Niva Bupa Health Insurance India, Niva Bupa Mediclaim Policy

There is no upper limit on the number of claims during the policy period. However, the total cumulative claim amount cannot exceed the Policy Sum Insured, unless the chosen plan has a Sum Insured Refill benefit, which provides additional coverage even after filing a claim.

A pre-existing disease is any condition, ailment or injury or related condition(s), for which the insured person had signs or symptoms, and /or were diagnosed, and / or received medical advice / treatment within 36 months prior to 1st health insurance policy issued by Us under which the insured person was covered.

No. Most Life Insurance products are designed to protect your family (or dependents) from a financial loss that may arise in the event of your untimely death. The payout is made mostly post the death of the person insured or at the maturity of the policy. Health Insurance on the other hand, protects you against ill health or diseases by covering the expenses you might incur for treatment, diagnosis etc. Health insurance policies need to be renewed annually.

Under cashless hospitalization, the insured person does not settle the hospitalization expenses at the time of discharge from hospital. The settlement is done directly by us for treatment that the insured person is eligible to receive under the terms of his/her policy. This is for your convenience. However, it is important to note here that prior approval is required from us before admission into the hospital. In some cases, you may have to pay for all or part of the treatment if it is not fully covered under the terms of the policy. However, in case of emergency hospitalization, you can obtain approval post-admission. Please note that the cashless facility is available only at our Network Hospitals.

Mediclaim is a type of health insurance. However some health insurance policies can be more comprehensive than mediclaim , as they cover more health benefits.

A medical checkup may be necessary when you sign up for a new health insurance policy. However, medical checkups are not usually needed for renewal of policies. It is in your best interests to undergo a medical check-up at the time of enrollment so that when you need us, we‘re there to provide speedy and efficient support and faster settlement of claims.

Of course. You can cover your family residing in India under one policy. Your health insurance policy can be used by you all across India. For cashless facility, you need to do is check for a Niva Bupa network hospital near your place of residence. You can also get your claims reimbursed if you get treated at a hospital which is not in Niva Bupa’s hospital network.

Naturopathy and homeopathy treatments are not covered under our Heartbeat Health insurance plans. Our coverage is available for allopathic treatments in recognized hospitals and nursing homes.

Yes, your Health Insurance covers all diagnostic tests like X- Rays, MRIs, Blood Tests etc. if they are associated with an insured person’s stay in the hospital. These tests must also have been conducted within a maximum of 30 days prior to hospitalization and/or 60 days post hospitalization or during hospitalization. In addition, we cover outpatient diagnostic tests if a specialist prescribes them and if you have chosen the Platinum Policy.

When you get a new health insurance policy, there will be a 90 day waiting period starting from the policy start date, during which period hospitalization charges will not be payable. However, this is not applicable to any emergency hospitalization occurring due to an accident. This 90 day waiting period is not applicable when the policy is renewed.

While filling up your health insurance proposal form, you will need to provide details of any health conditions in your medical history so far. At the time of enrolment, you should be aware of any current medical conditions and if you are undergoing any treatment. We refer such health issues to our medical panel to differentiate between pre-existing and newly contracted conditions. Note: It is important to disclose any medical condition that you may have, prior to buying the health insurance policy. Insurance is a contract based on good faith and any willful non-disclosure of facts might lead to repudiation or rejection of a claim in the future.

Most policies offer the benefit of treatment at home when:
a) The condition of the patient is such that he cannot be moved to a hospital or
b) There is no bed available in any of the hospitals and
c) Only if it resembles the treatment given at the hospital/nursing home that is
reimbursable under the policy. This is called domiciliary hospitalization and is subject to certain restrictions both in terms of the amount that is reimbursable as well as the diseases that are covered under it.

If you exhaust your entire sum insured & cumulative bonus (if any) and still require further hospitalisation for any related or unrelated illness, we will refill the full Sum Insured at no extra cost upto the original Base Sum Insured.

The premium paid on a health insurance policy is eligible for deduction under Section 80D of the Income Tax Act. So save with your policy now!

No, it is not possible to revise the sum insured during the policy period, the same can be carried out at the time of renewal of the policy.

Co-payment is a cost-sharing requirement under a health insurance policy, where the Policy Holder / insured will bear a specified percentage of the admissible costs.

A waiting period is the length of time you, the insured, will have to wait before the benefits under the health policy can be utilised.

A ‘Free Look Period’ is a period of 15 days from the date of receipt of the policy that a policyholder, in this case you, have to review the entire health insurance plan. If you disagree with any of the terms or conditions mentioned in the policy, you have the option of returning the policy by stating the reasons for the objection. Following this, you are entitled to a refund of the premium paid, provided no claim has been made under this mediclaim insurance policy (subject only to a deduction of the expenses incurred by the company on medical examination and the stamp duty charges). Please note that this facility is not applicable on renewal and portability cases.

A grace period refers to a period of 30 days immediately following the premium due date of the medical insurance policy. During this period you can pay the premium of your expired policy and avail continuity benefits such as waiting periods and coverage of pre-existing disease.

Hospital cash is a daily benefit which provides the insured person with a lump sum amount in case of hospitalisation. You can use the money for meeting additional expenses or for compensating the loss of income during the period of hospitalisation.

The hospital may ask you for a security deposit as part of its internal policy. However, this may vary from hospital to hospital and the deposit may be refunded as per hospital guidelines.

For your grievances, please write to the General Manager and grievance redressal officer at grievanceredressal@maxbupa.com

An unrecognised hospital or health facility refers to establishments who aren’t recognised by the relevant authorities in India or any other country where the treatment takes place. We have listed them on our website, and they can also be found on the policy document claims for treatment at hospitals which are not covered. Un-recognised hospitals can be seen on our website by visiting www.maxbupa.com and clicking on hospital network followed by clicking on List of Un-recognised hospitals.

The following KYC documents are required from the insured person/proposer in cases of reimbursement-

• If claim amount is below 1 lakh- Photo Id proof & address proof
• If claim amount is above 1 lakh- Photo Id proof, address proof and a recent photograph

A printed name cancel cheque under the name of the proposer/ patient has to be submitted. If the name is not printed on the cancel cheque, we will require an attested bank passbook along with the bank statements of the last three months.

The following KYC documents are required for reimbursement if there is a death of a policyholder-

• Photo Id proof, address proof and a recent photograph of either the patient/proposer
• Photo id proof, address proof and a recent photograph of the nominee.

A deductible is a cost-sharing requirement. It states that the insurer will not be liable for a specified amount in case of indemnity policies. This is applicable for a specified number of days/hours in case of hospital cash policies which apply before any benefits are payable by the insurer. Remember that a deductible does not reduce your sum insured.

We cover reasonable and customary charges for medical expenses incurred during the insured person’s medically necessary and medically advised in-patient hospitalisation during the policy period for treatments like Ayurveda, Unani, Sidha and Homeopathy (AYUSH). However, treatment must take place in a government hospital or in any institute recognised by the government and/or accredited by the Quality Council of India/the National Accreditation Board of Health.

The medical expenses traceable to childbirth (including complicated deliveries and caesarean sections during hospitalisation) and the expenses incurred towards any lawful medical termination of pregnancy during the policy period will be covered.

Do they only need to pay the difference for the room or for other services as well?

If the insured person is admitted in the hospital in a room category higher than their eligibility as specified in the product benefits table, then we shall only pay a pro-rated proportion of the total associated medical expenses (including surcharge or taxes thereon) in the proportion of the difference between the room rent actually incurred and the entitled room category.

Reasonable and customary charges refer to the expenses incurred for medical services/supplies as long as they are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services. We also take into account the nature of the illness/injury involved.

In-patient hospitalisation refers to the admission of an insured person in a hospital for a minimum of 24 consecutive hours. This is barring specified procedures/treatments, where such admission could be for a period of less than 24 consecutive hours. Our network hospitals are institutions established for in-patient care and day-care treatment for sickness and/or injuries and have been registered as a hospital with the local authorities, under the Clinical Establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act. It must comply with all the following criteria like-

• Should have a qualified nursing staff under its employment round the clock.
• Should have atleast 10 in-patient beds, in towns having a population of less than 10,00,000 and 15 in-patient beds in all other places.
• Should have qualified medical practitioners who are in-charge round the clock.
• Must have a fully equipped operation theatre of its own where surgical procedures are carried out.
• Must maintain a daily record of patients which can be accessible for our authorised personnel.

Day-care treatment refers to medical treatment and/or surgical procedure which is undertaken under general or local anaesthesia in a hospital/day care centre in less than 24 hours which would have otherwise required hospitalisation of more than 24 hours. Treatment normally taken on an OPD Treatment basis is not included in the scope of this definition.