Terms & Conditions:

Consent:

I agree to be contacted by Raheja QBE General Insurance Co. Ltd. for communications pertaining to this proposal and consent to override my DND registration.

DECLARATION & WARRANTY ON BEHALF OF ALL PERSONS PROPOSED TO BE INSURED

  • I/We hereby declare on my behalf and on behalf of all persons proposed to be insured that the above statements are true and complete in all respects to the best of my knowledge and that I/We am/are authorized to propose on behalf of these other persons.
  • I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the Insurance company and that the policy will come into force only after full receipt of the premium chargeable.
  • I/We further declare that I/We will notify in writing any change occurring in the occupation or general health of the life to be insured/ proposer after the proposal has been submitted but before communication of the risk acceptance by the company.
  • I/we declare and further consent to the company seeking medical information from any hospital who at anytime has attended on the life to be insured/ proposer or from any past or present employer concerning anything which affects the physical and mental health of the life to be insured/proposer and seeking information from any insurance company to which an application for insurance on the life to be insured/ proposer has been made for the purpose of underwriting the proposal and/or claim settlement.
  • I/We authorize the company to share information pertaining to my proposal including the medical records for the sole purpose of proposal underwriting and/or claims settlement and with any Governmental and/or Regulatory Authority.
    • Fraud Warning : This policy shall be voidable at the option of the Company in the event of mis-representation, mis-description or non-disclosure of any material particulars by the Proposer. Any person who, knowingly and with intent to defraud the insurance company or any other person, files a proposal for insurance containing any false information, or conceals for the purpose of misleading, Information concerning any fact material thereto, commits a fraudulent insurance act, which will render the policy voidable at the sole discretion of the insurance company and result in a denial of insurance benefits.
    • Anti-Rebating Warning : PROHIBITION OF REBATES – UNDER SECTION 41 OF THE INSURANCE LAWS (AMENDMENT) ACT, 2015.
      No person shall allow or offer to allow either directly or indirectly as inducement to any person to take out renew or continue an insurance in respect of any kind of risk relating to lives or property in India any rebate of the whole or part of the commission payable or any rebate of the premium shown on the Policy, nor shall any person taking out or renewing or continuing a Policy accept any rebate except such rebate as may be allowed in accordance with the published prospectuses or tables of the Insurer.Any person making default in complying with the provision of this section shall be punishable with fine which may extend to
      INR 10,00,000/-

Waiting Period

The Company shall not be liable to make any payment under the policy in connection with or in respect of following expenses till the expiry of waiting period mentioned below:

Pre-Existing Diseases: (Code- Excl01)

  1. Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with us.
  2. In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
  3. If the Insured Person is continuously covered without any break as defined 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.
  4. Coverage under the policy after the expiry of 48 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by us.

First Thirty Days Waiting Period: (Code- Excl03)

  1. Expenses related to the treatment of any illness within 30 days from the first policy commencement date shall be excluded except claims arising due to an accident, provided the same are covered.
  2. This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve months.
  3. The within referred waiting period is made applicable to the enhanced sum insured in the event of granting higher sum insured subsequently.

Specific Waiting Period: (Code- Excl02)

  1. Expenses related to the treatment of the following listed conditions, surgeries/treatments shall be excluded until the expiry of 24/48 months of continuous coverage, as may be the case after the date of inception of the first policy with the insurer. This exclusion shall not be applicable for claims arising due to an accident.
  2. In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
  3. If any of the specified disease/procedure falls under the waiting period specified for pre-existing diseases, then the longer of the two waiting periods shall apply.
  4. The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a specific exclusion.
  5. If the Insured Person is continuously covered without any break as defined under the applicable norms on portability stipulated by IRDAI, then waiting period for the same would be reduced to the extent of prior coverage.

24 Months waiting period

  1. Calculus diseases of gall bladder including Cholecystitis.
  2. Pancreatitis.
  3. Fissure/fistula in anus, hemorrhoids, pilonidal sinus.
  4. Ulcer and erosion of stomach and duodenum.
  5. GastroEsophageal Reflux Disorder (GERD).
  6. Cirrhosis (cirrhosis due to alcohol will be permanent exclusion).
  7. Perineal and/or Perianal Abscesses.
  8. Cholecystectomy and/or Surgery of hernia.
  9. Surgery of Hydrocele/Rectocele.
  10. Calculus diseases of Urogenital System and/or Surgery of prostate.
  11. Cataract.
  12. Dilatation and curettage (D&C).
  13. Non infective arthritis , Osteoarthrosis /Gout / Rheumatism / Spondylosis / Spondylitis / Intervertebral.
  14. Disc Prolapse and joint replacement surgeries (other than cause by an accident).
  15. Varicose veins and Varicose Ulcers.
  16. Internal tumors, cysts, nodules, polyps, skin tumors and any type of breast lumps.
  17. Chronic Suppurative Otitis Media (CSOM), Deviated Nasal Septum, Sinusitis, Surgery on Tonsils.
  18. Adenoids, Tympanoplasty and any other benign ear, nose and throat disorder or surgery.
  19. Hysterectomy for menorrhagia or fibromyoma or prolapsed of uterus unless necessitated by malignancy, myomectomy for fibroids.
  20. Congenital Internal diseases and anomalies.

48 Months waiting period

  1. Waiting period of 48 months will be applicable under the Policy to all Pre-existing Diseases, and those specifically declared and accepted at the time of proposal.
  2. Schizophrenia (ICD code: F20 to F29).
  3. Psychosis (IDC code: F29).
  4. Dissociative and conversion disorder (ICD Code: F44.9).

Exclusions

The Company shall not be liable to make any payment under the policy, in respect of any expenses incurred in connection with or in respect of:

Investigation & Evaluation: (Code- Excl04)

  1. Expenses related to any admission primarily for diagnostics and evaluation purposes.
  2. Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment.

Rest Cure, rehabilitation and respite care: (Code- Excl05)

  1. Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:
    1. 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.
    2. Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.

Obesity/ Weight Control: (Code- Excl06)

Expenses related to the surgical treatment of obesity that does not fulfil 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);
    1. greater than or equal to 40 or
    2. greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive methods of weight loss:
      1. Obesity-related cardiomyopathy
      2. Coronary heart disease
      3. Severe Sleep Apnea
      4. Uncontrolled Type2 Diabetes

Change-of-Gender treatments: (Code- Excl07)

Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.

Cosmetic or plastic Surgery: (Code- Excl08)

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 certified by the attending Medical Practitioner.

Hazardous or Adventure sports: (Code- Excl09)

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.

Breach of law: (Code- Excl10)

Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with criminal intent.

Excluded Providers: (Code-Excl11)

Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website / notified 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.

Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof: (Code- Excl12)

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)

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- Excl14)

Refractive Error: (Code- Excl15)

Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 diopters.

Unproven Treatments: (Code- Excl16)

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 significant medical documentation to support their effectiveness.

Sterility and Infertility: (Code- Excl17)

Expenses related to sterility and infertility. This includes:

  1. Any type of contraception, sterilization
  2. Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
  3. Gestational Surrogacy
  4. Reversal of sterilization

Maternity Expenses: (Code - Excl 18):

  1. Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalization) except ectopic pregnancy;
  2. expenses towards miscarriage (unless due to an accident) and lawful medical termination of pregnancy during the policy period.

War (whether declared or not) and or invasion, acts of foreign enemies, hostilities, civil war, rebellion, revolutions, insurrections, mutiny, military or usurped power, seizure, capture, arrest, restraints and detainment of all kinds.

Nuclear, chemical or biological attack as define below.

  1. Nuclear attack or weapons means the use of any nuclear weapon or device or waste or combustion of nuclear fuel or the emission, discharge, dispersal, release or escape of fissile/ fusion material emitting a level of radioactivity capable of causing any Illness, incapacitating disablement or death.
  2. Chemical attack or weapons means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing any Illness, incapacitating disablement or death.
  3. Biological attack or weapons means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organisms and/or biologically produced toxins (including genetically modified organisms and chemically synthesized toxins) which are capable of causing any Illness, incapacitating disablement or death.
  • Any expenses incurred on OPD treatment.
  • Treatment taken outside the geographical limits of India.
  • In respect of the existing diseases, disclosed by the insured and mentioned in the policy schedule (based on insured’s consent), policyholder is not entitled to get the coverage for specified ICD codes.
  • Any expense, condition or treatment not admissible in Annexure – I, List - I (Non Medical Expenses) except to the extent covered under Section (h) – Non-Medical Expenses (if applicable) under the Policy.
  • Dental Treatment, dentures or surgery of any kind unless necessitated due to an accident and requiring minimum 24 hours hospitalization.
  • Circumcision unless necessary for treatment of an Illness or as may be necessitated due to an Accident.