned admissions

& within 24 hours post hospitalization for emergency

hospitalization along with all the policy numbers.

Post discharge insured will send all original documents & bills

   along with duly lled claim form. The policyholder having

multiple policies shall also have the right to prefer claims

from other policy / policies for the amounts disallowed under the

earlier chosen policy / policies, even if the sum insured is not

exhausted. Then the Insurer(s) shall settle the claim subject

to the terms and conditions of the other policy / policies so chosen.

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

F.II .Annexure–I:

Ombudsman

NameoftheOfceofInsuranceOmbudsman State-wiseAreaofJurisdiction

AHMEDABAD

OfceoftheInsuranceOmbudsman,

Jeevan Prakash Building, 6

oor,

Tilak Marg, Relief Road,

Ahmedabad-380001.

Tel.:079-25501201/02/05/06

Email:- [email protected]

State of Gujarat and Union Territories of Dadra and Nagar Haveli and

Daman and Diu.

BENGALURU

OfceoftheInsuranceOmbudsman,

Jeevan Soudha Building, PID No. 57-27-N-19

Ground Floor, 19/19, 24

Main Road,

JP Nagar, 1

Phase,

Bengaluru-560078.

Tel.:080-26652048/26652049

Email:- [email protected]

State of Karnataka.

BHOPAL

OfceoftheInsuranceOmbudsman,

Janak Vihar Complex,

Floor,6,MalviyaNagar,Opp.AirtelOfce,

Near New Market,

Bhopal-462003

Tel.:0755-2769201/202

Fax:0755-2769203

Email:- [email protected]

States of Madhya Pradesh and Chhattisgarh.

BHUBANESWAR

OfceoftheInsuranceOmbudsman,

62, Forest park,

Bhubaneshwar-751009.

Tel.:0674-2596461/2596455

Fax:0674-2596429

Email:- [email protected]

State of Orissa.

CHANDIGARH

OfceoftheInsuranceOmbudsman,

S.C.O.No.101,102&103,2

Floor,

Batra Building, Sector 17 - D,

Chandigarh-160017.

Tel.:0172-2706196/6468

Fax:0172-2708274

Email:- [email protected]

States of Punjab, Haryana (excluding 4 districts viz Gurugram,

Faridabad, Sonepat and Bahadurgarh), Himachal Pradesh, Union

Territories of Jammu & Kashmir, Ladakh and Chandigarh.

CHENNAI

OfceoftheInsuranceOmbudsman,

Fatima Akhtar Court,

Floor, 453 (old 312), Anna Salai, Teynampet,

CHENNAI-600018.

Tel.:044-24333668/24335284

Fax:044-24333664

Email:- [email protected]

State of Tamil Nadu and Union Territories - Puducherry Town and

Karaikal (which are part of Union Territory of Puducherry).

DELHI

OfceoftheInsuranceOmbudsman,

2/2 A, Universal Insurance Building,

Asaf Ali Road,

NewDelhi-110002.

Tel.:011-23232481/23213504

Email:- [email protected]

Delhi, 4 Districts of Haryana viz. Gurugram, Faridabad, Sonepat and

Bahadurgarh.

GUWAHATI

OfceoftheInsuranceOmbudsman,

‘Jeevan Nivesh’, 5

Floor,

Nr. Panbazar over bridge, S.S. Road,

Guwahati-781001(ASSAM).

Tel.:0361-2132204/2132205

Email:- [email protected]

States of Assam, Meghalaya, Manipur, Mizoram, Arunachal Pradesh,

Nagaland and Tripura.

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

HYDERABAD

OfceoftheInsuranceOmbudsman,

6-2-46, 1

oor,“MoinCourt”

Lane Opp. Saleem Function Palace,

A. C. Guards, Lakdi-Ka-Pool,

Hyderabad-500004.

Tel.:040-65504123/23312122

Fax:040-23376599

Email:- [email protected]

State of Andhra Pradesh, Telangana and Yanam - a part of Union

Territory of Puducherry.

JAIPUR

OfceoftheInsuranceOmbudsman,

Jeevan Nidhi - II Bldg., Gr. Floor,

Bhawani Singh Marg,

Jaipur-302005.

Tel.:0141-2740363

Email:- [email protected]

State of Rajasthan.

KOCHI

OfceoftheInsuranceOmbudsman,

Floor,CC27/2603,PulinatBldg.,

Opp. Cochin Shipyard, M. G. Road,

Ernakulam-682015.

Tel.:0484-2358759/9338

Fax:0484-2359336

Email:- [email protected]

States of Kerala and Union Territory of (a) Lakshadweep (b) Mahe-a

part of Union Territory of Puducherry.

KOLKATA

OfceoftheInsuranceOmbudsman,HindustanBldg.Annexe,4,

C.R. Avenue, 4

Floor,KOLKATA-700072.

TEL.:033-22124340/22124339

Fax:033-22124341

Email:- [email protected]

States of West Bengal, Sikkim and Union Territories of Andaman &

Nicobar Islands.

LUCKNOW

OfceoftheInsuranceOmbudsman,

Floor, Jeevan Bhawan,

Phase-II, Nawal Kishore Road, Hazratganj,

Lucknow-226001.

Tel.:0522-2231330/1

Fax:0522-2231310

Email:- [email protected]

Districts of Uttar Pradesh

Lalitpur, Jhansi, Mahoba, Hamirpur, Banda, Chitrakoot, Allahabad,

Mirzapur, Sonbhadra, Fatehpur, Pratapgarh, Jaunpur,Varanasi,

Gazipur, Jalaun, Kanpur, Lucknow, Unnao, Sitapur, Lakhimpur,

Bahraich, Barabanki, Raebareli, Sravasti, Gonda, Faizabad, Amethi,

Kaushambi, Balrampur, Basti, Ambedkarnagar, Sultanpur, Maharajganj,

Santkabirnagar, Azamgarh, Kushinagar, Gorakhpur, Deoria, Mau,

Ghazipur, Chandauli, Ballia, Sidharthnagar.

MUMBAI

OfceoftheInsuranceOmbudsman,

Floor, Jeevan Seva Annexe,

S. V. Road, Santacruz (W),

Mumbai-400054.

Tel.:022-26106552/6960

Fax:022-26106052

Email:- [email protected]

State of Goa and Mumbai Metropolitan Region excluding Areas of Navi

Mumbai and Thane.

NOIDA

OfceoftheInsuranceOmbudsman,

Bhagwan Sahai Palace

Floor, Main Road,

Naya Bans, Sector 15,

Distt: Gautam Buddh Nagar,

U.P-201301.

Tel.:0120-2514252/2514253

Email:- [email protected]

State of Uttaranchal and the districts of Uttar Pradesh:

Agra, Aligarh, Bagpat, Bareilly, Bijnor, Budaun, Bulandshehar, Etah,

Kanooj, Mainpuri, Mathura, Meerut, Moradabad, Muzaffarnagar,

Oraiyya, Pilibhit, Etawah, Farukkabad, Firozbad, Gautambodhanagar,

Ghaziabad, Hardoi, Shahjahanpur, Hapur, Shamli, Rampur, Kashganj,

Sambhal, Amroha, Hathras, Kanshiramnagar, Saharanpur.

PATNA

OfceoftheInsuranceOmbudsman,

Floor,Kalpana Arcade Building,

Bazar Samiti Road,

Bahadurpur,

Patna-800006.

Tel.:0612-2680952

Email:- [email protected]

States of Bihar and Jharkhand.

PUNE

OfceoftheInsuranceOmbudsman,

Jeevan Darshan Bldg., 3

Floor,

C.T.S. No.s. 195 to 198,

N.C. Kelkar Road, Narayan Peth,

Pune-411030.

Tel.:020-41312555

Email:- [email protected]

State of Maharashtra, Areas of Navi Mumbai and Thane but excluding

Mumbai Metropolitan.

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

F.III.Annexure-II:

Title

Description

PleaserefertothePlanandSumInsuredyouhaveoptedtounderstandtheavailablebenetsunderyourplaninbrief

Your

Coverage

Details:

Identify your Plan Protect Advantage

BasicCover

This section

lists the Basic

benets

available on

your plan

Identify your Opted

Sum Insured (in `)

`3 Lacs, `4 Lacs, `5 Lacs, `7.5 Lacs,

`10Lacs,`12.5 Lacs, `15 Lacs,

`20Lacs,`25 Lacs, `30Lacs,`40Lacs,

`50Lacs,`100Lacs

`5 Lacs, `7.5 Lacs, `10Lacs,`12.5 Lacs, `15 Lacs,

`20Lacs,`25 Lacs, `30Lacs,`40Lacs,`50Lacs,`100

Lacs

Inpatient

Hospitalization

(When you are

hospitalized)

Room Rent: Covered up to Single Private A/C Room

For ICU - Covered up to Sum Insured

Thisbenetshallalsoofferthebelowcoversuptothelimitsmentioned:

a. Listed Modern and Advanced Treatments:

For Sum Insured <`5Lacs:Upto50%ofSumInsured

ForSumInsured>=`5 Lacs: Up to Sum Insured

b. HIV/AIDS & STD:

Up to Sum Insured

c. Mental Illness

Up to Sum Insured

For ICD Codes mentioned below: Waiting Period of 24 months shall apply

ICD 10

CODES

DISEASES

F05 Delirium due to known physiological condition

F06 Other mental disorders due to known physiological condition

F07 Personality and behavioural disorders due to known physiological condition

F10 Alcohol related disorders

F20 Schizophrenia

F23 Brief psychotic disorders

F25 Schizoaffective disorders

F29

Unspeciedpsychosisnotduetoasubstanceorknownphysiological

condition

F31 Bipolar disorder

F32 Depressive episode

F39 Unspeciedmood[affective]disorder

F40 Phobic Anxiety disorders

F41 Other Anxiety disorders

F42 Obsessive-compulsive disorder

F44 Dissociative and conversion disorders

F45 Somatoform disorders

F48 Other nonpsychotic mental disorders

F60 Specicpersonalitydisorders

F84 Pervasive developmental disorders

F90 Attention-decithyperactivitydisorders

F99 Mentaldisorder,nototherwisespecied

Pre-hospitalization MedicalExpensesCoveredupto60daysbeforethedateofhospitalization;CoveredUptotheSumInsured

Post-

hospitalization

MedicalExpensesCoveredupto180dayspostdischargefromthehospital;CoveredUptotheSum

Insured

Day Care

Treatment

Covered up to the Sum Insured

Domiciliary

Hospitalization

(Treatment at Home)

Coveredupto10%oftheSumInsured

PreandPostHospitalizationExpenses:30dayseach

Road Ambulance

(Reimbursement of

Ambulance Expenses)

Covered up to the Sum Insured

Donor Expenses

(Hospitalization

Expenses of the donor

providing the organ)

Covered up to the Sum Insured

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

Restoration of Sum

Insured

(When opted Sum

Insuredisinsufcient

due to claims)

Multiple Restoration is available in a Policy Year for all illnesses, whether unrelated or same, in addition to

the Sum Insured

Applicable for below covers only

1. D.I.1 - In-patient Hospitalization (Except for Bariatric Surgery)

2. D.I.2 - Pre - hospitalization

3. D.I.3 - Post - hospitalization

4. D.I.4 - Day Care Treatment

5. D.I.6 - Road Ambulance

6. D.I.7 - Donor Expenses

7. D.I.9 - AYUSH Treatment

8. D.IV.1 – Non-Medical Items

Restoration shall not get triggered for the 1

claim

The maximum liability under a single claim shall not be more than Base Sum Insured + Cumulative Bonus +

Restored Sum Insured

AYUSH Treatment (In-

patient Hospitalization)

Covered up to the Sum Insured

Air Ambulance Cover

Covered up to sum insured subject to maximum of `10LacsinadditiontotheSumInsuredforexpenses

incurred on Air Ambulance

Bariatric Surgery

Cover

Covered up to the Sum Insured opted subject to maximum of `5 Lacs Waiting Period of 36 months shall

apply for Bariatric Surgery

Outpatient Expenses Not Available

Option to choose from - `20,000,`30,000,`50,000Per

policy Year

Can be used to pay for Consultations and Diagnostics

includingDentalandVision:Upto100%oftheSumInsured

optedforOutpatientbenet.

Upto20%oftheOutpatientLimitcanbeusedforPharmacy

(Drugs and Medicines prescribed by Medical Practitioners).

Thisbenetisavailableonlyoncashlessbasisfromthe

Network providers of ManipalCigna Health Insurance

Company Limited.

Anyunutilizedamountunderthisbenetshallnotbecarried

forward to subsequent Policy Year.

Daily Cash for Shared

Accommodation

DailyCashbenetforoccupyingsharedaccommodationwhilehospitalized,shallbe

covered as below:-

a. For Sum Insured up to `10Lacs:`800perdayuptomaximumof`5,600

b. For Sum Insured above `10Lacs:`1,000perdayuptomaximumof`7,000

Payable for each continuous and completed 24 Hours of Hospitalization during the

Policy Year

Thisbenetgetstriggeredpost48hoursofIn-patienthospitalizationandshallbepayablefrom1stday

onwards.

ValueAdded

Covers

This section

lists the

additional

value added

benetsthat

are available

along with

your plan

Health Check Up

Availableeachpolicyyear(includingtherstyear),toallAdultinsuredpersonswhohavecompleted18

years of Age.

• For Sum Insured Up to `5 lacs: Package 1 subject to a maximum of Up to `1000per

adult member

• For Sum Insured above `5 lacs and Up to `10lacs:Package2subjecttoamaximum

of Up to `2500peradultmember

• For Sum Insured above `10lacs:Package3subjecttomaximumofUpto`5000per

adult member

Annually from 1

year onwards

The packages shall be offered on cashless basis only. However, the eligible insured may avail any health

checkfromtheMCHINetworkofHealthCheckUpCenterUptothelimitspecied

Domestic Second

Opinion

Available for 36 listed Critical Illnesses

Tele-Consultation Unlimited Tele-consultation during the Policy Year

Cumulative Bonus

Aguaranteedbonusof25%ofSumInsuredforeverycompletedPolicyYear,subjecttoamaximum

accumulationupto200%oftheSumInsured.

SwitchOffBenet

The Policy can be Switched Off, after one year, any time during the Policy Year except for Personal Accident

Cover, Worldwide Emergency Hospitalization with Outpatient Cover under Freedom optional package and

Critical Illness Add-On cover, if opted, in case you/ Insured Person travel out of India, for a period maximum

upto30days.

Thisbenetshallnotbeavailableforthelast90daysofthePolicyYear.

Premium discount shall be calculated on pro-rated basis if Policy is switched off due to Insured Person (in

individualpolicy)orallInsuredPersons(underoaterpolicy)travellingoutofIndiaandthisdiscountshallbe

adjusted in the renewal premium falling due immediately after the expiring Policy Period.

The Policy will reactivate the cover Switch-On on the requested date of Switch On as intimated to Us by

You/ Insured Person.

TheoptiontoSwitchOffthecovershallbeavailableonlyonceinapolicyyearandUptoamaximumof30

days at a stretch. This shall not deactivate the following cover, if opted:

1. Worldwide Emergency Hospitalization with Outpatient Cover under Freedom

optional package

2. Personal Accident Cover

3. Critical Illness Add-on

ManipalCigna ProHealth Prime | Protect Plan and Advantage Plan | Terms & Conditions | UIN: MCIHLIP22224V012122 | April 2022

Optional

Packages

This section

lists the

available

optional

packages

under your

plan and the

limits under

each of these

options.

The limits

specied

under these

optional

packages

shall override

the applicable

limits

mentioned as

part of base

cover for the

respective

coverages.

Enhance Plus

1. Maternity & New Born Hospitalization Expenses

a. Maternity Cover (up to maximum 2 deliveries or terminations) -

 Coveredupto10%ofSumInsuredOptedsubjecttoa

maximum

of `1 Lac in addition to the Sum Insured opted

b. New Born Baby -

Coverage for the In-patient hospitalization expenses of a new

born up to the limit provided under Maternity Expenses

c. First Year Vaccination

Covered as per national immunization program, up to the limit

provided under Maternity Expenses

Not Available

2. Room Accommodation upgrade

The Insured Person shall be eligible to upgrade the

room type category eligibility under the Policy to “Any

Room Category” in a Hospital.

3. Health Maintenance Benefit

Up to `3000perPolicyYear.

Reimbursement of the Reasonable and Customary Charges

incurred

by the Insured Person for Medically Necessary charges incurred

during the Policy Year on an Out Patient basis for:

i. Consultation with Medical Practitioner, Diagnostic tests,

preventive tests, drugs, prosthetics, medical aids (spectacles

and contact lenses, hearing aids, crutches, wheel chair, walker,

walking stick, lumbo-sacral belt), prescribed by the specialist

Medical Practitioner.

ii. Towards Dental Treatments and AYUSH forms of Medicines

wherever prescribed by a Medical Practitioner.

Assure (Applicable for

Sum Insured `3 Lacs,

`4 Lacs and `5 Lacs)

i. Room Accommodation Limit

RoomRent-Upto1%ofSumInsuredperday.

ICU-Upto2%ofSumInsuredperday.

ii. Disease Specific Sub-limits

Sum Insured (In `) `3 and `4 Lacs `5 Lacs

Treatment for each Ailment/

Procedure mentioned below:

1. Surgery for treatment of all

types of Hernia

2. Hysterectomy

3. Surgeries for benign

Prostate Hypertrophy

4. Surgical treatment of stones

of renal system

`50,000 `65,000

Treatment of Cataract (Per

Eye)

`20,000 `30,000

Treatment of Total Knee

replacement (Per knee)

`80,000 `1,00,000

Treatment for breakage of

bones

`2,00,000 `2,50,000

iii. Modern and Advanced Treatments

CoveredUpto10%ofSumInsured

Wellness Program

RewardscanbeearnedbycompletingactivitiesspeciedunderOurHealthyLifeManagementProgramup

tomaximumof20%ofexpiringbasePremium(excludingPremiumforoptionalcovers,Riderandtaxes).

These earned Reward Points can be used against payable Renewal premium (excluding Premium for

optional covers, Rider and taxes) as discount from 1

Renewal of the Policy.

Carry forward of earned Reward Points shall not be allowed.

Discount from Network

Provider

Discount on Pharmacy, Diagnostics and Health Supplements, offered by the Network Providers of

ManipalCigna Health Insurance Company Limited

Premium Waiver

Benet

Waives off one year Policy Premium (including optional covers, rider and taxes) upon occurrence of any

of the listed contingencies (Accidental death/ listed Critical Illnesses) to the Policyholder who is also an

Insured Person in the Policy

ManipalCignaProHealthPrime|ProtectPlanandAdvantagePlan|Terms&Conditions|UIN:MCIHLIP22224V012122|April2022

Enhance Not Available

1. Maternity & New Born

Hospitalization Expenses

a. Maternity Cover (up to

maximum 2 deliveries or

terminations) -

Coveredupto10%of

Sum Insured Opted

subject to a maximum

of `1 Lac in addition to

the Sum Insured opted

b. New Born Baby -

Coverage for the In-

patient hospitalization

expenses of a new born

up to the limit provided

under Maternity

Expenses

c. First Year Vaccination

Covered as per national

immunization program,

up to the limit provided

under Maternity

Expenses

2. Room Accommodation

upgrade

The Insured Person

shall be eligible to

upgrade the room type

category eligibility under

the Policy to “Any Room

Category” in a Hospital.

Freedom (Applicable

to Indian Residents

only)

1. Room Accommodation upgrade

The Insured Person shall be eligible to upgrade the room type category eligibility under the Policy to “Any

Room Category” in a Hospital.

2. Worldwide Emergency Hospitalization with Outpatient Cover

Covered up to Sum Insured opted for Emergency In-patient Hospitalization or Emergency Outpatient

outside India.

AnyclaimpayableunderthisbenetisoverandabovetheSumInsured.

Optional

Covers

This section

lists the

available

optional

covers under

your plan

and the limits

under each of

these options

Non-Medical Items

Non-Medical items covered up to Sum Insured opted in case of In-patient Hospitalization and/or Day Care

Treatment

Deductible

Deductible of `10,000or`25,000canbeoptedattheinceptionor

during any Renewal of the Policy.

For Deductible of `10,000,thecovercanberemovedatthetimeof

Policy Renewal.

For Deductible of `25,000,theInsuredPersoncanremovethe

deductible of `25,000onlyatthetimeofrenewalfallingimmediately

due after 4 continuous Policy Years or any subsequent renewals

thereon, from the year of opting `25,000deductible

Thisbenetwillnotbeavailableif‘Assure’optionalpackageisopted

Not Available

Infertility Treatment

Infertility Cover (Available if D.III.1 ‘Enhance Plus’ or D.III.3 ‘Enhance’ optional package is opted and for

`7.5 Lacs and above Sum Insured options)

Covered for Infertility Expenses up to `2.5 Lacs in addition to Maternity Sum Insured under Maternity

Cover.

Waiting period of 36 months shall apply for this cover.

Maximum upto 2 successful procedures shall be covered during the lifetime of the eligible Insured Person

and the coverage shall terminate thereafter.

ThecovershallautomaticallyceaseupontheeligibleInsuredPersonattaining60yearsofage.

Personal Accident

Cover

LumpsumbenetequaltotwotimesofSumInsuredsubjecttoamaximumof`50Lacsincaseof

Accidental Death or Permanent Total Disablement of Insured Member due to accident.

Cumulative Bonus

booster

Aguaranteedbonusof50%increaseinSumInsuredperPolicyYearirrespectiveofclaims,subjecttoa

maximumaccumulationupto200%oftheSumInsured.

ThisbenetisapplicableforSumInsuredoptedfor`5 lacs and above.

OptingforthisBenetwillreplacetheCumulativeBonusintheBaseCover.

Addoncover

(Rider)

This section

lists the Add

on cover

available

under your

plan

ManipalCigna Critical

Illness Add On Cover

Lumpsumpaymentofanadditional100%ofSumInsuredOpted.

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F.IV.Annexure-lII

ListI-ItemsforwhichCoverageisnotavailableinthePolicy

Sl.

No.

Item

1. BABY FOOD

2. BABY UTILITIES CHARGES

3. BEAUTY SERVICES

4. BELTS / BRACES

5. BUDS

6. COLD PACK / HOT PACK

7. CARRY BAGS

8. EMAIL I INTERNET CHARGES

9. FOOD CHARGES (OTHER THAN PATIENT’s DIET PROVIDED

BY HOSPITAL)

10. LEGGINGS

11. LAUNDRY CHARGES

12. MINERAL WATER

13. SANITARY PAD

14. TELEPHONE CHARGES

15. GUEST SERVICES

16. CREPE BANDAGE

17. DIAPER OF ANY TYPE

18. EYELET COLLAR

19. SLINGS

20. BLOOD GROUPING AND CROSS MATCHING OF DONORS

SAMPLES

21. SERVICE CHARGES WHERE NURSING CHARGE ALSO

CHARGED

22. TELEVISION CHARGES

23. SURCHARGES

24. ATTENDANT CHARGES

25. EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH

FORMS PART OF BED CHARGE)

26. BIRTH CERTIFICATE

27. CERTIFICATE CHARGES

28. COURIER CHARGES

29. CONVEYANCE CHARGES

30. MEDICAL CERTIFICATE

31. MEDICAL RECORDS

32. PHOTOCOPIES CHARGES

33. MORTUARY CHARGES

34. WALKING AIDS CHARGES

35. OXYGEN CYLINDER (FOR USAGE OUTSIDE THE

HOSPITAL)

36. SPACER

37. SPIROMETRE

38. NEBULIZER KIT

39. STEAM INHALER

40. ARMSLING

41. THERMOMETER

42. CERVICAL COLLAR

43. SPLINT

44. DIABETIC FOOT WEAR

45. KNEE BRACES (LONG / SHORT / HINGED)

46. KNEE IMMOBILIZER / SHOULDER IMMOBILIZER

47. LUMBO SACRAL BELT

48. NIMBUS BED OR WATER OR AIR BED CHARGES

49. AMBULANCE COLLAR

50. AMBULANCE EQUIPMENT

51. ABDOMINAL BINDER

52. PRIVATE NURSES CHARGES - SPECIAL NURSING

CHARGES

53. SUGAR FREE Tablets

54. CREAMS POWDERS LOTIONS (Toiletries are not payable,

only prescribed medical pharmaceuticals payable)

55. ECG ELECTRODES

56. GLOVES

57. NEBULISATION KIT

58. ANYKITWITHNODETAILSMENTIONED[DELIVERYKIT,

ORTHOKIT,RECOVERYKIT,ETC]

59. KIDNEY TRAY

60. MASK

61. OUNCE GLASS

62. OXYGEN MASK

63. PELVIC TRACTION BELT

64. PAN CAN

65. TROLLY COVER

66. UROMETER, URINE JUG

67. AMBULANCE

68. VASOFIX SAFETY

ListII-ItemsthataretobesubsumedintoRoomCharges

SI.

No.

Item

1. BABY CHARGES (UNLESS SPECIFIED / INDICATED)

2. HAND WASH

3. SHOE COVER

4. CAPS

5. CRADLE CHARGES

6. COMB

7. EAU-DE-COLOGNE I ROOM FRESHNERS

8. FOOT COVER

9. GOWN

10. SLIPPERS

11. TISSUE PAPER

12. TOOTH PASTE

13. TOOTH BRUSH

14. BED PAN

15. FACE MASK

16. FLEXI MASK

17. HAND HOLDER

18. SPUTUM CUP

19. DISINFECTANT LOTIONS

20. LUXURY TAX

21. HVAC

22. HOUSE KEEPING CHARGES

23. AIR CONDITIONER CHARGES

24. IM IV INJECTION CHARGES

ManipalCignaProHealthPrime|ProtectPlanandAdvantagePlan|Terms&Conditions|UIN:MCIHLIP22224V012122|April2022

25. CLEAN SHEET

26. BLANKET / WARMER BLANKET

27. ADMISSION KIT

28. DIABETIC CHART CHARGES

29. DOCUMENTATION CHARGES I ADMINISTRATIVE

EXPENSES

30. DISCHARGE PROCEDURE CHARGES

31. DAILY CHART CHARGES

32. ENTRANCE PASS I VISITORS PASS CHARGES

33. EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE

34. FILE OPENING CHARGES

35. INCIDENTAL EXPENSES I MISC. CHARGES (NOT

EXPLAINED)

36. PATIENT IDENTIFICATION BAND I NAME TAG

37. PULSEOXYMETER CHARGES

ListIII-ItemsthataretobesubsumedintoProcedureCharges

1. HAIR REMOVAL CREAM

2. DISPOSABLES RAZORS CHARGES (for site preparations)

3. EYE PAD

4. EYE SHEILD

5. CAMERA COVER

6. DVD, CD CHARGES

7. GAUSE SOFT

8. GAUZE

9. WARD AND THEATRE BOOKING CHARGES

10. ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS

11. MICROSCOPE COVER

12. SURGICAL BLADES, HARMONICSCALPEL, SHAVER

13. SURGICAL DRILL

14. EYE KIT

15. EYE DRAPE

16. X-RAY FILM

17. BOYLES APPARATUS CHARGES

18. COTTON

19. COTTON BANDAGE

20. SURGICAL TAPE

21. APRON

22. TORNIQUET

23. ORTHOBUNDLE, GYNAEC BUNDLE

ListIV-Itemsthataretobesubsumedintocostsoftreatment

SI.

No.

Item

1. ADMISSION / REGISTRATION CHARGES

2. HOSPITALIZATION FOR EVALUATION / DIAGNOSTIC

PURPOSE

3. URINE CONTAINER

4. BLOOD RESERVATION CHARGES AND ANTE NATAL

BOOKING CHARGES

5. BIPAP MACHINE

6. CPAP / CAPO EQUIPMENTS

7. INFUSION PUMP - COST

8. HYDROGEN PEROXIDE \SPIRIT \ DISINFECTANTS ETC

9. NUTRITION PLANNING CHARGES - DIETICIAN

CHARGES - DIET CHARGES

10. HIV KIT

11. ANTISEPTIC MOUTHWASH

12. LOZENGES

13. MOUTH PAINT

14. VACCINATION CHARGES

15. ALCOHOL SWABES

16. SCRUB SOLUTIONISTERILLIUM

17. GLUCOMETER & STRIPS

18. URINE BAG

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A. Preamble

This is a legal contract between You and Us subject to the receipt of full

premium, Disclosure to Information Norm including the information

provided by You in the Proposal Form and the terms, conditions and

exclusions of this Policy.

If any Claim arising as a result of a Disease/Illness or Injury that

occurred during the Policy Period becomes payable, then We shall pay

 thebenetsinaccordancewithterms,conditionsandexclusionsofthe

Policy subject to availability of Sum Insured and Cumulative Bonus (if

any). All limits mentioned in the Policy Schedule are applicable for each

Policy Year of coverage.

B. Denitions

B.I. StandardDenitions

1. Accident means a sudden, unforeseen and involuntary event caused

by external, visible and violent means.

2. Any one Illness means continuous Period of illness and it includes

relapse within 45 days from the date of last consultation with the

Hospital/Nursing Home where the treatment was taken.

3. AYUSH Hospital is a healthcare facility wherein medical/ surgical/

para-surgical treatment procedures and interventions are carried out

by AYUSH Medical Practitioner (s) comprising any of the following:

a) Central or State Government AYUSH Hospital; or

b) Teaching hospitals attached to AYUSH College recognized by the

Central Government / Central Council of Indian Medicine / Central

Council for Homeopathy; or

c) AYUSH Hospital, standalone or co-located with in-patient

healthcare facility of any recognized system of medicine,

registered with the local authorities, wherever applicable, and is

  under the supervision of a qualied registered AYUSH Medical

Practitioner and must comply with all the following criterion:

  i) Havingatleastvein-patientbeds;

  ii) Having qualiedAYUSHMedicalPractitioner inchargeround

the clock;

iii) Having dedicated AYUSH therapy sections as required and/

or has equipped operation theatre where surgical procedures

are to be carried out;

iv) Maintaining daily record of the patients and making them

accessible to the insurance company’s authorized

representative.

4. Cashless Facility means a facility extended by the insurer to the

insured where the payments, of the costs of treatment undergone by

the insured in accordance with the Policy terms and conditions, are

directly made to the network provider by the insurer to the extent

pre-authorization approved.

5. Co-payment means a cost-sharing requirement under a health

insurance policy that provides that the policyholder/insured will bear a

 specied percentage of the admissible claim amount.A co-payment

does not reduce the Sum Insured.

6. ConditionPrecedent means a policy term or condition upon which the

Insurer’s Liability under the Policy is conditional upon.

7. CongenitalAnomaly refers to a condition(s) which is present since

birth, and which is abnormal with reference to form, structure or

position.

a. Internal Congenital Anomaly - which is not in the visible and

accessible parts of the body is called Internal Congenital Anomaly

b. ExternalCongenitalAnomaly - Congenital Anomaly which is in the

visible and accessible parts of the body.

8. CriticalIllness means the following:

 a) CancerofSpeciedSeverity

A malignant tumour characterised by the uncontrolled growth & spread

of malignant cells with invasion & destruction of normal tissues. This

diagnosis must be supported by histological evidence of malignancy.

The term cancer includes leukemia, lymphoma and sarcoma.

The following are excluded –

i. All tumors which are histologically described as carcinoma in situ,

benign, pre-malignant, borderline malignant, low malignant

potential, neoplasm of unknown behavior, or non-invasive,

including but not limited to: Carcinoma in situ of breasts, Cervical

dysplasia CIN-1, CIN -2 and CIN-3.

ii. Any non-melanoma skin carcinoma unless there is evidence of

metastases to lymph nodes or beyond;

iii. Malignant melanoma that has not caused invasion beyond the

epidermis;

 iv. Alltumorsoftheprostateunlesshistologicallyclassiedashaving

a Gleason score greater than 6 or having progressed to at least

  clinicalTNMclassicationT2N0M0.

 v. All Thyroid cancers histologically classied as T1N0M0 (TNM

  Classication)orbelow;

vi. Chronic lymphocytic leukaemia less than RAI stage 3

vii. Non-invasive papillary cancer of the bladder histologically

  describedasTaN0M0orofalesserclassication,

 viii.All Gastro-Intestinal Stromal Tumors histologically classied as

  T1N0M0 (TNM Classication) or below and with mitotic count of

  lessthanorequalto5/50HPFs;

ix. All tumors in the presence of HIV infection.

b) MyocardialInfarction(FirstHeartAttackofSpecicSeverity)

I The rst occurrence of heart attack or myocardial infarction, which

means the death of a portion of the heart muscle as a result of

inadequate blood supply to the relevant area. The diagnosis for this will

be evidenced by all of the following criteria:

i. a history of typical clinical symptoms consistent with the diagnosis

of Acute Myocardial Infarction (for e.g. typical chest pain)

ii. new characteristic electrocardiogram changes

 iii. elevationofinfarctionspecicenzymes,Troponinsorotherspecic

biochemical markers.

II The following are excluded:

i. Other acute Coronary Syndromes

ii. Any type of angina pectoris.

iii. A rise in cardiac biomarkers or Troponin T or I in absence of overt

ischemic heart disease OR following an intra-arterial cardiac

procedure.

c) OpenChestCABG

I The actual undergoing of heart surgery to correct blockage ornarrowing

in one or more coronary artery (s), by coronary artery bypass grafting

done via a sternotomy (cutting through the breast bone) or minimally

invasive keyhole coronary artery bypass procedures. The diagnosis

must be supported by a coronary angiography and the realisation of

 surgeryhastobeconrmedbyacardiologist.

II The following are excluded:

a. Angioplasty and/or any other intra-arterial procedures

d) OpenHeartReplacementorRepairofHeartValves

The actual undergoing of open-heart valve surgery is to replace or

repair one or more heart valves, as a consequence of defects in,

abnormalities of, or disease-affected cardiac valve (s). The diagnosis of

the valve abnormality must be supported by an echocardiography and

 therealizationofsurgeryhastobeconrmedbyaspecialistmedical

practitioner. Catheter based techniques including but not limited to,

balloon valvotomy/valvuloplasty are excluded.

e) ComaofSpeciedSeverity

1. A state of unconsciousness with no reaction or response to external

stimuli or internal needs.

PolicyContract

Plans:Active

MANIPALCIGNAPROHEALTHPRIME

ManipalCignaProHealthPrime|ActivePlan|Terms&Conditions|UIN:MCIHLIP22224V012122|April2022

This diagnosis must be supported by evidence of all of the following:

i. no response to external stimuli continuously for at least 96 hours;

ii. life support measures are necessary to sustain life; and

 iii. permanentneurologicaldecitwhichmustbeassessedatleast30

days after the onset of the coma.

2. Theconditionhastobeconrmedbyaspecialistmedicalpractitioner.

Coma resulting directly from alcohol or drug abuse is excluded.

f) KidneyFailureRequiringRegularDialysis

End stage renal disease presenting as chronic irreversible failure of

both kidneys to function, as a result of which either regular renal

dialysis (haemodialysis or peritoneal dialysis) is instituted or renal

 transplantation is carried out. Diagnosis has to be conrmed by a

specialist medical practitioner.

g) StrokeResultinginPermanentSymptoms

Any cerebrovascular incident producing permanent neurological

sequelae. This includes infarction of brain tissue, thrombosis in an

intracranial vessel, haemorrhage and embolization from an extra

 cranialsource.Diagnosishastobeconrmedbyaspecialistmedical

practitioner and evidenced by typical clinical symptoms as well as

 typicalndingsinCTScanorMRIofthebrain.Evidenceofpermanent

 neurologicaldecitlastingforatleast3monthshastobeproduced.

The following are excluded:

1. Transient ischemic attacks (TIA)

2. Traumatic injury of the brain

3. Vascular disease affecting only the eye or optic nerve or vestibular

functions.

h) MajorOrgan/BoneMarrowTransplant

The actual undergoing of a transplant of:

1. One of the following human organs: heart, lung, liver, kidney,

pancreas, that resulted from irreversible end-stage failure of the

relevant organ, or

2. Human bone marrow using haematopoietic stem cells. The

  undergoing of a transplant has to be conrmed by a specialist

medical practitioner.

The following are excluded:

i. Other stem-cell transplants

ii. Where only islets of langerhans are transplanted

i) PermanentParalysisofLimbs

Total and irreversible loss of use of two or more limbs as a result of

injury or disease of the brain or spinal cord. A specialist medical

practitioner must be of the opinion that the paralysis will be permanent

with no hope of recovery and must be present for more than 3 months.

j) MotorNeuronDiseasewithPermanentSymptoms

Motor neuron disease diagnosed by a specialist medical practitioner as

spinal muscular atrophy, progressive bulbar palsy, amyotrophic lateral

sclerosis or primary lateral sclerosis. There must be progressive

degeneration of corticospinal tracts and anterior horn cells or bulbar

 efferent neurons. There must be current signicant and permanent

functional neurological impairment with objective evidence of motor

dysfunction that has persisted for a continuous period of at least

3 months.

k) MultipleSclerosiswithPersistingSymptoms

I. TheunequivocaldiagnosisofDeniteMultipleSclerosisconrmedand

evidenced by all of the following:

 i. investigations including typical MRI ndings which unequivocally

  conrmthediagnosistobemultiplesclerosisand

ii. there must be current clinical impairment of motor or sensory

function, which must have persisted for a continuous period of

at least 6 months.

II. Other causes of neurological damage such as SLE and HIV are

excluded.

9. CumulativeBonus

Cumulative Bonus means any increase in the Sum Insured granted by

the insurer without an associated increase in premium.

10. DayCareCentre- A day care centre means any institution established

for day care treatment of illness and / or injuries or a medical set - up

within a hospital and which has been registered with the local

authorities, wherever applicable, and is under the supervision of a

 registeredandqualiedmedicalpractitionerANDmustcomplywithall

minimum criteria as under:-

 a. hasqualiednursingstaffunderitsemployment

 b. hasqualiedmedicalpractitioner(s)incharge

c. has a fully equipped operation theatre of its own where surgical

procedures are carried out

d. maintains daily records of patients and will make these accessible

to the Insurance company’s authorized personnel.

11. Day Care Treatment means medical treatment, and/or surgical

procedure which is:

i) Undertaken under General or Local Anesthesia in a hospital/day

care centre in less than 24 hrs because of technological

advancement, and

ii) Which would have otherwise required a Hospitalization of more

than 24 hours.

Treatment normally taken on an out-patient basis is not included in

  thescopeofthisdenition.

12. Deductible means a cost-sharing requirement under a health

insurance policy that provides that the Insurer will not be liable for a

 speciedrupeeamountincaseofindemnitypoliciesandforaspecied

number of days/hours in case of hospital cash policies, which will apply

 beforeanybenetsarepayablebytheinsurer.Adeductibledoesnot

reduce the sum insured.

13. Dental Treatment Dental treatment means a treatment related to

 teeth or structures supporting teeth including examinations, llings

(where appropriate), crowns, extractions and surgery.

14. DisclosuretoInformationNorm means the Policy shall be void and

all premium paid hereon shall be forfeited to the Company, in the event

of misrepresentation, mis-description or non-disclosure of any material

fact.

15. DomiciliaryHospitalization means medical treatment for an illness/

disease/injury which in the normal course would require care and

 treatment at a hospital but is actually taken while conned at home

under any of the following circumstances:

a) the condition of the patient is such that he/she is not in a condition

to be removed to a hospital, or

b) the patient takes treatment at home on account of non - availability

of room in a hospital.

16. Emergency Care means management for a severe illness or injury

which results in symptoms which occur suddenly and unexpectedly,

and requires immediate care by a medical practitioner to prevent death

or serious long term impairment of the insured person’s health.

17. GracePeriodmeansthespeciedperiodoftimeimmediatelyfollowing

the premium due date during which a payment can be made to renew or

 continueapolicyinforcewithoutlossofcontinuitybenets such as

waiting periods and coverage of pre- existing diseases. Coverage is not

available for the period for which no premium is received.

18. Hospital means any institution established for in - patient care and day

care treatment of illness and/or injuries and which has been registered

as a hospital with the local authorities, under the Clinical

 Establishments(RegistrationandRegulation)Act,2010orunderthe

 enactmentsspeciedundertheScheduleofSection56(1)ofthesaid

Act OR complies with all minimum criteria as under:

 - hasqualiednursingstaffunderitsemploymentroundtheclock;

 - hasatleast10In-patientbeds,intownshavingapopulationofless

  than10,00,000andatleast15In-patientbedsinallotherplaces;

 - hasqualiedmedicalpractitioner(s)inchargeroundtheclock;

- has a fully equipped operation theatre of its own where surgical

procedures are carried out

- maintains daily records of patients and makes these accessible to

the Insurance company’s authorized personnel.

ManipalCignaProHealthPrime|ActivePlan|Terms&Conditions|UIN:MCIHLIP22224V012122|April2022

19.HospitalizationorHospitalized means admission in a hospital for a

minimum period of 24 consecutive in patient care hours except for

 speciedprocedures/treatments,where such admissioncouldbefor

a period of less than 24 consecutive hours.

20.Illness means a sickness or disease or pathological condition leading

to the impairment of normal physiological function and requires medical

treatment.

a) Acute condition Acute condition is a disease, illness or injury

that is likely to respond quickly to treatment which aims to return

the person to his or her state of health immediately before suffering

the disease/illness/injury which leads to full recovery

b) Chroniccondition-Achronicconditionisdenedasadisease,

illness, or injury that has one or more of the following characteristics:

1. it needs ongoing or long-term monitoring through consultations,

examinations, check-ups, and /or tests

2. it needs ongoing or long-term control or relief of symptoms

3. it requires rehabilitation for the patient or for the patient to be

specially trained to cope with it

  4. itcontinuesindenitely

5. it recurs or is likely to recur

21. Injury means accidental physical bodily harm excluding illness or

disease solely and directly caused by external, violent and visible and

 evidentmeanswhichisveriedandcertiedbyaMedicalPractitioner.

22. In-patientCare means treatment for which the Insured Person has to

stay in a hospital for more than 24 hours for a covered event.

23. Intensive Care Unit means an identiedsection,wardorwingofa

Hospital which is under the constant supervision of a dedicated medical

practitioner (s), and which is specially equipped for the continuous

monitoring and treatment of patients who are in a critical condition, or

require life support facilities and where the level of care and supervision

is considerably more sophisticated and intensive than in the ordinary

and other wards.

24. Medical Advice means any consultation or advise from a Medical

Practitioner including the issue of any prescription or follow-up

prescription.

25. Medical Expenses means those expenses that an Insured Person

has necessarily and actually incurred for medical treatment on account

of Illness or Accident on the advise of a Medical Practitioner, as long as

these are no more than would have been payable if the Insured Person

had not been insured and no more than other hospitals or doctors in the

same locality would have charged for the same medical treatment.

26.  Medically Necessary Treatment or Medically Necessary means

any treatment, tests, medication, or stay in Hospital or part of a stay in

Hospital which

• Is required for the medical management of the Illness or injury

suffered by the Insured;

• Must not exceed the level of care necessary to provide safe,

adequate and appropriate medical care in scope, duration or

intensity.

• Must have been prescribed by a Medical Practitioner.

• Must conform to the professional standards widely accepted in

international medical practice or by the medical community in India.

27. MedicalPractitionerA Medical practitioner means a person who holds

a valid registration from the medical council of any state or Medical

Council of India or Council for Indian Medicine or for Homeopathy set

up by Government of India or a State Government and is and is thereby

entitled to practice medicine within its jurisdiction; and is acting within

the scope and jurisdiction of license.

28. NetworkProvider means hospitals or health care provider enlisted by

an insurer, TPA or jointly by an insurer and TPA to provide medical

services to an insured by a cashless facility.

29. Non-NetworkProvider Any hospital, day care centre or other provider

that is not part of the network.

30. Notication of Claim Notication of claim means the process of

intimating a claim to the insurer or TPA through any of the recognized

modes of communication.

31. Migration means, the right accorded to health insurance policyholders

(including all members under family cover and members of group

Health insurance policy), to transfer the credit gained for pre-existing

conditions and time bound exclusions, with the same insurer.

32. OPDTreatment- OPD treatment is one in which the Insured visits a

clinic / hospital or associated facility like a consultation room for

diagnosis and treatment based on the advice of a Medical Practitioner.

The Insured is not admitted as a day care or In-Patient.

33. Pre-existingDisease means any condition, ailment, injury or disease

a. That is/are diagnosed by a physician within 48 months prior to the

effective date of the policy issued by the insurer or its reinstatement

b. For which medical advice or treatment was recommended by, or

received from, a physician within 48 months prior to the effective

date of the policy issued by the insurer or its reinstatement.

34. Pre-hospitalizationMedicalExpenses

Pre-hospitalization Medical Expenses means medical expenses

 incurredduringpredenednumberofdaysprecedingtheHospitalization

of the Insured Person, provided that:

- Such Medical Expenses are incurred for the same condition for

which the Insured Person’s Hospitalization was required, and

- The In-patient Hospitalization claim for such Hospitalization is

admissible by the Insurance Company.

35. Post-hospitalizationMedicalExpenses

Post-hospitalization Medical Expenses means medical expenses

 incurred during predened number of days immediately after the

insured person is discharged from the hospital provided that:

i. Such Medical Expenses are for the same condition for which the

insured person’s Hospitalization was required, and

ii. The inpatient Hospitalization claim for such Hospitalization is

admissible by the insurance company.

36. Portability means the right accorded to an individual health insurance

policyholder (including all members under family cover), to transfer the

credit gained for pre-existing conditions and time bound exclusions,

from one insurer to another insurer.

37. QualiedNurse means a person who holds a valid registration from

the Nursing Council of India or the Nursing Council of any state in

India.

38. Reasonable and Customary Charges means the charges for

 servicesor supplies,which arethe standardcharges forthespecic

provider and consistent with the prevailing charges in the geographical

area for identical or similar services, taking into account the nature of

the illness / injury involved.

39. Renewal means the terms on which the contract of insurance can be

renewed on mutual consent with a provision of grace period for treating

the renewal continuous for the purpose of gaining credit for pre-existing

diseases, time-bound exclusions and for all waiting periods.

40. Room Rent Room Rent means the amount charged by a Hospital

towards Room and Boarding expenses and shall include the associated

medical expenses.

41. Surgery or Surgical Procedure means manual and / or operative

procedure (s) required for treatment of an illness or injury, correction of

deformities and defects, diagnosis and cure of diseases, relief from

suffering and prolongation of life, performed in a hospital or day care

centre by a medical practitioner

42. Unproven/Experimentaltreatmentmeans the treatment including

drug experimental therapy which is not based on established medical

practice in India, is treatment experimental or unproven.

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B.II.SpecicDenitions

1. Age or Aged is the age at last birthday, and which means completed

years as at the date of Inception of the Policy.

2. Ambulance means a road vehicle operated by a licenced authorised

service provider and equipped for the transport and paramedical

treatment of the person requiring medical attention.

3. Annexure means a document attached and marked as Annexure to

this Policy

4. Associated Medical Expenses. shall include Room Rent, nursing

charges, operation theatre charges, fees of Medical Practitioner/

surgeon/ anesthetist/ Specialist, excluding cost of pharmacy and

consumables, cost of implants and medical devices, cost of diagnostics

conducted within the same Hospital where the Insured Person has

been admitted. It shall not be applicable for Hospitalization in ICU.

Associated Medical Expenses shall be applicable for covered

expenses, incurred in Hospitals which follow differential billing based on

the room category.

5. AYUSH treatment refers to the medical and /or hospitalization

treatments given under Ayurveda, Yoga and Naturopathy, Unani,

Siddha and Homeopathy Systems.

6. InceptionDatemeanstheInceptiondateofthisPolicyasspeciedin

the Schedule

7. CosmeticSurgerymeansSurgeryorMedicalTreatmentthatmodies,

improves, restores or maintains normal appearance of a physical

feature, irregularity, or defect.

8. CoveredRelationshipsshallinclude spouse, children, brother and

sister of the Policyholder who are children of same parents, father,

mother, grandparents, grandchildren, parent in laws, son in law,

daughter in law, Uncle, Aunt, Niece and Nephew.

9. DependentChild A dependent child refers to a child (natural or legally

 adopted),whoisnanciallydependentonthePolicyHolder,doesnot

have his / her independent source of income, is up to the age of 17

years.

10. Emergency shall mean a serious medical condition or symptom

resulting from injury or sickness which arises suddenly and

unexpectedly, and requires immediate care and treatment by a medical

practitioner, generally received within 24 hours of onset to avoid

jeopardy to life or serious long term impairment of the insured person’s

health, until stabilisation at which time this medical condition or

symptom is not considered an emergency anymore.

11. Indian Resident - An individual will be considered to be resident of

India, if he is in India for a period or periods amounting in all to one

hundred and eighty-two days or more, in the immediate preceding 365

days.

12. In-patient means an Insured Person who is admitted to hospital and

stays for at least 24 consecutive hours for the sole purpose of receiving

treatment.

13. InsuredPerson means the person (s) named in the Schedule to this

Policy, who is / are covered under this Policy, for whom the insurance is

proposed and the appropriate premium paid.

14. Policy means this Terms & Conditions document, the Proposal Form,

 PolicySchedule,Add-OnBenetDetails(ifapplicable)andAnnexures

which form part of the Policy contract including endorsements, as

amended from time to time which form part of the Policy Contract and

shall be read together.

15. PolicyPeriod means the period between the inception date and the

 expirydateofthepolicyasspeciedintheScheduletothisPolicyor

the date of cancellation of this policy, whichever is earlier.

16. PolicyYear means a period of 12 consecutive months within the Policy

Period commencing from the Policy Anniversary Date / Commencement

Date.

17. PolicySchedule means Schedule attached to and forming part of this

Policy mentioning the details of the Policy Holder, Insured Persons, the

 Sum Insured, the period and the limits to which benets under

the Policy are subject to, Premium Paid (including taxes), including any

annexures and/or endorsements, made to or on it from time to time,

and if more than one, then the latest in time.

18. RestoredSumInsured means the amount restored in accordance with

Section D.I.8 of this Policy

19. SinglePrivateA/CRoom means a single Hospital room with any rating

and of most economical category available at the time of hospitalization

with air-conditioning facility where a single patient is accommodated

and which has an attached toilet (lavatory and bath). The room should

have the provision for accommodating an attendant. This excludes a

suite or higher category.

20. Sum Insured means, subject to terms, conditions and exclusions of

this Policy, the amount representing Our maximum liability for any or

 all claims during the Policy Period specied in the Schedule to this

Policy separately in respect of that Insured Person.

i. In case where the Policy Period for 2/3 years, the Sum Insured

  speciedon thePolicyisthelimitforthe rstPolicyYear.These

  limitswilllapseattheendoftherstyearandthefreshlimitsupto

the full Sum Insured as opted will be available for the second/third

year.

ii. In the event of a claim being admitted under this Policy, the Sum

Insured for the remaining Policy Period shall stand correspondingly

reduced by the amount of claim paid (including ’taxes’) or admitted

and shall be reckoned accordingly.

21. TPA Third Party Administrator (TPA) means a company registered

with the Authority, and engaged by Us, for a fee or, by whatever name

called and as may be mentioned in the health services agreement, for

providing health services as mentioned under TPA Regulations.

22. We/Our/Us/Insurer means ManipalCigna Health Insurance Company

Limited

23. You/Your/PolicyHolder means the person named in the Schedule as

the policyholder and who has concluded this Policy with Us.

C. Benetscoveredunderthepolicy

C.I. Basiccovers

C.I.1.InpatientHospitalization

We will cover Medical Expenses of an Insured Person in case of

Medically Necessary Hospitalization arising from a Disease/ Illness or

Injury provided such Medically Necessary Hospitalization is for more

than 24 consecutive hours provided that the admission date of the

Hospitalization due to Disease/ Illness or Injury is within the Policy

Year. We will pay Medical Expenses as mentioned in the Policy

Schedule for:

a. Reasonable and Customary Charges for Room Rent for

accommodation in Hospital room up to Category as per opted Sum

  InsuredandasspeciedinthePolicySchedule.

b. Intensive Care Unit charges for accommodation in ICU,

c. Operation theatre charges,

d. Fees of Medical Practitioner/ Surgeon,

e. Anaesthetist,

 f. QualiedNurses,

g. Specialists,

h. Cost of diagnostic tests,

i. Medicines,

j. Drugs and consumables, blood, oxygen, surgical appliances and

prosthetic devices recommended by the attending Medical

Practitioner and that are used intra operatively during a Surgical

Procedure.

Room category coverage for Sum Insured under each plan will be up

 tothelimitaspertheSumInsuredoptedandasspeciedinthePolicy

Schedule. For ICU accommodation, we will cover up to Sum Insured

ManipalCignaProHealthPrime|ActivePlan|Terms&Conditions|UIN:MCIHLIP22224V012122|April2022

 optedandasspeciedinthePolicySchedule.

If the Insured Person is admitted in a room category that is higher than

 theonethatisspeciedinthePolicySchedule,thenthePolicyholder/

Insured Person shall bear a ratable proportion of the total Associated

Medical Expenses (including surcharge or taxes thereon) in the

proportion of the difference between the room rent of the entitled room

category to the room rent actually incurred.

Under In-patient Hospitalization expenses, when availed under

 In-patient care, we will cover the expenses towards articial life

maintenance, including life support machine use, even 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

 certiedbythetreatingMedicalPractitioner.

We will indemnify the Medical Expenses incurred by an Insured Person

in respect of the below listed ailments / procedures (refer the table

 below) up to the limits specied against each and every ailment /

procedure for the applicable Sum Insured options:

Sum Insured (in `) `3 Lacs `5 Lacs `7.5 and

`10Lacs

>`10

Lacs

Treatment for each

ailment / procedure

mentioned below:

1. Surgery for

treatment of all

types of Hernia

2. Hysterectomy

3. Surgeries for

benign Prostate

Hyper trophy

4. Surgical treatment

of stones of renal

system

`50,000 `65,000 `80,000

Treatment of

Cataract (Per Eye)

`20,000 `30,000 `30,000

Treatment of Total

Knee replacement

(Per knee)

`80,000 `1,00,000 `1,20,000

Treatment for

breakage of bones

`2,00,000 `2,50,000 `3,00,000

Wherever the above mentioned Sub-limits are applied, the Mandatory

Co-payment under section F.II.6 shall not be applicable. The following

procedures will be covered (wherever medically indicated) either as

 In-patientoraspartofDayCareTreatmentinahospitalupto50%of

 theSumInsuredasspeciedinthePolicySchedule,duringthePolicy

Year:

a. Uterine Artery Embolization and HIFU (High intensity focused

ultrasound)

b. Balloon Sinuplasty

c. Deep Brain stimulation

d. Oral chemotherapy

e. Immunotherapy - Monoclonal Antibody to be given as injection

f. Intra vitreal injections

g. Robotic surgeries

h. Stereotactic radio surgeries

i. Bronchial Thermoplasty

j. Vaporization of the prostrate (Green laser treatment or holmium

laser treatment)

k. IONM - (Intra Operative Neuro Monitoring)

l. Stem cell therapy: Hematopoietic stem cells for bone marrow

transplant for hematological conditions to be covered.

Medical Expenses incurred towards Medically Necessary Treatment of

the Insured Person for In-patient Hospitalization due to a condition

 caused by or associated with Human Immunodeciency Virus (HIV)

 or HIV related Illnesses, including Acquired Immune Deciency

Syndrome (AIDS) or AIDS Related Complex (ARC) and/or any mutant

derivative or variations thereof, sexually transmitted diseases (STD), in

respect of an Insured Person, will be covered up to the Sum Insured as

 speciedinthePolicyScheduleduringthePolicyYear.Thenecessity

 of the Hospitalization is to be certied by an authorized Medical

Practitioner.

Medical Expenses incurred towards Medically Necessary treatment

taken during In-patient Hospitalization of the Insured Person, arising

out of a condition caused by or associated to a Mental illness, or a

 medicalconditionimpactingmentalhealthwillbecoveredupto50%

 oftheSumInsuredasspeciedinthePolicyScheduleduringthePolicy

Year. For the below mentioned ICD Codes, the Insured Person should have

been continuously covered under this Policy for at least 24 months before

availingthisbenet.

ICD 10

CODES

DISEASES

F05 Delirium due to known physiological condition

F06 Other mental disorders due to known physiological condition

F07

Personality and behavioural disorders due to known

physiological condition

F10 Mental and behavioural disorders due to use of alcohol

F20 Schizophrenia

F23 Brief psychotic disorders

F25 Schizoaffective disorders

F29

Unspeciedpsychosisnotduetoasubstanceorknown

physiological condition

F31 Bipolar disorder

F32 Depressive episode

F39 Unspeciedmood[affective]disorder

F40 Phobic Anxiety disorders

F41 Other Anxiety disorders

F42 Obsessive-compulsive disorder

F44 Dissociative and conversion disorders

F45 Somatoform disorders

F48 Other nonpsychotic mental disorders

F60 Specicpersonalitydisorders

F84 Pervasive developmental disorders

F90 Attention-decithyperactivitydisorders

F99 Mentaldisorder,nototherwisespecied

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.4 and G.I.5.

C.I.2 Pre-hospitalization

We will, on a reimbursement basis cover Medical Expenses of an

Insured Person which are incurred due to a Disease/ Illness or Injury

that occurs during the Policy Year immediately prior to the Insured

 Person’s date of Hospitalization up to the limits as specied in the

Policy Schedule, provided that a Claim has been admitted under

 In-patientbenetunderSectionD.I.1andisrelatedtothesameillness/

condition.

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.5 & G.I.9.

C.I.3 Post-hospitalization

We will, on a reimbursement basis cover Medical Expenses of an

Insured Person which are incurred due to a Disease/ Illness or Injury

that occurs during the Policy Year immediately post discharge of the

 InsuredPersonfromthe Hospital uptothelimits as speciedinthe

Policy Schedule, provided that a Claim has been admitted under

 In-patientbenetunderSectionD.I.1andisrelatedtothesameillness/

condition.

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.5 & G.I.9.

C.I.4 DayCareTreatment

We will cover payment of Medical Expenses of an Insured Person in

case of Medically Necessary Day Care Treatment or Surgery that

requires less than 24 hours of Hospitalization due to advancement in

technology and which is undertaken in a Hospital / nursing home/ Day

Care Centre on the recommendation of a Medical Practitioner, up to

 theSumInsuredasspeciedinthePolicySchedule,providedthat:

ManipalCignaProHealthPrime|ActivePlan|Terms&Conditions|UIN:MCIHLIP22224V012122|April2022

a. The Day Care Treatment is Medically Necessary and follows the

written advice of a Medical Practitioner.

b. The Medical Expenses incurred are Reasonable and Customary

Charges for any procedure where such procedure is undertaken by

an Insured Person as Day Care Treatment.

c. We will not cover any OPD Treatment and Diagnostic Services

  underthisbenet.

Coverage will also include pre-post hospitalization expenses as per the

 limitsapplicableandspeciedunderthePlanopted.

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.4 & G.I.5.

C.I.5 DomiciliaryHospitalization

We will cover Medical Expenses of an Insured Person up to the limits

 speciedinthePolicySchedule,whicharetowardsaDisease/Illness

or Injury which in the normal course would otherwise have been covered

for Hospitalization under the policy but is taken at home on the advice

of the attending Medical Practitioner, under the following circumstances:

i. The condition of the Insured Person does not allow a Hospital

transfer; or

ii. A Hospital bed was unavailable;

Provided that, the treatment of the Insured Person continues for at

least 3 days, in which case the reasonable cost of any Medically

Necessary treatment for the entire period shall be payable.

a) We will pay for Pre-hospitalization, Post-hospitalization Medical

  Expensesupto30dayseach.

 b) RestorationofSumInsuredshallnotbeavailableunderthisbenet

c) We shall not be liable under this Policy for any Claim in connection

with or in respect of the following:

i. Asthma, COPD, bronchitis, tonsillitis and upper & lower

respiratory tract infection including laryngitis and pharyngitis,

   coughandcold,inuenza,

ii. Arthritis, gout and rheumatism including the rheumatism of

bones, joints and also rheumatic heart disease,

iii. Chronic nephritis and nephritic syndrome,

iv. All types of Diarrhea and dysenteries, including gastroenteritis,

v. Diabetes mellitus and Diabetes Insipidus,

vi. Epilepsy / Seizure disorder,

vii. Hypertension,

viii. Pyrexia of unknown origin.

  All Claims under this benet can be made as per the process

  denedunderSectionG.I.5.

C.I.6. RoadAmbulance

We will provide for reimbursement of Reasonable and Customary

 expensesuptotheSumInsuredasspeciedinthePolicySchedule

that are incurred towards road transportation of an Insured Person by a

registered Healthcare or Ambulance Service Provider to a nearest

Hospital for treatment of an Illness or Injury covered under the Policy

in case of an Emergency, necessitating the Insured Person’s admission

to the Hospital, provided that a Claim has been admitted under In-

 patientbenetunderSectionD.I.1andisrelatedtothesameillness/

condition.

 ThenecessityofuseofanAmbulancemustbecertiedbythetreating

Medical Practitioner.

a. Reasonable and Customary expenses shall include:

(i) Costs towards transferring the Insured Person from one

Hospital to another Hospital or diagnostic centre for advanced

diagnostic treatment where such facility is not available at the

existing Hospital; or

(ii) When the Insured Person requires to be moved to a better

Hospital facility due to lack of super speciality treatment in the

existing Hospital.

  AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.5.

C.I.7.DonorExpenses

We will cover In-patient Hospitalization Medical Expenses towards the

 donorforharvestingtheorganuptotheSumInsuredasspeciedin

the Policy Schedule, subject to the below mentioned conditions:

a. The organ donor is any person in accordance with the Transplantation

of Human Organs Act 1994 (amended) and other applicable laws and

rules, provided that -

i. The organ donated is for the use of the Insured Person who has

been asked to undergo an organ transplant on Medical Advice.

b. We have admitted a claim under Section D.I.1 - towards In-patient

Hospitalization

c. We will not cover expenses towards the Donor in respect of:

i. Any Pre or Post-hospitalization Medical Expenses,

ii. Cost towards donor screening,

iii. Cost associated to the acquisition of the organ,

iv. Any other medical treatment or complication in respect of the

donor, consequent to harvesting.

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.4 & G.I.5.

C.I.8 RestorationofSumInsured:

 We will provide for a 100% restoration of the Sum Insured for any

number of times in a Policy Year, provided that:

a. The Sum Insured inclusive of earned Cumulative Bonus (if any) is

  insufcientasaresultofpreviousclaimsinthatPolicyYear.

b. The Restored Sum Insured shall not be available for claims towards

an Illness/ disease/ Injury (including its complications) for which a

claim has been paid in the current Policy Year for the same Insured

Person.

c. The Restored Sum Insured will be available only for claims made

by Insured Persons in respect of future claims that become

  payableunderSectionDofthePolicyandshallnotapplytotherst

claim in the Policy Year. Restoration of the Sum Insured will only

be provided for coverage under Section D.I.1 ‘In-patient

Hospitalization’, Section D.I.2 ‘Pre-Hospitalization’, Section D.I.3

‘Post-Hospitalization’, Section D.I.4 ‘Day Care Treatment’, Section

D.I.6 ‘Road Ambulance’, Section D.I.7 ‘Donor Expenses’, Section

D.I.9 ‘AYUSH Treatment (In-patient Hospitalization)’ Section D.III.1

‘Non-Medical Items’.

d. The Restored Sum Insured will not be considered while calculating

the Cumulative Bonus.

e. Such restoration of Sum Insured will be available for any number of

times, during a Policy Year to each insured in case of an Individual

Policy and can be utilized by Insured Persons who stand covered

under the Policy before the Sum Insured was exhausted.

f. If the Restored Sum Insured is not utilized in a Policy Year, it shall

not be carried forward to subsequent Policy Year.

g. For any single claim during a Policy Year the maximum claim

amount payable shall be sum of:

i. The Sum Insured

ii. Cumulative Bonus (if earned)

iii. Restored Sum Insured

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.4 & G.I.5.

C.I.9AYUSHTreatment(In-patientHospitalization)

We will pay the Medical Expenses incurred during the Policy Year, up

 totheSumInsured,asspeciedinthePolicySchedule,foranInsured

Person in case of Medically Necessary Treatment taken during In-

patient Hospitalization for AYUSH Treatment for an Illness or Injury that

occurs during the Policy Year, provided that:

The Insured Person has undergone treatment in an AYUSH Hospital

where AYUSH Hospital is a healthcare facility wherein medical/

surgical/ para-surgical treatment procedures and interventions are

carried out by AYUSH Medical Practitioner (s) comprising any of the

following:

i) Central or State Government AYUSH Hospital; or

ii) Teaching hospitals attached to AYUSH College recognized by

Central Government / Central Council of Indian Medicine and

Central Council of Homeopathy; or

iii) AYUSH Hospital, standalone or co-located with in-patient

healthcare facility of any recognized system of medicine, registered

with the local authorities, wherever applicable, and is under the

  supervision of a qualied registeredAYUSH Medical Practitioner

and must comply with all the following criterion:

  a) Havingatleastvein-patientbeds;

ManipalCignaProHealthPrime|ActivePlan|Terms&Conditions|UIN:MCIHLIP22224V012122|April2022

  b) Having qualiedAYUSHMedicalPractitioner inchargeround

the clock;

c) Having dedicated AYUSH therapy sections as required and/or

has equipped operation theatre where surgical procedures are

to be carried out;

d) Maintaining daily record of the patients and making them

accessible to the insurance company’s authorized

representative.

The following exclusions will be applicable in addition to the other

Policy exclusions:

Facilities and services availed for pleasure or rejuvenation or as a

  preventiveaid,likebeautytreatments,Panchakarma,purication,

  detoxicationandrejuvenation.

  AllclaimsunderthisBenetcanbemadeaspertheprocessdened

under Section G.I.4 & G.I.5.

C.I.10 ConvalescenceBenet:

We will pay, a lump sum amount as per the Sum Insured opted and as

 specied in the Policy Schedule against this benet, if the Insured

 PersonhasbeenHospitalizedforatleast10consecutivedaysforAny

one illness or Accident, provided that:

i. The Hospitalization is only for In-patient care for the Insured

Person; and

  ii. The benets payable under this cover are for each

Hospitalization

  iii. Benets payable under this cover are over and above Sum

Insured.

iv. We have accepted claim under Section D.I.1 In-patient

Hospitalization during the Policy Year

  All claims under this benet can be made as per the process

  denedunderSectionG.I.5.

C.I.11 DailyCashforSharedAccommodation

 WewillpayadailycashamountasspeciedinthePolicyScheulefor

the Insured Person for each continuous and completed period of 24

hours of Hospitalization provided that,

a. We have accepted claim under Section D.I.1 In-patient

Hospitalization during the Policy Year

b. The Insured Person has occupied a shared room accommodation

during such Hospitalization

c. The Insured Person has been admitted in a Hospital for a minimum

period of 48 hours continuously.

d. Sum Insured opted under the Policy and mentioned in Policy

Schedule is Rs. 5 Lacs and above.

What is not covered:

 This benet will not be payable if the Insured Person stays in an

Intensive Care Unit or High Dependency Units / wards.

 AllClaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.5

C.II.Valueaddedcovers

C.II.1 DomesticSecondOpinion:

You may choose to secure a second opinion from Our Network of

Medical Practitioners in India, if an Insured Person is diagnosed with the

covered Critical Illness during the Policy Year. The expert opinion would

be directly sent to the Insured Person.

You understand and agree that You can exercise the option to secure

an expert opinion, provided:

(a) We have received a request from You to exercise this option.

(b) That the expert opinion will be based only on the information and

documentation provided by You that will be shared with the Medical

Practitioner

 (c)This benet can be availed by each Insured Person only once

during a Policy Year for one Critical Illness and multiple times for

different Critical Illness/es with the same limitation of one opinion

per critical illness

 (d)ThisbenetisonlyavalueaddedserviceprovidedbyUsanddoes

not deem to substitute the Insured Person’s visit or consultation to

an independent Medical Practitioner.

(e) The Insured Person is free to choose whether or not to obtain the

expert opinion, and if obtained then whether or not to act on it.

(f) We shall not, in any event be responsible for any actual or alleged

errors or representations made by any Medical Practitioner or in

any expert opinion or for any consequence of actions taken or not

taken in reliance thereon.

(g) The expert opinion under this Policy shall be limited to covered

Critical Illnesses and not be valid for any medico legal purposes.

(h) We do not assume any liability towards any loss or damage arising

out of or in relation to any opinion, advice, prescription, actual or

alleged errors, omissions and representations made by the Medical

Practitioner.

 (i) AnyclaimunderthisbenetwillnotimpacttheSumInsuredand/

or Cumulative Bonus.

  For the purpose of this benet, covered Critical Illnesses shall

include as below:

1. CancerofSpeciedSeverity

A malignant tumour characterised by the uncontrolled growth & spread

of malignant cells with invasion & destruction of normal tissues. This

diagnosis must be supported by histological evidence of malignancy.

The term cancer includes leukemia, lymphoma and sarcoma.

The following are excluded -

i. All tumors which are histologically described as carcinoma in situ,

benign, pre-malignant, borderline malignant, low malignant

potential, neoplasm of unknown behavior, or non-invasive,

including but not limited to: Carcinoma in situ of breasts, Cervical

dysplasia CIN-1, CIN -2 and CIN-3.

ii. Any non - melanoma skin carcinoma unless there is evidence of

metastases to lymph nodes or beyond;

iii. Malignant melanoma that has not caused invasion beyond the

epidermis;

 iv. Alltumorsoftheprostateunlesshistologicallyclassiedashaving

a Gleason score greater than 6 or having progressed to at least

  clinicalTNMclassicationT2N0M0

 v. All Thyroid cancers histologically classied as T1N0M0 (TNM

  Classication)orbelow;

vi. Chronic lymphocytic leukaemia less than RAI stage 3

vii. Non - invasive papillary cancer of the bladder histologically

  describedasTaN0M0orofalesserclassication,

 viii.All Gastro-Intestinal Stromal Tumors histologically classied as

  T1N0M0 (TNM Classication) or below and with mitotic count of

  lessthanorequalto5/50HPFs;

ix. All tumors in the presence of HIV infection.

2. MyocardialInfarction(FirstHeartAttackofSpeciedSeverity)

I The rst occurrence of heart attack or myocardial infarction, which

means the death of a portion of the heart muscle as a result of

inadequate blood supply to the relevant area. The diagnosis for this

will be evidenced by all of the following criteria:

i. a history of typical clinical symptoms consistent with the diagnosis

of Acute Myocardial Infarction (for e.g. typical chest pain)

ii. new characteristic electrocardiogram changes

 iii. elevation of infarction specic enzymes, Troponins or other

  specicbiochemicalmarkers.

II The following are excluded:

1. Other acute Coronary Syndromes

2. Any type of angina pectoris.

3. A rise in cardiac biomarkers or Troponin T or I in absence of

overt ischemic heart disease OR following an intra - arterial cardiac

procedure.

3. OpenChestCABG

I The actual undergoing of heart surgery to correct blockage or

narrowing in one or more coronary artery (s), by coronary artery bypass

grafting done via a sternotomy (cutting through the breast bone) or

minimally invasive keyhole coronary artery bypass procedures. The

diagnosis must be supported by a coronary angiography and the

 realisationofsurgeryhastobeconrmedbyacardiologist.

II The following are excluded:

a. Angioplasty and/or any other intra-arterial procedures

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4. OpenHeartReplacementorRepairofHeartValves

The actual undergoing of open-heart valve surgery is to replace or

repair one or more heart valves, as a consequence of defects in,

abnormalities of, or disease-affected cardiac valve (s). The diagnosis

of the valve abnormality must be supported by an echocardiography

 and the realization of surgery has to be conrmed by a specialist

medical practitioner. Catheter based techniques including but not

limited to, balloon valvotomy/valvuloplasty are excluded.

5. ComaofSpeciedSeverity

1. A state of unconsciousness with no reaction or response to external

stimuli or internal needs.

This diagnosis must be supported by evidence of all of the following:

i. no response to external stimuli continuously for at least 96 hours;

ii. life support measures are necessary to sustain life; and

 iii. permanent neurological decit which must be assessed at least

  30daysaftertheonsetofthecoma.

2. Theconditionhastobeconrmedbyaspecialistmedicalpractitioner.

Coma resulting directly from alcohol or drug abuse is excluded.

6. KidneyFailureRequiringRegularDialysis

End stage renal disease presenting as chronic irreversible failure of

both kidneys to function, as a result of which either regular

renaldialysis (haemodialysis or peritoneal dialysis) is instituted or renal

 transplantation is carried out. Diagnosis has to be conrmed by a

specialist medical practitioner.

7. StrokeResultinginPermanentSymptoms

Any cerebrovascular incident producing permanent neurological

sequelae. This includes infarction of brain tissue, thrombosis in an

intracranial vessel, haemorrhage and embolization from an extra

 cranialsource.Diagnosishastobeconrmedbyaspecialistmedical

practitioner and evidenced by typical clinical symptoms as well as

 typical ndings in CT Scan or MRI of the brain. Evidence of

 permanentneurologicaldecitlastingforatleast3monthshastobe

produced.

The following are excluded:

1. Transient ischemic attacks (TIA)

2. Traumatic injury of the brain

3. Vascular disease affecting only the eye or optic nerve or vestibular

functions.

8. MajorOrgan/BoneMarrowTransplant

The actual undergoing of a transplant of:

1. One of the following human organs: heart, lung, liver, kidney,

pancreas, that resulted from irreversible end - stage failure of the

relevant organ, or

2. Human bone marrow using haematopoietic stem cells. The

  undergoing of a transplant has to be conrmed by a specialist

medical practitioner.

The following are excluded:

i. Other stem-cell transplants

ii. Where only islets of langerhans are transplanted

9. PermanentParalysisofLimbs

Total and irreversible loss of use of two or more limbs as a result of

injury or disease of the brain or spinal cord. A specialist medical

practitioner must be of the opinion that the paralysis will be permanent

with no hope of recovery and must be present for more than 3 months.

10.MotorNeuronDiseasewithPermanentSymptoms

Motor neuron disease diagnosed by a specialist medical practitioner

as spinal muscular atrophy, progressive bulbar palsy, amyotrophic

lateral sclerosis or primary lateral sclerosis. There must be

progressive degeneration of corticospinal tracts and anterior horn

 cellsorbulbarefferentneurons.Theremustbecurrentsignicantand

permanent functional neurological impairment with objective evidence

of motor dysfunction that has persisted for a continuous period of at

least 3 months.

11 MultipleSclerosiswithPersistingSymptoms

I. TheunequivocaldiagnosisofDeniteMultipleSclerosisconrmedand

evidenced by all of the following:

 1. investigations including typical MRI ndings which unequivocally

  conrmthediagnosistobemultiplesclerosis;

2. there must be current clinical impairment of motor or sensory

function, which must have persisted for a continuous period of at

least 6 months, and

II. Other causes of neurological damage such as SLE and HIV are

excluded.

12. Primary(Idiopathic)PulmonaryHypertension

I. An unequivocal diagnosis of Primary (Idiopathic) Pulmonary

Hypertension by a Cardiologist or specialist in respiratory medicine with

evidence of right ventricular enlargement and the pulmonary arterypres

 sureabove30mmofHgonCardiacCauterization. 

There must be permanent irreversible physical impairment to the

degree of at least Class IV of the New York Heart Association

 Classicationofcardiacimpairment.

II. TheNYHAClassicationofCardiacImpairmentareasfollows:

i. Class III: Marked limitation of physical activity. Comfortable at rest,

but less than ordinary activity causes symptoms.

ii. Class IV: Unable to engage in any physical activity without

discomfort. Symptoms may be present even at rest.

III. Pulmonary hypertension associated with lung disease, chronichy

poventilation, pulmonary thromboembolic disease, drugs and toxins,

diseases of the left side of the heart, congenital heart disease and any

 secondarycausearespecicallyexcluded.

13. AortaGraftSurgery

The actual undergoing of major Surgery to repair or correct aneurysm,

narrowing, obstruction or dissection of the Aorta through surgical

opening of the chest or abdomen.

 Forthepurposeofthisbenet,Aortameansthethoracicandabdomnal

aorta but not its branches.

You understand and agree that We will not cover:

a. Surgery performed using only minimally invasive or intra-arterial

techniques.

b. Angioplasty and all other intra-arterial, catheter based techniques,

“keyhole” or laser procedures.

c. Congenital narrowing of the aorta and traumatic injury of the aorta

  arespecicallyexcluded.

14. Deafness

Total and irreversible Loss of hearing in both ears as a result of Illness

or accident.

This diagnosis must be supported by pure tone audiogram test and

 certiedbyanEar,NoseandThroat(ENT)specialist.Totalmeans“the

 lossofhearingtotheextentthatthelossisgreaterthan90decibels

across all frequencies of hearing” in both ears.

15. Blindness

I. Total, permanent and irreversible loss of all vision in both eyes as a

result of illness or accident.

II. The Blindness is evidenced by:

 i. correctedvisualacuitybeing3/60orlessinbotheyesor;

 ii. theeldofvisionbeinglessthan10degreesinbotheyes.

III. The diagnosis of blindness must be conrmed and must not be

correctable by aids or surgical procedure.

16. AplasticAnemia

Chronic persistent bone marrow failure which results in anemia,

neutropenia and thrombocytopenia requiring treatment with at least

one of the following:

a. Blood product transfusion;

b. Marrow stimulating agents;

c. Immunosuppressive agents; or

d. Bone marrow transplantation.

 The diagnosis must be conrmed by a hematologist Medical

Practitioner using relevant laboratory investigations including Bone

 MarrowBiopsyresultinginbone marrowcellularityoflessthan 25%

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which is evidenced by any two of the following:

 a.Absoluteneutrophilcountoflessthan500/mm³orless;

 b. Plateletscountlessthan20,000/mm³orless;

 c. Reticulocytecountoflessthan20,000/mm³orless.

We will not cover temporary or reversible Aplastic Anemia under this

Section.

17. CoronaryArteryDisease

 The rst evidence of narrowing of the lumen of at least one

 coronaryarterybyaminimumof75%andoftwoothersbyaminimum

 of 60%, regardless of whether or not any form of  coronaryartery

Surgery has been performed. Coronary arteries herein refer to left

 main stem, left anterior descending circumex and right coronary

artery and not its branches which is evidenced by the following:

a. evidence of ischemia on Stress ECG (NYHA Class III symptoms)

b. coronary arteriography (Hearth Cath)

18. EndStageLungFailure

End Stage Lung Disease, causing chronic respiratory failure, as

 conrmedandevidencedbyallofthefollowing:

i. FEV1 test results consistently less than 1 liter measured on 3

occasions 3 months apart; and

ii. Requiring continuous and permanent supplementary oxygen

therapy for hypoxemia; and

iii. Arterial blood gas analysis with partial oxygen pressure of

55mmHgor less (PaO2 < 55 mm Hg); and

iv. Dyspnea at rest.

19. EndStageLiverFailure

Permanent and irreversible failure of liver function that has resulted in

all three of the following:

a. Permanent jaundice;

b. Ascites; and

c. Hepatic Encephalopathy.

Liver failure secondary to drug or alcohol abuse is excluded.

20. ThirdDegreeBurns

 Theremustbethird-degreeburnswithscarringthatcoveratleast20%

 ofthebody’ssurfacearea.Thediagnosismustconrmthetotalarea

involved using standardized, clinically accepted, body surface

 areachartscovering20%ofthebodysurfacearea.

21. FulminantHepatitis

A sub-massive to massive necrosis of the liver by the Hepatitis virus,

leading precipitously to liver failure. This diagnosis must be supported

by all of the following:

a. Rapid decreasing of liver size;

b. Necrosis involving entire lobules, leaving only a collapsed reticular

framework;

c. Rapid deterioration of liver function tests;

d. Deepening jaundice; and

e. Hepatic encephalopathy.

Acute Hepatitis infection or carrier status alone does not meet the

diagnostic criteria.

22. Alzheimer’sDisease

Alzheimer’s disease is a progressive degenerative Illness of the

brain, characterized by diffuse atrophy throughout the cerebral cortex

with distinctive histopathological changes. Deterioration or loss of

 intellectualcapacity, as conrmed byclinicalevaluationandimaging

tests, arising from Alzheimer’s disease, resulting in progressive

 signicant reduction in mental and social functioning, requiring the

continuous supervision of the Insured Person. The diagnosis must be

 supported by the clinical conrmation of a Neurologist Medical

Practitioner and supported by Our appointed Medical Practitioner.

The following conditions are however not covered:

a. non-organic diseases;

b. alcohol related brain damage; and

c. any other type of irreversible organic disorder/dementia.

23. BacterialMeningitis

 Bacterialinfectionresultinginsevereinammationofthemembranes

 of the brain or spinal cord resulting in signicant, irreversible and

 Permanentneurologicaldecit.Theneurologicaldecitmustpersistfor

 atleast6weeks.Thisdiagnosismustbeconrmedby:

 a. Thepresenceofbacterialinfectionincerebrospinaluidbylumbar

puncture; and

b. A consultant neurologist Medical Practitioner.

We will not cover Bacterial Meningitis in the presence of HIV infection

under this Section.

24. BenignBrainTumor

 a. Benignbraintumorisdenedasalifethreatening,non-cancerous

tumor in the brain, cranial nerves or meninges within the skull.

  The presence of the underlying tumor must be conrmed by

imaging studies such as CT scan or MRI.

b. This brain tumor must result in at least one of the following and

  mustbeconrmedbytherelevantmedicalspecialist.

  i. Permanent Neurological decit with persisting clinical

   symptoms for a continuous period of at least 90consecutive

days or

ii. Undergone surgical resection or radiation therapy to treat the

brain tumor.

The following conditions are however not covered by Us:

a. cysts;

b. granulomas;

c. malformations in the arteries or veins of the brain;

d. hematoma;

e. Abscesses

f. Pituitary Tumors

g. tumors of skull bones and

h. tumors of the spinal cord

25. ApallicSyndrome

Universal necrosis of the brain cortex with the brainstem remaining

 intact. The diagnosis must be conrmed by a Neurologist Medical

Practitioner acceptable to Us and the condition must be documented

by such Medical Practitioner for at least one month.

26. Parkinson’sDisease

The unequivocal diagnosis of progressive, degenerative idiopathic

Parkinson’s disease by a Neurologist Medical Practitioner acceptable

to Us.

The diagnosis must be supported by all of the following conditions:

a. the disease cannot be controlled with medication;

b. signs of progressive impairment; and

c. inability of the Insured Person to perform at least 3 of the 6 activities

of daily living as listed below (either with or without the use of

mechanical equipment, special devices or other aids and

adaptations in use for disabled persons) for a continuous period of

at least 6 months:

Activities of daily living:

i. Washing: the ability to wash in the bath or shower (including getting

into and out of the shower) or wash satisfactorily by other means

and maintain an adequate level of cleanliness and personal

hygiene;

ii. Dressing: the ability to put on, take off, secure and unfasten all

  garmentsand,asappropriate,anybraces,articiallimbsorother

surgical appliances;

iii. Transferring: The ability to move from a lying position in a bed to a

sitting position in an upright chair or wheel chair and vice versa;

iv. Toileting: the ability to use the lavatory or otherwise man age

bowel and bladder functions so as to maintain a satisfactory level

of personal hygiene;

v. Feeding: the ability to feed oneself, food from a plate or bowl to the

mouth once food has been prepared and made available.

vi. Mobility: The ability to move indoors from room to room on level

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surfaces at the normal place of residence.

We will not cover Parkinson’s disease secondary to drug and/or

alcohol abuse under this Section.

27. MedullaryCysticDisease

A progressive hereditary disease of the kidneys characterized by the

 presenceofcystsinthemedulla,tubularatrophyandinterstitialbrosis

with the clinical manifestations of anemia, polyuria and renal loss

of sodium, progressing to chronic renal failure. The diagnosis must be

supported by renal biopsy.

28. MuscularDystrophy

A group of hereditary degenerative diseases of muscle characterized

by progressive and permanent weakness and atrophy of certain

muscle groups. The diagnosis of muscular dystrophy must be

unequivocal and made by a Neurologist Medical Practitioner acceptable

 toUs,withconrmationofatleast3ofthefollowing4conditions

a. Family history of muscular dystrophy;

b. Clinical presentation including absence of sensory disturbance,

  normalcerebrospinaluidandmildtendonreexreduction;

c. Characteristic electromyogram;

 d. Clinicalsuspicionconrmedbymusclebiopsy.

The condition must result in the inability of the Insured Person to

perform at least 3 of the 6 activities of daily living as listed below (either

with or without the use of mechanical equipment, special devices or

other aids and adaptations in use for disabled persons) for a continuous

period of at least 6 months:

Activities of daily living:

i. Washing: the ability to wash in the bath or shower (including getting

into and out of the shower) or wash satisfactorily by other means

and maintain an adequate level of cleanliness and personal

hygiene;

ii. Dressing: the ability to put on, take off, secure and unfasten all

  garmentsand,asappropriate,anybraces,articiallimbsorother

surgical appliances;

iii. Transferring: The ability to move from a lying position in a bed to a

sitting position in an upright chair or wheel chair and vice versa;

iv. Toileting: the ability to use the lavatory or otherwise manage bowel

and bladder functions so as to maintain a satisfactory level of

personal hygiene;

v. Feeding: the ability to feed oneself, food from a plate or bowl to the

mouth once food has been prepared and made available;

vi. Mobility: The ability to move indoors from room to room on level

surfaces at the normal place of residence.

29. LossofSpeech

a. Total and irrecoverable loss of the ability to speak as a result of

injury or disease to the vocal cords. The inability to speak must be

established for a continuous period of 12 months. This diagnosis

must be supported by medical evidence furnished by an Ear, Nose,

Throat (ENT) specialist.

b. All psychiatric related causes are excluded.

30. SystemicLupusErythematous

A multi-system, multifactorial, autoimmune disorder characterized by

the development of auto-antibodies directed against various self -

antigens. Only those forms of systemic lupus erythematous which

involve the kidneys (Class III to Class V lupus nephritis, established by

renal biopsy, and in accordance with the World Health Organization

 (WHO) classication) will be covered by Us under this Section. The

 naldiagnosismustbeconrmedbyaregisteredMedicalPractitioner

specializing in Rheumatology and Immunology acceptable to Us.

Other forms of systemic lupus erythematous, discoid lupus and those

forms with only hematological and joint involvement are however not

covered:

 TheWHOlupusclassicationisasfollows:

• Class I: Minimal change – Negative, normal urine.

• Class II: Mesangial – Moderate proteinuria, active sediment.

• Class III: Focal Segmental – Proteinuria, active sediment.

• Class IV: Diffuse – Acute nephritis with active sediment and/or

nephritic syndrome.

• Class V: Membranous – Nephrotic Syndrome or severe proteinria.

31. LossofLimbs

a. The physical separation of two or more limbs, at or above the wrist

or ankle level limbs as a result of injury or disease. This will include

medically necessary amputation necessitated by injury or disease.

The separation has to be permanent without any chance of surgical

correction. Loss of Limbs resulting directly or indirectly from self-

 inictedinjury,alcoholordrugabuseisexcluded.

32. MajorHeadTrauma

a. Accidental head injury resulting in permanent Neurological decit

to be assessed no sooner than 3 months from the date of the accident.

 This diagnosis must be supported by unequivocal ndings on

Magnetic Resonance Imaging, Computerized Tomography, or other

reliable imaging techniques. The accident must be caused solely and

directly by accidental, violent, external and visible means and

independently of all other causes.

b. The Accidental Head injury must result in an inability to perform

at least three (3) of the following Activities of Daily Living either with or

without the use of mechanical equipment, special devices or other aids

and adaptations in use for disabled persons. For the purpose of this

 benet,theword“permanent”shallmeanbeyondthescopeofrecovery

with current medical knowledge and technology.

c. The Activities of Daily Living are:

i. Washing: the ability to wash in the bath or shower (including getting

into and out of the bath or shower) or wash satisfactorily by other

means;

ii. Dressing: the ability to put on, take off, secure and unfasten all

  garmentsand,asappropriate,anybraces,articiallimbsorother

surgical appliances;

iii. Transferring: the ability to move from a bed to an upright chair or

wheelchair and vice versa;

iv. Mobility: the ability to move indoors from room to room on level

surfaces;

v. Toileting: the ability to use the lavatory or otherwise manage bowel

and bladder functions so as to maintain a satisfactory level of

personal hygiene;

vi. Feeding: the ability to feed oneself once food has been prepared

and made available.

d. The following are excluded:

a) Spinal cord injury

33. BrainSurgery

The actual undergoing of surgery to the brain, under general

anesthesia, during which a Craniotomy is performed. Burr hole and

brain surgery as a result of an accident is excluded. The procedure

 mustbeconsiderednecessarybyaqualiedspecialistandthebenet

shall only be payable once corrective surgery has been carried out.

34. Cardiomyopathy

The unequivocal diagnosis by a consultant cardiologist of

Cardiomyopathy causing impaired ventricular function suspeced by

 ECGabnormalitiesandconrmedbycardiacechoofvariableetiology

and resulting in permanent physical impairments to the degree of at

 least Class IV of the NewYorkAssociation (NYHA) Classication of

cardiac impairment.

 The NYHA Classication of Cardiac Impairment (Source: “Current

Medical Diagnosis and Treatment – 39th Edition”):

a. Class I: No limitation of physical activity. Ordinary physical activity

does not cause undue fatigue, dyspnea, or angina pain.

b. Class II: Slight limitation of physical activity. Ordinary physical

activity results in symptoms.

c. Class III: Marked limitation of physical activity. Comfortable at rest,

but less than ordinary activity causes symptoms.

d. Class IV: Unable to engage in any physical activity without

discomfort. Symptoms may be present even at rest.

We will not cover Cardiomyopathy related to alcohol abuse under this

Section.

35. Creutzfeldt-JacobDisease(CJD)

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A Diagnosis of Creutzfeldt-Jakob disease must be made by a Specialist

Medical Practitioner (Neurologist). There must be permanent clinical

loss of the ability in mental and social functioning for a minimum period

 of30daystotheextentthatpermanentsupervisionorassistancebya

third party is required.

 Socialfunctioningisdenedastheabilityoftheindividualtointeractin

the normal or usual way in society.

Mental functioning would mean functions /processes which we can do

with our minds.

36. TerminalIllness

An Insured Person shall be regarded as terminally ill only if he/ she is

diagnosed as suffering from a condition which, in the opinion of two

appropriate independent Medical Practitioners, is highly likely to lead

to death within 12 months from the date of the diagnosis and the

Insured Person is not receiving any active treatment for the terminal

illness, other than that of the pain relief. The terminal illness must be

 diagnosedandconrmedbyMedicalPractitionersregisteredwiththe

Indian Medical Association and approved by Us.

 Any claim under this benet will not impact the Sum Insured and/or

Cumulative Bonus.

 Allclaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.12

C.II.2 TeleConsultation

Insured Person may avail tele-consultations with our Medical

Practitioner(s) through our network in India. These consultations would

be available through tele/chat mode.

 Any claim under this benet will not impact the Sum Insured and/or

Cumulative Bonus.

 Allclaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.13.

C.II.3.CumulativeBonus

a) On Sum Insured

 WewillincreaseYourSumInsured@10%oftheBaseSumInsured,

 as specied under Policy Schedule, at the end of every claim free

Policy Year, if the Policy is renewed with Us without any break:

a) No Cumulative Bonus will be added if the Policy is not renewed

with Us by the end of the Grace Period.

 b) TheCumulativeBonuswillnotbeaccumulatedinexcessof100%of

the Sum Insured under the current Policy with Us under any

circumstances.

c) Any Cumulative Bonus that has accrued for a Policy Year will be

credited at the end of that Policy Year if the policy is renewed with

us within grace period and will be available for any claims made in

the subsequent Policy Year.

d) If a cumulative bonus has been applied and a claim is made, then in

the subsequent Policy Year We will automatically decrease the

accumulated Cumulative Bonus by same rate at which it has

  accrued i.e.@10% of the Base Sum Insured. There will be no

impact on the Base Sum In sured, only the accumulated Cumulative

Bonus will be reduced.

 e) IfaclaimismadeintheexpiringPolicyYear,andisnotiedtous

after the acceptance of Renewal premium, in such cases any

awarded Cumulative Bonus shall be withdrawn.

f) Reduction in Sum Insured: If the Sum Insured has been reduced at

the time of Renewal, the applicable Cumulative Bonus shall be

calculated on the revised Sum Insured on pro-rata basis.

g) Increase in Sum Insured: If the Sum Insured under the Policy has

been increased at the time of Renewal the Cumulative Bonus shall

be calculated on the Sum Insured of the last completed Policy Year.

h) This clause does not alter Our right to decline a Renewal or

cancellation of the Policy for reasons as mentioned under Section

F.I.6

C.II.4 WellnessProgram

Whocanavailthesewellnessprograms:

If You have been suffering from one or more of the following conditions

such as Asthma, Diabetes, Hypertension, Dyslipidaemia, Obesity and

 thesamehasbeendeclared/identiedatthetimeofbuyingthepolicy

or subsequently in any policy year, You can be a part of Wellness

Program based on the covered conditions as per the applicability of the

opted plan and earn rewards based on adherence to program metrics.

The details of the Wellness Programs are as below:

PlanType ActivePlan

Wellness Program Condition Management Program

Conducted By ManipalCigna along with its Network Partners

Program Compo-

nents

- Health Risk Assessment

- Baseline assessment (Medical test)

- Coaching by experts

- Improvement assessment (Medical test)

Medical Tests

Diabetes HbA1c+Lipidprole+Serumcreatinine+Microal-

buminuria + MER + Ophthalmologist Consultation

+ ECG

Hypertension Lipidprole+Serumcreatinine+Microalbuminuria

+ Uric acid + MER + ECG

Obesity Lipidprole+Serumcreatinine+ThyroidProle+

HbA1c + MER

Dyslipidaemia Lipidprole+Serumcreatinine+HbA1c+MER

Asthma MER + Spirometry

More than 1

disease

Combination of tests pertaining to each condition

(No repetition of tests)

Program Metric - Health Risk Assessment completion

- Medical tests undertaken at the beginning of the

program in the policy year

- Coaching completion

- Improvements achieved at the end of the program

in the policy year

Reward Accrual

– 1 year Policy

Tenure

(Refer Annexure

A for illustration,

provided as part

ofthebenet)

Maximum reward points which could be accrued is

upto15%oftheexistingbasepremium(excluding

Premium for optional cover(s), Rider(s) and taxes)

applicable for the respective insured

Reward Accrual

– 2/3 years Policy

Tenure

(Refer Annexure

A for illustration,

provided as part

ofthebenet)

Maximum reward points which could be accrued is

upto15%oftheapplicableexistingbasepremium

for the respective policy year (excluding Premium

for optional cover(s), Rider(s) and taxes)

Applicable for the respective insured, earned each

policy year and shall be accumulated till the next

renewal

In order to be eligible for the rewards, You shall adhere to all the

 components of the programs as specied under program metric, as

per the applicability of opted plan.

At the end of the policy year, ‘Health Scores’ shall be calculated based

 on the nal test values and improvement in health parameters

(wherever applicable). Thereafter, ‘Weighted Health Score’ shall be

calculated provided there was no hospitalization during the Policy

Period for the covered conditions and/or its complications.

RewardAccrualMethodologyunderActivePlan:

 Disease-wiseHealthScoreforActivePlan:

Final Test Values and Improvement will be considered for health score

allocation.

Diabetes:

Diabetes

(HbA1c

Final Test

Value)

<or=

6.5%

Final value <or=6.5

Health Score 100

>6.5% Final Value

Reduced by

(improvement by)

0.50% 0.51%

to1%

>1%

Health Score 25 50 75

Reward Principle:

1. Reward points will be allocated for improvement in HbA1C values

only

2. No rewards will be allocated for increase in HbA1c value or

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  reduction<0.5%(forHbA1c>6.5)

3. Eligible for rewards provided there is no hospitalization for

diabetes or its complications

Hypertension:

Hyperten-

sion

(SBP/

DBP

Final Test

Value)

SBP<or=140

mm Hg

andDBP<or=

90mmHg

(AND)

Final value SBP<or=140andDBP

<or=90

Health

Score

100

SBP>140mm

Hg and /or

DBP>90mm

Hg (AND / OR)

Final Value

Reduced by

(improve-

ment by)

5 mm

6to10

mm Hg

>10

Health

Score

25 50 75

Reward Principle:

1. Reward points will be allocated for improvement in BP values only

2. Increase in any one marker (SBP/DBP) will disqualify the rewards

3. No rewards will be allocated for improvement in BP values <5 mm

  Hg(forSBP>140mmHgand/orDBP>90mmHg)

4. Eligible for rewards provided there is no hospitalization for

hypertension or its complications

Obesity:

Obesity

(BMI)

Final BMI

upto 29

Final value BMI upto 29

Health Score 100

Final BMI

above 29

Final Value Reduced

by (improvement by)

1 >1 to 2 >2

Health Score 25 50 75

Reward Principle:

1. Reward points will be allocated for improvement in BMI values only

2. No rewards will be allocated for increase in BMI value and reduction

in BMI <1 (for Final BMI above 29)

3. Eligible for rewards provided there is no hospitalization for obesity

or its complications

Dyslipidaemia:

Dyslipi-

daemia

Total

Cho-

lesterol

(TC) and

Triglycer-

ides (TG)

TCupto200

and TG upto

150

Final value TCupto200and

TGupto150

Health Score 100

TC>200

and/or TG >

150

Final Value Reduced

by (improvement by)

20 21

>40

Health Score 25 50 75

Reward Principle:

1. Reward points will be allocated for improvement in both TC and TG

value only

2. Increase in any one marker (TC / TG) will disqualify the rewards

3. No rewards will be allocated for increase in TC and TG and

  reductioninTCand/orTGvalues<20mg/dl(forTC>200and/or

  TG>150)

4. Eligible for rewards provided there is no hospitalization for

Dyslipidaemia or its complications

Asthma:

Asthma Treatment

type

Final

Value

On oral

medications

except

steroids/

immunodi-

lators

On Inhal-

ers

Not on

treat-

ment

Health

Score

50 75 100

Reward Principle:

1. Reward points will be allocated for improvement or status quo in

type of treatment only

2. No rewards will be allocated for change in line of treatment to a

higher category

3. Hierarchy for type of treatment: Category 1:Not on treatment;

Category 2: On Inhalers; Category 3: On oral medications;

Category 4: On steroids/immunomodilators

4. Eligible for rewards provided there is no hospitalization for asthma

or its complications

HealthScoreandRewardAllocation:

 a. Health Score will be allocated against the nal value of each

ailment

b. In case of more than one ailment, a weighted average of all health

scores will be calculated. The weights will be assigned for

ailments in decreasing order as follows: Diabetes, Hypertension,

Obesity, Dyslipidaemia, Asthma

RewardAllocationGrid:

Weighted Health Score <25 >25to50 >50to75 >75

Rewards-%ofpremium

paid (Excluding Optional

Covers/Rider and taxes) in

the existing Policy

0% 5% 10% 15%

Conditionsunderthisbenet:

i. The reward points earned will be at eligible member level.

ii. Maximum reward points that can be earned in a single Policy Year

  willbelimitedto15%ofpremiumpaid(excludingOptionalcovers,

Riders and taxes) in the existing Policy. In case of 2 or 3 year

policies, maximum reward points that can be earned shall not

  exceed15%ofthetotalpremiumpaid(excludingOptionalcovers,

Riders and taxes) for 2 years or 3 years as applicable.

iii. Each earned reward point will be valued at 1 Rupee. Accrued

rewards can be redeemed against payable premium (excluding

premium for Optional covers, Riders and Taxes) from 1st Renewal

of the Policy.

iv. The earned reward points can be utilized as Discount in the renewal

premium falling due immediately after the accrual. Carry forward of

earned reward points shall not be allowed.

v. Redemption against renewal premium will be available only at the

time such renewal is due. Any earned rewards will lapse at the end

of the grace period if the policy is not renewed with us.

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Refer Annexure- A below on the Illustration of Reward Points.

Annexure–A–IllustrationofRewardPoints

ReductionofRenewalPolicyYear

PolicyTerm-3years

(Premium indicated here is just for illustration purposes in case of 1

Adult policy and may not be the actual premium.)

Each earned reward point will be valued at 1 Rupee

Year Premi-

umPaid

(Excluding

Optional

covers,

Riderand

taxes)

Weight-

ed

Health

Score

Re-

ward

RewardPoints

Earned

Year 1 10000 80 15% 1500

Year 2 11000 78 15% 1650

Year 3 12000 65 10% 1200

Total 33000

4350

The earned reward points could be redeemed as discount as per

the below process to pay a portion of the renewal premium

RenewalofPolicyasperbelowtable

IfRenewed

Policy

Termis

Renewal

Premium

(Excluding

Optional

Covers,

Riderand

taxes)

Rewarddiscount

utilized

RenewalPre-

miumPayable

afteradjusting

Rewarddis-

count

1 Year

Policy

13000 1450(4350*1/3as

Insured is renew-

ing 3 Year policy to

1 Year Policy)

11550

2 Years

Policy

27000 2900(4350*2/3as

Insured renewing

3 Year policy to 2

Year Policy)

24100

3 Years

Policy

42000 4350(Insured

renewing to the

same policy tenure

of 3 years)

37650

IncreaseofRenewalPolicyYear

PolicyTerm-1year

(Premium indicated here is just for illustration purposes and may

not be the actual premium.)

Each earned reward point will be valued at 1 Rupee

Year Premium

(Ex-

cluding

Optional

Cover,

Riderand

taxes)

Weighted

Health

Score

Rewards% Points

Earned

Year 1 10000 40 5% 500

Total 10000 500

The earned reward points could be redeemed as discount as per

the below process to pay a portion of the renewal premium

RenewalofPolicyasperbelowtable

IfRenewed

Policy

Termis

Renewal

Premium

(Ex-

cluding

Optional

Cover/

Riderand

taxes)

Rewardsdiscount

utilized

Renewal

Premium

Payable

after

adjusting

Rewards

discount

1 Year

Policy

11000 500(asInsuredisre-

newing 1 Year policy to 1

Year Policy)

10500

2 Year

Policy

21000 500(asInsuredisre-

newing 1 Year policy to 2

Year Policy)

20500

3 Year

Policy

33000 500(asInsuredisre-

newing 1 Year policy to 3

Year Policy)

32500

The notications related to wellness programs will be communicated via

SMS, email and the program specic phone / web application. Details

about reward points will be available on the program app (if any) or would

be shared through SMS and/or Renewal Notice which would be sent to

customers.

C.II.5 DiscountfromNetworkProviders

The Insured Person can avail discount on Diagnostic, Pharmacy

and Health Supplements offered through Our Network Providers.

C.II.6 PremiumWaiverBenet

In case, the Policyholder who is also an Insured Person under the

Policy suffers Death due to an injury caused by an Accident within

365 days from the date of the event or he/she is diagnosed with a

Critical Illness, listed under this section, We will pay the next one full

Policy Year’s Renewal Premium (including Optional covers, Riders and

Taxes) of the Policy, for a policy tenure of 1 year. The premium shall be

paid towards existing Insured Persons covered under the same policy,

 withbenetssameastheexpiringPolicy.

 IncaseofanychangeinPolicybenets,completepremiumwillbepaid

by the Policyholder.

The cover is available subject to below conditions:

• If only one person is covered under the Policy, policy will not be

renewed in case of death of the Policyholder.

• The Policyholder is not added in the Policy in the middle of the

  PolicyYear. There is no change in covers, Sum Insured, benet

structure, limits and conditions applicable under the Policy, at the

time of renewal.

• No new member is being added under the renewed Policy.

• In case of a policy with existing tenure of 2 or 3 years, it will be

renewed only for one year, provided all the terms and conditions,

  benetsandpolicylimitsremainsame.

  Forthepurposeof this benet, CriticalIllnessesshallincludeas

below-

  1. CancerofSpeciedSeverity

  2. MyocardialInfarction(FirstHeartAttackofSpecicSeverity)

3. Open Chest CABG

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4. Open Heart Replacement or Repair of Heart Valves

  5. ComaofSpeciedSeverity

6. Kidney Failure Requiring Regular Dialysis

7. Stroke Resulting in Permanent Symptoms

8. Major Organ/Bone Marrow Transplant

9. Permanent Paralysis of Limbs

  10.MotorNeuronDiseasewithPermanentSymptoms

11. Multiple Sclerosis with Persisting Symptoms

  Onceaclaimhasbeenacceptedandpaidunderthisbenet,this

cover will automatically terminate in respect of that Insured Person.

  AnyclaimunderthisbenetwillnotimpacttheSumInsuredand/or

Cumulative Bonus.

C.III.Optionalcovers

The following optional covers shall apply under the Policy for an

 Insured Person if specically mentioned on the Schedule and shall

apply to all Insured Persons under a single policy without any individual

selection.

C.III.1 Non-MedicalItems

We will cover the cost of Non-Medical items, listed under Annexure III

List 1 of the Policy, incurred towards Medically Necessary

Hospitalization of the insured person, arising out of Disease/ Illness or

Injury.

The cover is available subject to the claim being admissible under

Section D.I.1 In-patient Hospitalization and/ or Section D.I.4 Day Care

Treatment cover under this policy and the expenses on Non-medical

items are related to the same Illness/ Injury.

 ExclusionE.II.13shallnotbeapplicableforthisbenet.

 Any claim made under this optional benet will reduce the Sum

Insured.

 Allclaimsunderthisbenetcanbemadeaspertheprocessdened

under Section G.I.4 & G.I.5.

C.III.2.WaiverofMandatoryCo-pay

The Policyholder shall have an option to remove the Mandatory Co-

 paymentwhichisapplicableforallinsuredpersonsasspeciedunder

section F.II.6 and available on payment of additional premium.

C.III.3 WorldwideAccidentalEmergencyHospitalizationCover:

We will cover Medical Expenses incurred during the Policy Year, for

Emergency In-patient Hospitalization Treatments of the Insured

Person, due to an Injury arising out of an Accident, incurred outside

 India,covereduptotheSum Insured and as specied inthePolicy

Schedule, provided that:

 (a)The treatment is Medically Necessary and has been certied as

an Emergency by a Medical Practitioner, where such treatment

cannot be postponed until the Insured Person has returned to India

and is payable under Section D.I.1 In-patient Hospitalization of the

  Policy.Ourmaximumliabilityunderthisbenet,inasinglePolicy

Year shall not exceed the limit available under this cover age and

  asspeciedinthePolicySchedule.

(b) The Medical Expenses payable shall be limited to In-patient

Hospitalization only.

 (c)AnypaymentunderthisbenetwillonlybemadeinIndia,inIndian

rupees on a re-imbursement basis and subject to availability of

limits under this coverage. Insured Person can contact Us at the

numbers provided on the Health Card for any claim assistance.

 (d) Thepaymentofanyclaimunderthisbenetwillbebasedonthe

rate of exchange as on the date of payment to the Hospital

published by Reserve Bank of India (RBI) and shall be used for

conversion of foreign currency into Indian rupees for payment of

claim.You further understand and agree that where on the date of

discharge, if RBI rates are not published, the exchange rate next

published by RBI shall be considered for conversion.

(f) You have given Us, intimation of such hospitalization within 48

hours of admission.

 (g)Any claim made under this benet will be as per the claims

procedure provided under Clause G.I.5 & G.I.14 of this Policy.

 (h)Anyclaim payableunderthisbenetis overandabovetheSum

Insured.

 (i) ExclusionE.II.8doesnotapplytothisbenet.

 (j) RestorationofSumInsuredshallnotbeavailableunderthisbenet

(k) This cover is available to all Insured Persons provided they are

Indian resident at inception of the Policy and at subsequent

renewals of this Policy.

C.III.4 HealthCheckUp

 (a) Health Check Up benet can be availed only in case where the

  WellnessBenetisnotchosenbytheInsuredperson.

(b) If the Insured Person has completed 18 years of Age, the Insured

Person may avail a comprehensive health check-up with Our

Network Provider as per the eligibility details mentioned in the table

below. Health Check Ups will be arranged by Us and conducted at

Our Network Providers.

 (c)Thisbenetis available once every third policy year.And all the

tests must have been done on the same date

(d) Original Copies of all reports will be provided to You.

HealthCheckUp

SumInsured Agegroup Listoftests–Cashless

For All Sum

Insured

Upto40Years ECG,FBS,LipidProle,

Sr. Creatinine, CBC-ESR,

SGOT, SGPT, GGT, TSH,

USG - Abdomen & pelvis

Above40

years

ECG,FBS,LipidProle,

Sr. Creatinine, CBC-ESR,

SGOT, SGPT, GGT, HbA1c,

USG Abdomen & Pelvis,

PSA (for Males)/ Mammogram/

PAP Smear (for females)

Full explanation of Tests is provided here: FBS - Fasting Blood

Sugar, ECG - Electrocardiogram, CBC-ESR - Complete Blood Count-

Erythrocyte Sedimentation Rate, Sr. Creatinine - Serum Creatinine,

HbA1c - Glycosylated Hemoglobin, SGOT - Serum Glutamate

oxaloacetate transaminase, SGPT - Serum Glutamate Pyruvate

Transaminase, GGT - Gamma Glutamyl Transferase, PSA - Prostate

 Specic Antigen, USG - Ultrasound Sonography, TSH - Thyroid

Stimulating Hormone, CBC - Complete Blood Count

 (e) Thisbenetshallbeoverandabovethesuminsured.

(f) Opting this cover shall mean that the coverage under section D.II.4

Wellness Program shall not be applicable for the Insured members

for the lifetime of the Policy. The Insured members shall not be able

to participate in any of the wellness programs and shall not be able

to earn any rewards under the coverage section D.II.4 Wellness

Program.

(g) We shall cover Health Check Up only on cashless basis within

MCHI Network.

 (h)ThisbenetshallonlybeoptedatthetimeofrenewalofthePolicy

or at inception and once opted, cannot be removed.

 (i) RestorationofSumInsuredshallnotbeavailableunderthisbenet

 (j) All Claims under this benet can be made as per the process

  denedunderSectionG.I.13&G.I.5

C.III.5 WaiverofDiseaseSpecicSublimit

 ThePolicyholdershallhaveanoptiontoremovetheDiseaseSpecic

 Sublimitwhichisapplicableforlistedailments/proceduresasspecied

under section D.I.1 and available on payment of additional premium.

D. Exclusions

We shall not be liable to make any payment under this Policy caused

by, based on, arising out of or howsoever attributable to any of the

 followingunlessotherwisecoveredorspeciedunderthePolicyorany

Cover opted under the Policy. All the waiting period shall be applicable

individually for each Insured Person and claims shall be assessed

accordingly.

D.I.StandardExclusions

D.I.1.Pre-existingDisease-Code-Excl.01

a. Expenses related to the treatment of a Pre-existing Disease (PED) and

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its direct complications shall be excluded until the expiry of 24 months

 ofcontinuouscoverageafterthedateofinceptionoftherstpolicywith

Us.

b. In case of enhancement of sum insured the exclusion shall apply afresh

to the extent of sum insured increase.

c. If the Insured Person is continuously covered without any break as

 dened under the portability norms of the extant IRDAI (Health

Insurance) Regulations then waiting period for the same would be

reduced to the extent of prior coverage.

d. Coverage under the policy after the expiry of Pre-existing disease

waiting period for any pre-existing disease is subject to the same being

declared at the time of application and accepted by us.

 Any condition or illness, complication or ailment as specied in the

Policy Schedule out of any of the below mentioned conditions, shall not

be considered as part of this waiting period. Wherein, they shall be

 coveredafterthe rst90daysfrom theInceptionDateof rstpolicy

with Us.

a. Asthma

b. Diabetes

c. Dyslipidaemia

d. Obesity

e. Hypertension

D.I.2.Specieddisease/procedureWaitingPeriod-Code-E.I.2

a. Expenses related to the treatment of the listed Conditions, surgeries/

treatments shall be excluded until the expiry of 24 months of continuous

 coverage after the date of inception of the rst policy with us. This

exclusion shall not be applicable for claims arising due to an accident.

b. In case of enhancement of sum insured the exclusion shall apply afresh

to the extent of sum insured increase.

c. Ifanyofthespecieddisease/procedurefallsunderthewaitingperiod

 speciedforpre-Existingdiseases,thenthelongerofthetwowaiting

periods shall apply.

d. The waiting period for listed conditions shall apply even if contracted

 afterthepolicyordeclaredandacceptedwithoutaspecicexclusion.

e. If the Insured Person is continuously covered without any break as

 denedundertheapplicablenormsonportabilitystipulatedbyIRDAI,

then waiting period for the same would be reduced to the extent of prior

coverage.

f. Listofspecicdiseases/procedures:

i. Cataract,

ii. Hysterectomy for Menorrhagia or Fibromyoma or prolapse of

  Uterus or myomectomy for broids unless necessitated by

malignancy,

iii. Knee Replacement Surgery (other than caused by an Accident),

Non-infectious Arthritis, Gout, Rheumatism, Oestoarthritis and

Osteoposrosis, Joint Replacement Surgery (other than caused by

Accident), Prolapse of Intervertibral discs (other than caused by

Accident), all Vertibrae Disorders, including but not limited to

Spondylitis, Spondylosis, Spondylolisthesis, Congenital Internal,

iv. Varicose Veins and Varicose Ulcers,

v. Stones in the urinary uro-genital and biliary systems including

calculus diseases and complications thereof,

vi. Benign Prostate Hypertrophy, all types of Hydrocele,

vii. Fissure, Fistula in anus, Piles, all types of Hernia, Pilonidal sinus,

Hemorrhoids and any abscess related to the anal region.

viii. 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.

ix. gastric and duodenal ulcer, any type of Cysts/Nodules/Polyps/

internal tumors / skin tumors, and any type of Breast lumps (unless

malignant), Polycystic Ovarian Diseases,

x. Any surgery of the genito-urinary system unless necessitated by

malignancy.

If these diseases are pre-existing at the time of proposal or

subsequently found to be pre-existing the highest between the

  Specied disease/procedure Waiting Period or Pre-existing

Diseases waiting period as mentioned in the Policy Schedule shall

apply.

D.I.3.30daysWaitingPeriod-Code-E.I.3

a) Expenses related to the treatment of any illness within 30 days of

 continuouscoveragefromtherstpolicycommencementdateshallbe

excluded except claims arising due to an accident, provided the same

are covered.

b) This exclusion shall not, however, apply if the Insured Person has

Continuous Coverage for more than twelve months.

c) The within referred waiting period is made applicable to the enhanced

sum insured in the event of granting higher sum insured subsequently

D.I.4.Investigation&Evaluation-Code-Excl04

a. Expenses related to any admission primarily for diagnostics and

evaluation purposes only are excluded.

b. Any diagnostic expenses which are not related or not incidental to the

current diagnosis and treatment are excluded.

D.I.5.RestCure,rehabilitationandrespitecare-Code-Excl05

a) Expenses related to any admission primarily for enforced bed rest and

not for receiving treatment. This also includes:

i. 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.

ii. Any services for people who are terminally ill to address physical,

social, emotional and spiritual needs.

D.I.6.Obesity/WeightControlCode-Excl06

 Expensesrelatedtothesurgicaltreatmentofobesitythatdoesnotfull

all the below conditions:

1. Surgery to be conducted is upon the advice of the Doctor

2. The surgery/Procedure conducted should be supported by clinical

protocols

3. The member has to be 18 years of age or older and

4. Body Mass Index (BMI);

  a. greaterthanorequalto40or

b. greater than or equal to 35 in conjunction with any of the

following severe comorbidities following failure of less invasive

methods of weight loss:

i. Obesity-related cardiomyopathy

ii. Coronary heart disease

iii. Severe Sleep Apnea

iv. Uncontrolled Type 2 Diabetes

D.I.7.Change-of-GendertreatmentsCode-Excl07

Expenses related to any treatment, including surgical management, to

change characteristics of the body to those of the opposite sex.

D.I.8.CosmeticorPlasticSurgeryCode-Excl08

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 certied by the attending Medical

Practitioner.

D.I.9.HazardousorAdventuresportsCode-Excl09

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.

D.I.10.BreachoflawCode-Excl10

Expenses for treatment directly arising from or consequent upon any

Insured Person committing or attempting to commit a breach of law

with criminal intent.

D.I.11.ExcludedProvidersCode-Excl11

Expenses incurred towards treatment in any hospital or by any Medical

 PractitioneroranyotherproviderspecicallyexcludedbytheInsurer

 and disclosed in its website / notied to the policyholders are not

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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.

D.I.12. Treatment for Alcoholism, drug or substance abuse or any addictive

condition and consequences thereof. Code-Excl12

D.I.13. 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. Code-Excl13

D.I.14. 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.

Code-Excl14

D.I.15.RefractiveErrorCode-Excl15

Expenses related to the treatment for correction of eye sight due to

refractive error less than 7.5 dioptres.

D.I.16.UnprovenTreatmentsCode-Excl16

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

  signicantmedicaldocumentationtosupporttheireffectiveness.

D.II.SpecicExclusions

D.II.1.PersonalWaitingperiod

A special Waiting Period not exceeding 48 months, may be applied

to individual Insured Persons for the list of acceptable Medical

Ailments listed under the Underwriting Manual of the Product,

depending upon declarations on the proposal form and existing

  healthconditions.Suchwaitingperiodsshallbespecicallystated

  intheScheduleandwillbeappliedonlyafterreceivingYourspecic

consent.

D.II.2. Dental Treatment, orthodontic treatment, dentures or Surgery of any

kind unless necessitated due to an Accident and requiring minimum 24

hours Hospitalization. Treatment related to gum disease or tooth

disease or damage unless related to irreversible bone disease

involving the jaw which cannot be treated in any other way, unless

  specicallycoveredunderthePolicy.

D.II.3. Circumcision unless necessary for treatment of a disease, illness or

injury not excluded hereunder or due to an accident.

D.II.4. Instrument used in treatment of Sleep Apnea Syndrome (C.P.A.P.)

and Continuous Peritoneal Ambulatory Dialysis (C.P.A.D.) and

Oxygen Concentrator for Bronchial Asthmatic condition, Infusion

pump or any other external devices used during or after treatment.

D.II.5. External Congenital Anomaly or defects or any complications or

conditions arising therefrom.

D.II.6. Prostheses, corrective devices and medical appliances, which are

not required intra-operatively for the disease/ illness/ injury for which

the Insured Person was Hospitalised.

D.II.7. Any stay in Hospital without undertaking any treatment or any other

purpose other than for receiving eligible treatment of a type that

normally requires a stay in the hospital.

D.II.8 Treatment received outside India other than for coverage under

Worldwide Accidental Emergency Hospitalization Cover (if opted).

D.II.9. Costs of donor screening or costs incurred in an organ transplant

surgery involving organs not harvested from a human body.

D.II.10. Any form of Non-Allopathic treatment (except AYUSH In-patient

  Treatment),Hydrotherapy,Acupuncture,Reexology,Chiropractic

treatment or any other form of indigenous system of medicine.

D.II.11. All Illness/expenses caused by ionizing radiation or contamination

by radioactivity from any nuclear fuel (explosive or hazardous form) or

from any nuclear waste from the combustion of nuclear fuel nuclear,

chemical or biological attack or in any other sequence to the loss.

D.II.12. All expenses caused by or arising from or attributable to foreign

invasion, act of foreign enemies, hostilities, warlike operations

(whether war be declared or not or while performing duties in the

armed forces of any country), participation in any naval, military

or air-force operation, civil war, public defense, rebellion, revolution,

insurrection, military or usurped power, active participation in riots,

  conscation or nationalization or requisition of or destruction of

or damage to property by or under the order of any government or

local authority.

D.II.13. All non-medical expenses including convenience items for personal

comfort not consistent with or incidental to the diagnosis and

treatment of the disease/illness/injury for which the Insured Person

was hospitalized - belts, collars, splints, slings, braces, stockings of

any kind, diabetic footwear, thermometer and any medical

equipment that is subsequently used at home except when they

form part of room expenses, procedure charges and cost of

treatment.For complete list of Non-medical expenses, please refer

to the Annexure III List – I “Items for which Coverage is not available

in the Policy”

D.II.14. Any percentage of admissible claim under co-payment if applicable

  andasspeciedinthePolicySchedule.

D.II.15. Existing diseases disclosed by the Insured Person (limited to the

extent of the ICD codes mentioned in line with Chapter IV,

Guidelines on Standardization of Exclusions in Health Insurance

  Contracts,2019),providedthesameisappliedattheunderwriting

and consented by You/ Insured Person.

E.  GeneralTermsandClauses

E.I. StandardGeneralTermsandClauses

E.I.1. DisclosureofInformation

The Policy shall be null and void and all premium paid thereon shall be

forfeited to the Company in the event of misrepresentation, mis-

description or non-disclosure of any material fact by the policyholder.

(“Material facts” for the purpose of this policy shall mean all relevant

information sought by the company in the proposal form and other

connected documents to enable it to take informed decision in the

context of underwriting the risk)

E.I.2. ConditionPrecedenttoAdmissionofLiability

 The terms and conditions of the Policy must be fullled by the

Insured Person for the Company to make any payment for claim (s)

arising under the policy.

E.I.3. ClaimSettlement(provisionforPenalInterest)

i. The Company shall settle or reject the claim, as the case may be, within

 30daysfromthedateofreceiptoflastnecessarydocument.

ii. In the case of delay in the payment of a claim, the Company shall be

liable to pay interest to the policyholder from the date of receipt of last

 necessarydocumenttothedateofpaymentofclaimatarate2%above

the bank rate.

iii. However, where the circumstances of a claim warrant an investigation

in the opinion of the Company, it shall initiate and complete such

 investigationattheearliest,inanycasenotlaterthan30daysfromthe

date of receipt of last necessary document. In such cases, the

Company shall settle or reject the claim within 45 days from the date of

receipt of last necessary document.

iv. In case of delay beyond stipulated 45 days, the Company shall be liable

 topayinteresttothepolicyholderatarate2%abovethebankratefrom

the date of receipt of last necessary document to the date of payment

of claim.

 “Bank rate” shall mean the rate xed by the Reserve Bank of lndia

 (RBl)atthebeginningofthenancial yearinwhichclaimhas fallen

due.

ManipalCignaProHealthPrime|ActivePlan|Terms&Conditions|UIN:MCIHLIP22224V012122|April2022

E.I.4. CompleteDischarge

Any payment to the policyholder, insured person or his/her nominees or

his/her legal representative or assignee or to the Hospital, as the case

 may be, for any benet under the policy shall be a valid discharge

towards payment of claim by the Company to the extent of that amount

for the particular claim.

E.I.5. MultiplePolicies

- In case of multiple policies taken by an insured person during a period

from one or more insurers to indemnify treatment costs, the insured

person shall have the right to require a settlement of his/her claim in

terms of any of his/her policies. In all such cases, the insurer chosen by

the insured person shall be obliged to settle the claim as long as the

claim is within the limits of and according to the terms of the chosen

policy.

- Insured person having multiple policies shall also have the right to

prefer claims under this policy for the amounts disallowed under any

other policy / policies even if the sum insured is not exhausted. Then

the insurer shall independently settle the claim subject to the terms and

conditions of this policy.

- If the amount to be claimed exceeds the sum insured under a single

policy, the insured person shall have right to choose insurer from whom

he/she wants to claim the balance amount.

- Where an insured person has policies from more than one insurer to

cover the same risk on indemnity basis, the insured person shall only

 beindemniedthetreatmentcostsinaccordancewiththetermsand

conditions of the chosen policy.

E.I.6. Fraud

If any claim made by the insured person, is in any respect fraudulent,

or if any false statement, or declaration is made or used in support

thereof, or if any fraudulent means or devices are used by the insured

 personoranyoneactingonhis/herbehalftoobtainanybenetunder

 thispolicy,allbenetsunderthispolicyshallbeforfeited.

Any amount already paid against claims made under this policy

but which are found fraudulent later shall be repaid by all recipient(s) /

policyholder(s), who has made that particular claim, who shall be

jointly and severally liable for such repayment to the Insurer.

For the purpose of this clause, the expression “fraud” means any of

the following acts committed by the Insured Person or by his agent or

the hospital / doctor / any other party acting on behalf of the insured person,

with intent to deceive the insurer or to induce the insurer to issue an

insurance Policy

a) the suggestion, as a fact of that which is not true and which the

Insured Person does not believe to be true;

b) the active concealment of a fact by the Insured Person having

knowledge or belief of the fact;

 c) anyotheractttedtodeceive;and

d) any such act or omission as the law specially declares to be

fraudulent

The company shall not repudiate the claim and / or forfeit the policy

 benets on the ground of Fraud, if the insured person / beneciary

can prove that the misstatement was true to the best of his knowledge

and there was no deliberate intention to suppress the fact or that such

mis-statement of or suppression of material fact are within the

knowledge of the insurer.

E.I.7. Cancellation

i. The policyholder may cancel this policy by giving 15 days written notice

and in such an event, the Company shall refund premium for the

unexpired policy period as detailed below.

RefundGridasa%ofPremium

PolicyCancelation

Within(Days)

PolicyYear-1

Policy

Year-2

Policy

Year-3

0-30Days 85.00% 87.50% 89.00%

31-90Days 75.00% 80.00% 82.50%

91 - 181 Days 50.00% 70.00% 75.00%

182 - 272 Days 30.00% 60.00% 70.00%

273 - 365 Days 0.00% 50.00% 60.00%

366 - 456 Days

NIL

35.00% 55.00%

457 - 547 Days 25.00% 45.00%

548 - 638 Days 15.00% 40.00%

639-730Days 0.00% 30.00%

731 - 821 Days

NIL

25.00%

822 - 912 Days 15.00%

913-1003Days 5.00%

1004andmore

Days

0.00%

No refund will be processed for cancellation of policies with Premium

Payment Mode as Half-yearly, Quarterly or Monthly.

Notwithstanding anything contained herein or otherwise, no refunds of

premium shall be made in respect of Cancellation where, any claim has

 beenadmittedorhasbeenlodgedoranybenethasbeenavailedby

the insured person under the policy.

ii. The Company may cancel the policy at any time on grounds of

misrepresentation, non- disclosure of material facts, fraud by

the insured person by giving 15 days written notice. There would

be no refund of premium on cancellation on grounds of

misrepresentation, non-disclosure of material facts or fraud.