SBI General Insurance Company Limited

SAMPOORNA AROGYA - GROUP

CERTIFICATE OF INSURANCE
UIN:- SBIHLGP21605VO12021

Master Policy No GSA002242024

Policy No: POGSA00100295644 Issue Date: 02/04/2024

Intermediary Name & Code Sbi Bhankur Indl Estate 7572 0008877

Phone/Mobile/Email Id: /+91-8474-2204482 /

Intermediary Contact details Address:
[email protected]

Periodicity of
From 02/04/2024 (13:29 Hrs) to Midnight of
Policy Period payment of Yearly
01/04/2025(23:59 Hrs)
premium

Insured Ayyamma Ayyamma

near hudiyya,W/O Shivayogi muttaga,Mutga,Bhankur,Gulbarga,
Gulbarga,
Address
Karnataka-585228,
India.
PAN No.
Cover Opted for number of members 2
Previous Policy No
Date of 1st inception of Policy 02/04/2024

INSURED PERSON'S DETAILS

Appointe Coverage Under

e Name
Relationshi
Me Age in Nominee &
p with Nominee Person
mbe Member complete Name & Relation Hospita Hospita
S No Gender Primary DOB Age
r ID Name d years Relationship ship(If lization Critical l Daily al
Insured Illness Accide
Nominee Cover Cash
is Minor) nt

0000
01/0
0000 Ayyamma Shreenivas
1 Female Self 1/19 54 22 Y N Y N
7331 Ayyamma Shreenivas
70
2944
0000
21/0
0000 Shreenivas Shreenivas
2 Male Son 1/20 22 22 Y N Y N
7331 Shreenivas Shreenivas
02
2952

SBI General Insurance and SBI are separate legal entities and SBI is working as Corporate Agent of the company for sourcing of insurance products

PAGE 1 OF 38
SBI General Insurance Company Limited

Special Underwriting Conditions:

• Cashless facility will be applicable only for 'Section 1 - Hospitalization Cover' of this policy
• Specific waiting period as defined under Exclusions Point 2 (Excl02) under Policy wordings
• Pre-existing disease as defined under Exclusions Point 1 (Excl01) under Policy wordings
• First Thirty Days Waiting Period as defined under Exclusions Point 2 (Excl02) under Policy wordings
• Permanent Exclusions as defined under Exclusions Point 17 under Policy wordings
• Covid-19 Waiting Period

Additional Conditions, Exclusions, Warranties:

Coverage subject to the following additional Conditions and Clauses / Endorsements / Warranties with reference to the Section that it Is
applicable to

Insured Person Name Pre-Existing Conditions Special Exclusions

Ayyamma Ayyamma No
Shreenivas Shreenivas No

Sum Insured Details:

Section Coverage Members Sum Insured Basis of Sum Insured

I Hospitalization Cover Floater / Individual
Ayyamma Ayyamma 500,000.00
Shreenivas Shreenivas 500,000.00
II Critical Illness Individual
III Hospital Daily Cash Individual
Ayyamma Ayyamma 30,000.00
Shreenivas Shreenivas 30,000.00
IV Personal Accident Individual

PAGE 2 OF 38
 SBI General Insurance Company Limited

Contact Details:

Email [email protected]
Toll Free number 1800 210 3366, 1800 210 6366
Website www.sbigeneral.in
Fax No NA
Name: SBI General Insurance
Claims Administrator Address: 9th Floor,Westport,Pan Card Club Road,Baner Gaon,Baner,Pune,Maharashtra,India-
411045

If You are not satisfied with Our redressal of grievance through one of the above methods, You/ Insured Person may approach the nearest
Insurance Ombudsman for resolution of the grievance. The contact details of Ombudsman offices are attached as Annexure I to the Policy
Wordings.
For any communications with respect to the Insurance Contract you can contact our nearest branch office or write to us at “SBI General
Insurance Company Limited. “Natraj 301, Junction of Western Express Highway and Andheri Kurla-Road, Andheri East. Mumbai-400069

Premium Details
Premium Details Hospitalization Cover Critical Illness Daily Hospital Cash Personal Accident
Premium 7,131.30 0.00 526.85 0.00
Add: Loading 0.00 0.00 0.00 0.00
Less: Discount 0.00 0.00 0.00 0.00
Net Premium 8,595.01
Taxes as applicable 1547.10
Add Kerala Cess @1%
Final Premium 10,142.11

Signed at (RO/BO/DO - Details) For SBI General Insurance Company Limited

Dated: 02/04/2024 Authorised Signatory

For SBI General Insurance Company Limited

Signed at (RO/BO/DO-Details)

Digitally signed by
Dated: 02/04/2024 VISHWANATHAN
SUBRAMANIAN
Date: 2024.04.02 Authorised Signatory

P.S. If premium paid through cheque, the policy is void abinitio in case of dishonour of cheque.
773.55
Consolidated Stamp Duty paid Rs. 56.00/- towards Insurance Policy Stamps vide Order No.LOA/ENF-2/CSD/12/2023/(Validity Period
Dt.04/01/2024 to Dt.05/12/2025)/136 Date:- 04/01/2024 Dated 02/04/2024 of General Stamp Office, Mumbai

0
1.1

591.3
1.1
1
773.55
0.9

0.9
0
1

8003.

PAGE 3 OF 38
SBI General Insurance Company Limited

Service Tax Reg. No. 27AAMCS8857L1ZC

PREMIUM CERTIFICATE (Applicable to all sections except Section IV. Personal Accident))
Premium certificate for the purpose of deduction under section 80 - (D) of Income Tax (Amendment) Act, 1986
Transaction Id: SBIYB24093133804833995287
This is to certify that Mr./Ms./Mrs. Ayyamma Ayyamma has paid INR 10142(In Words Rupees Ten Thousand One Hundred and Forty Two)
towards the premium for Health Insurance vide Direct Credit Transaction ID/Cheque No.SBIYB24093133804833995287
for the period from 02/04/2024 To 01/04/2025 Midnight for Policy No. POGSA00100295644
Date: 02/04/2024 For SBI General Insurance Company Limited

Place: Mumbai Authorised Signatory

Important Note:
Insurance is a contract of Utmost Good Faith requiring the Insured not only to disclose all information related to his health and which has a
bearing on the acceptance or rejection of the Proposal by the Insurer and also not to suppress any factual information in response to the
questions in the Proposal form.
Please examine this Policy including its attached Schedules/ Annexure if any. In the event of any discrepancy, contact the office of the Insurer
immediately, it being noted that this Policy shall be otherwise considered as being entirely in order.
In case of payment by cheque, in the event of dishonor of cheque for any reason whatsoever, insurance provided under this document
automatically stands cancelled from the inception of the Policy irrespective of whether a separate communication is sent or not.
All terms, conditions and exclusions as per standard Policy wordings attached with this Schedule.
INSURANCE IS THE SUBJECT MATTER OF SOLICITATION

Deductible/Co Payment
Non- Network hospitalization Co Payment at 10% (if opted)
Voluntary Co- Payment at 20% (if opted)
Hospital Daily Cash - 24 hours

Waiting Periods applicable to different Sections

Hospitalization Cover Critical Illness Daily Hospital Cash Personal Accident

Pre- Existing disease -48 months Pre- Existing disease -48 months Pre- Existing disease -48 months No Waiting Period
30 days Waiting period except for 30 days Waiting period except
Renewal policies and Claims as a First 90 days Waiting Period for Renewal policies and Claims
result of Accident as a result of Accident
12 months Waiting period for 12 months Waiting period for
specific diseases as listed in the Survival Period - 28 days specific diseases as listed in the
Policy Policy
90 Days Waiting Period for Specific
diseases as listed in the policy
Maternity waiting period- 24
months

PAGE 4 OF 38
SBI General Insurance Company Limited

COVERAGE DETAILS( to be populated as per plan chosen)

Sum Insured Limit- 50,000 to 5.5 Sum Insured Limit- Limit- 6 Lakh-
Section Details Details of Coverage
Lakhs 10 Lakh
Section I: Hospitalization Cover
Members Covered
Ayyamma Ayyamma
Shreenivas Shreenivas
Room Rent boarding and Nursing 2% of sum insured, 2% of sum insured,
Charges.
4% of sum insured,
ICU charges 4% of sum insured,

Pre-Hospitalization Medical 30 days prior to date of admission 60 days prior to date of admission
expenses into the hospital/ Up to SI into the hospital/ Up to SI
Post Hospitalization Medical 60 days prior to date of admission 90 days prior to date of admission
expenses into the hospital/ Up to SI into the hospital/ Up to SI
1% of SI up to a max of Rs. 5000 1% of SI up to a max of Rs. 10,000
Ambulance Expenses but available for road ambulance but available for road ambulance
only and per policy year only and per policy year
20% of the Sum Insured 20% of the Sum Insured
Domiciliary Hospitalization
maximum up to Rs. 50000 maximum up to Rs. 200000

Day Care Procedures Upto Sum Insured Upto Sum Insured

Alternative Treatment Expenses Not Applicable Upto Sum Insured
Not Applicable
Organ Donor Expenses Up to 50% of Sum Insured

Maternity Expenses 10% of sum insured subject to a

Not Applicable
maximum Up to 100,000/-
Not Applicable 20% of sum insured subject to a
New Born Baby Expenses
maximum Up to 200,000/-

Not Applicable 1% of sum insured subject to a

Out Patient Expenses maximum upto 10,000 per policy
limit each year
Not Applicable Once up to 100% not for same
Reinstatement of Sum Insured
illness within the same year
Not Applicable 2/3/5 lacs deductible as opted for
High Deductible

Mental Healthcare 10% of the SI, max Rs. 50,000 10% of the SI, max Rs. 50,000
HIV/AIDS Cover upto 25% of Sum insured) upto 25% of Sum insured)
Genetic Disorder/Diseases upto Rs. 1 Lac upto Rs. 1 Lac
Internal Congenital Diseases upto 25% of Sum insured) upto 25% of Sum insured
Advance Treatments for 12
Procedure as mentioned in the upto 25% of Sum insured) upto 25% of Sum insured
policy
Section II:Critical Illness
Members Covered
Ayyamma Ayyamma
Shreenivas Shreenivas

PAGE 5 OF 38
SBI General Insurance Company Limited

1. Cancer of specific severity

2. Myocardial Infarction (First
heart attack of specific severity)
3. Open Chest CABG
4.Open Heart Replacement or
Repair of Heart Valves
5. Coma of Specified Severity
6. Kidney Failure Requiring
Regular Dialysis
7. Stroke Resulting in Permanent
Symptoms
As per Sum Insured opted (1 As per Sum Insured opted (1
8.Major Organ/Bone Marrow
lakh- 10 lakhs) lakh- 10 lakhs)
Transplant
9. Permanent Paralysis of Limbs
10. Multiple Sclerosis with
Persisting Symptoms
11.Blindness
12.Primary(Idiopathic)
Pulmonary Hypertension
13. Aorta Graft Surgery
14. Benign Brain Tumor
15. Motor Neurone disease with
Permanent Symptoms
Section III:Hospital Daily Cash
Members Covered
Ayyamma Ayyamma
Shreenivas Shreenivas
Up to the Sum insured limit and Up to the Sum insured limit and
Sickness Hospital Cash Benefit
for the number of days as opted for the number of days as opted
Accident Hospital Cash Benefit 2 times the Daily Cash benefit 2 times the Daily Cash benefit
3 times the Daily Cash benefit 3 times the Daily Cash benefit
maximum of 15 days in aggregate maximum of 15 days in aggregate
ICU Cash Benefit
per Insured Person per Policy per Insured Person per Policy
Year. Year.
5 times the Daily Cash Benefit for 5 times the Daily Cash Benefit for
each continuous and completed each continuous and completed
Convalescence Benefit
period of 24 hours of period of 24 hours of
Hospitalisation. Hospitalisation.
10 times the Daily Cash Benefit 10 times the Daily Cash Benefit
Compassionate Benefit amount subject to admissibility amount subject to admissibility
of the claim under the base of the claim under the base
cover. cover.
5 times the Daily Cash Benefit or 5 times the Daily Cash Benefit or
Rs. 10,000/- to the Insured Rs. 10,000/- to the Insured
Person for such Day Care (Day Person for such Day Care (Day
Care Treatment for less than 24 Care Treatment for less than 24
Day Care Treatment Benefit hours.) hours.)
The benefit under this Section The benefit under this Section
shall be available for a maximum shall be available for a maximum
of 2 Day Care Treatments per of 2 Day Care Treatments per
Insured Person per Policy Year. Insured Person per Policy Year.
Section IV: Personal Accident
Members Covered
Ayyamma Ayyamma
Shreenivas Shreenivas
As per SI limit opted As per SI limit opted
Accidental Death Benefit (1,2,4, 5,10, 15,20 lakhs as opted (1,2,4, 5,10, 15,20 lakhs as opted
for) for)
1% of Sum Insured subject to a 1% of Sum Insured subject to a
Funeral Expenses Benefit
max of Rs. 10,000/- max of Rs. 10,000/-

PAGE 6 OF 38
SBI General Insurance Company Limited

Name : Ayyamma Ayyamma

Claim Administrator : SBI General Insurance
Member ID : 0000000073312944
Relation : Self
Age/Gender : 54, Female
Start Date : 02/04/2024
Policy Number : POGSA00100295644

This card identifies you as a SBI General beneficiary and valid for cashless hospitalisation at
SBI General Insurance network hospitals subject to your policy terms and valid authorization
letter from SBI General Insurance. Presentation of a valid photo identity along with this card is
mandatory to avail cashless access at SBI General Insurance Network Hospitals. Insured needs
to pay for non-medical hospitalisation bills, amount in excess of limit specified in
authorisation letter and conditions not covered in the policy. In case of any concerns /
clarifications related to policy and service, please do not hesitate to get in touch with your
insurer i.e. SBI General at [email protected] <mailto:[email protected]> or
call Customer Care Toll Free Numbers 1800 210 3366 / 1800 210 6366 (Available 24*7)

SBI General Insurance Company Limited 9th Floor, Westport, Pan Card Club Road, Baner,
Pune, Maharashtra - 411 045 www.sbigeneral.in

SBI General Insurance and SBI are seperable legal entities and SBI is working as corporate
agent of the company for sourcing of insurance products

Name : Shreenivas Shreenivas

Claim Administrator : SBI General Insurance
Member ID : 0000000073312952
Relation : Son
Age/Gender : 22, Male
Start Date : 02/04/2024
Policy Number : POGSA00100295644

PAGE 7 OF 38
SBI General Insurance Company Limited

This card identifies you as a SBI General beneficiary and valid for cashless hospitalisation at
SBI General Insurance network hospitals subject to your policy terms and valid authorization
letter from SBI General Insurance. Presentation of a valid photo identity along with this card is
mandatory to avail cashless access at SBI General Insurance Network Hospitals. Insured needs
to pay for non-medical hospitalisation bills, amount in excess of limit specified in
authorisation letter and conditions not covered in the policy. In case of any concerns /
clarifications related to policy and service, please do not hesitate to get in touch with your
insurer i.e. SBI General at [email protected] <mailto:[email protected]> or
call Customer Care Toll Free Numbers 1800 210 3366 / 1800 210 6366 (Available 24*7)

SBI General Insurance Company Limited 9th Floor, Westport, Pan Card Club Road, Baner,
Pune, Maharashtra - 411 045 www.sbigeneral.in

SBI General Insurance and SBI are seperable legal entities and SBI is working as corporate
agent of the company for sourcing of insurance products

PAGE 8 OF 38
SBI General Insurance Company Limited

SAMPOORNA AROGYA - GROUP

POLICY WORDING

8 AYUSH Hospital is a healthcare facility wherei medical/surgical/

PREAMBLE para-surgical treatment procedures and interventions are
carried out by AYUSH Medical Practitioner(s) comprising of any
of the following
In consideration of payment of Premium by You, We will provide
a. Central or State government AYUSH Hospital; or
insurance cover to the Insured Person(s) under this Policy up to Sum
b. Teaching hospital attached to AYUSH College recognized by
Insured and subject to waiting period, minimum hospitalization
the Central Government/Central Council of Indian
period and deductible/ Time Deductible/ Aggregate Deductible/
Medicine/ Central Council for Homeopathy; or
CoPay/ Voluntary Co-Pay as mentioned on Policy Schedule/ Certificate c. AYUSH hospital standalone or co-located with in-patient
of Insurance. healthcare facility of any recognized system of medicine,
registered with the local authorities, wherever applicable,
This Policy is subject to Your statements in respect of all the Insured and is under the supervision of a qualified registered
Persons in Proposal Form /Enrolment AYUSH Medical Practitioner and must comply with the
following criterion:
Form, declarations, payment of premium and terms and conditions of i. Having at least 5 in-patient beds
this Policy ii. Having qualified AYUSH Medical Practitioner in charge
round the clock
DEFINITIONS iii. Having dedicated AYSUH therapy sections as required
1 and/or has equipped operation theatre where surgical
Accident or Accidental means a sudden, unforeseen and
procedures are to be carried out
involuntary event caused by external, visible and violent means.
iv. Maintaining daily records of patients and making them
2 Age or Aged means the completed age (in years) of the Insured
accessible to the insurance company’s authorized
Person as on his/ her last birthday.
representative
3 Aggregate Deductible is a cost-sharing requirement under this 9 Cashless Facility means a facility extended by the Insurer to the
Policy that provides that the Company will not be liable for a
Insured Person where the payments, of the costs of treatment
specified Rupee amount of the covered expenses, which will
undergone by the Insured in accordance with the Policy terms
apply before any benefits are payable by the Company. A
and conditions, are directly made to the Network provider by
deductible does not reduce the Sum Insured. The deductible is
the Insurer to the extent pre-authorization approved.
applicable in aggregate towards hospitalization expenses 10 Condition Precedent means a Policy term or condition upon
incurred during the policy period by insured (individual policy)
which Our liability under the Policy is conditional upon.
or insured family (in case of floater policy)
11 Congenital Anomaly refers to a condition(s) which is present
4 Alternative Treatments are forms of treatments other than
since birth, and which is abnormal with reference to form,
"Allopathy" or "modern medicine" and includes Ayurveda,
structure or position.
Unani, Siddha and Homeopathy (AYUSH) in the Indian context
a. Internal Congenital Anomaly - Congenital anomaly which is
5 Any one illness means continuous period of illness and includes
not in the visible and accessible parts of the body
relapse within 45 days from the date of last consultation with b. External Congenital Anomaly - Congenital anomaly which
the hospital/day care centre where treatment was taken. is in the visible and accessible parts of the body
6 Associated Medical Expenses shall include Room Rent, nursing 12 Co-Payment means a cost sharing requirement under a health
charges, operation theatre charges, fees of Medical
insurance policy that provides that the policyholder/ insured
Practitioner/surgeon/ anaesthetist/ Specialist conducted within
will bear a specified percentage of the admissible claims
the same Hospital where the Insured Person has been admitted.
amount. A co-payment does not reduce the Sum Insured.
The below expenses are not part of associate medical expenses
13 Day Care Centre means any institution established for day care
a. Cost of Pharmacy and consumables
treatment of illness and/or injuries or a medical setup within a
b. Cost of implants and medical devices
c. Cost of diagnostics Hospital and which has been registered with the local
7 AYUSH Day Care Centre means or includes Community Health authorities, wherever applicable, and is under the supervision of
Centre (CHC), Primary Health Centre (PHC), Dispensary, Clinic, a registered and qualified Medical Practitioner AND must
Polyclinic or any such health centre which is registered with comply with all minimum criterion as under -
local authorities, wherever applicable and having facilities for a. has qualified nursing staff under its employment;
b. has qualified Medical Practitioner(s) in charge;
carrying out treatment procedures and medical or
c. has a fully equipped operation theatre of its own where
surgical/para-surgical interventions or both under the
surgical procedures are carried out;
supervision of registered AYUSH Medical Practitioner(s) on day d. maintains daily records of patients and will make these
care basis without in-patient services and must comply with all accessible to the insurance company’s authorized
the following criterion: personnel
a. Having qualified registered AYUSH Medical Practitioner(s) 14 Day Care Treatment means medical treatment, and/or surgical
in charge procedure which is
b. Having dedicated AYUSH therapy sections as required
a. undertaken under General or Local Anesthesia in a
and/or has equipped operation theatre
hospital/day care center in less than 24 hours because of
c. Maintaining daily records of patients and making them
technological advancement, and
accessible to the insurance company’s
b. 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 definition

PAGE 9 OF 38
SBI General Insurance Company Limited

15 Deductible means a cost sharing requirement under a health 25 llness means a sickness or a disease or pathological condition
insurance policy that provides that the Insurer will not be liable leading to the impairment of normal physiological function
for a specified rupee amount in case of indemnity policies and which manifests itself during the Policy Period and requires
for a specified number of days/hours in case of hospital cash medical treatment.
policies which will apply before any benefits are payable by the a. Acute condition - Acute condition is a disease, illness or
Insurer. A deductible does not reduce the Sum Insured. injury that is likely to respond quickly to treatment which
(Deductible will be applicable as specified under the Policy) aims to return the person to his or her state of health
16 Dental Treatment means a treatment related to teeth or immediately before suffering the disease/ illness/ injury
structures supporting teeth including examinations, fillings which leads to full recovery
(where appropriate), crowns, extractions and surgery. b. Chronic condition - A chronic condition is defined as a
17 Dependent means the Insured Person’s legal spouse or children disease, illness, or injury that has one or more of the
or parents or parent-in-law who have been enrolled in the following characteristics:
Group Policy. i. it needs ongoing or long-term monitoring through
18 Dependent Child or a child (natural or legally adopted), who is consultations, examinations, check-ups, and /or tests
financially dependent on the Policy Holder, does not have his ii. it needs ongoing or long-term control or relief of symptoms
/her independent source of income, is up to the age of 25 years iii. it requires rehabilitation for the patient or for the patient to
and unmarried. be specially trained to cope with it
19 Disclosure to information norm - The policy shall be void and all iv. it continues indefinitely
premium paid thereon shall be forfeited to the Company in the v. it recurs or is likely to recur
event of misrepresentation, mis-description or non-disclosure of 26 Injury means accidental physical bodily harm excluding illness or
any material fact. disease solely and directly caused by external, violent and visible
20 Domiciliary Hospitalization means medical treatment for an and evident means which is verified and certified by a Medical
illness/ disease/ injury which in the normal course would require Practitioner.
care and treatment at a hospital but is actually taken while 27 In-patient means an Insured Person who is admitted to a
confined at home under any of the following circumstances: Hospital and stays for at least 24 hours for the sole purpose of
a. the condition of the patient is such that he/she is not in a receiving
condition to be removed to a hospital, or treatment.
b. the patient takes treatment at home on account of 28 Inpatient Care means treatment for which the Insured Person
nonavailability of room in a hospital. has to stay in a Hospital for more than 24 hours for a covered
21 Emergency Care means management for a Illness or Injury event.
which results in symptoms which occur suddenly and 29 Insured Person means the Insured Member or Dependants
unexpectedly and requires immediate care by a Medical named in the Policy Schedule/Certificate, who is/are covered
Practitioner to prevent death or serious long-term impairment under this Policy, for whom the insurance is proposed, and the
of the Insured Person’s health. appropriate premium is received.
22 Grace Period means the specified period of time immediately 30 Intensive Care Unit(ICU) means an identified section, ward or
following the premium due date during which a payment can be wing of a hospital which is under the constant supervision of a
made to renew or continue a policy in force without loss of dedicated Medical Practitioner(s), and which is specially
continuity benefits such as waiting periods and coverage of equipped for the continuous monitoring and treatment of
preexisting diseases. Coverage is not available for the period for patients who are in a critical condition, or require life support
which no premium is received. facilities and where the level of care and supervision is
23 Hospital means any institution established for in-patient care considerably more sophisticated and intensive than in the
and day care treatment of Illness and/or Injuries and which has ordinary and other wards.
been registered as a hospital with the local authorities under the 31 Intensive Care Unit (ICU) Charges means the amount charged
Clinical Establishments (Registration and Regulation) Act, 2010 by a Hospital towards ICU expenses which shall include the
or under the enactments specified under the Schedule of expenses for ICU bed, general medical support services provided
Section of 56(1) of the said Act OR complies with all minimum to any ICU patient including monitoring devices, critical care
criteria as under: nursing and intensivist charges.
a. Has a fully equipped operation theatre of its own where 32 Maternity Expense means:
Surgical Procedures are carried out; a. Medical treatment expenses traceable to childbirth
b. Has at least 10 in-patient beds in towns having a population (including complicated deliveries and caesarean sections
of less than 10,00,000 and at least 15 in-patient beds in all incurred during Hospitalisation);
other places; b. Expenses towards lawful medical termination of pregnancy
c. Has qualified Medical Practitioner(s) in charge round the during the Policy Period
clock; 33 Medical Advice means any consultation or advice from a
d. Has qualified nursing staff under its employment round the Medical Practitioner including the issuance of any prescription
clock; or followup prescription.
e. Maintains daily records of patients and makes this accessible 34 Medical Expenses means those expenses that an Insured Person
to the insurance company’s authorized personnel. has necessarily and actually incurred for medical treatment on
24 Hospitalization or Hospitalised means admission in a Hospital account of Illness or Accident on the advice of a Medical
for a minimum period of 24 In-patient Care consecutive hours Practitioner, as long as these expenses are not more than what
except for specified procedures/treatments, where such would have been payable if the Insured Person had not been
admission could be for a period of less than 24 consecutive insured and not more than other hospitals or doctors in the
hours. same locality would have charged for the same medical
treatment.

PAGE 10 OF 38
SBI General Insurance Company Limited

35 Medically Necessary means any treatment, test, medication, or 46 Policy means Policy document, the Group Proposal Form /
stay in Hospital or part of stay in Hospital which Enrolment Form, the Policy Schedule/Certificate of Insurance
a. Is required for the medical management of the Illness or issued to Insured Persons, Annexures, insuring clauses (if
Injury suffered by the Insured Person; applicable to individual sections), definitions, exclusions,
b. Must not exceed the level of care necessary to provide conditions and other terms contained herein, including
safe, adequate and appropriate medical care in scope, endorsements (as amended from time to time), attaching to or
duration or intensity. forming part hereof, either at inception or during the Policy
c. Must conform to the professional standards widely Period.
accepted in international medical practice or by the 47 Policy Holder means the person or entity named in the Policy
medical community in India. Schedule/Certificate as the Policy Holder.
d. Must conform to the professional standards widely 48 Policy Period means the period commencing from Policy start
accepted in international medical practice or by the date and time as specified in the Policy Schedule/Certificate or
medical community in India. Insurance and terminating at midnight on the Policy end date as
36 Medical Practitioner means a person who holds a valid specified in the Policy Schedule/Certificate of Insurance.
registration from the Medical Council of any State or Medical 49 Policy Schedule/Certificate of Insurance means the Schedule
Council of India or Council for Indian Medicine or for attached to and forming part of thisPolicy mentioning the details
Homeopathy set up by the Government of India or a State of the Insured Persons, the Sum Insured, the Policy Period and
Government and is thereby entitled to practice medicine within the limits and conditions to which the Benefits under the Policy
its jurisdiction; and is acting within the scope and jurisdiction of are subject to, including any Annexures and/or endorsements
license. Medical Practitioner should not be the Insured Person 50 "Portability” means, the right accorded to individual health
or his/her Immediate Family Member or anyone who is living in insurance policyholders (including all members under family
the same household as the Insured Person. cover), to transfer the credit gained for pre-existing conditions
37 Mental health establishment means any health establishment, and time bound exclusions, from one insurer to another insurer.
including Ayurveda, Yoga and Naturopathy, Unani, Siddha and 51 Post-hospitalization Medical Expenses means Medical Expenses
Homoeopathy establishment, by whatever name called, either means medical expenses incurred during pre-defined number of
wholly or partly, meant for the care of persons with mental days immediately after the Insured Person is discharged from
Illness, established, owned, controlled or maintained by the the Hospital, provided that:
appropriate Government, local authority, trust, whether private a. Such Medical Expenses are incurred for the same condition
or public, corporation, co-operative society, organisation or any for which the Insured Person’s Hospitalization was
other entity or person, where persons withmental Illness are required, and
admitted and reside at, or kept in, for care, treatment, b. The inpatient Hospitalization claim for such
convalescence and rehabilitation, either temporarily or Hospitalization is admissible by the Insurance company.
otherwise; and includes any general Hospital or general nursing 52 Pre-hospitalization Medical Expenses means Medical Expenses
home established or maintained by the appropriate incurred during pre-defined number of days preceding the
Government, local authority, trust, whether private or public, hospitalization of the Insured Person, provided that:
corporation, co-operative society, organisation or any other a. Such Medical Expenses are incurred for the same
entity or person; but does not include a family residential place condition for which the Insured Person’s Hospitalization
where a person with mental Illness resides with his relatives or was required, and
friends b. The inpatient Hospitalization claim for such
38 “Migration” means, the right accorded to health insurance Hospitalization is admissible by the Insurance company.
53 Pre-existing Disease means any condition, ailment, injury or
policyholders (including all members under family cover and
members of group health insurance policy), to transfer the disease:
credit gained for pre existing conditions and time bound a. That is/are diagnosed by a physician within 48 months
exclusions, with the same insurer. prior to the effective date of the policy issued by the
39 Network Provider means hospitals or health care providers insurer or its reinstatement
enlisted by an Insurer, TPA or jointly by an Insurer and TPA to b. For which medical advice or treatment was recommended
provide medical services to an insured on payment by a by, or received from, a physician within 48 months prior
cashless facility. to the effective date of the policy of the policy issued or
40 Non-Network Provider - means any hospital, day care centre or its reinstatement
other provider that is not part of the network. 54 Qualified Nurse means a person who holds a valid registration
41 New Born Baby means baby born during the Policy Period and from the Nursing Council of India or the Nursing Council of any
is aged upto 90 days. state in India.
42 N o m i n e e m e a n s t h e p e r s o n n a m e d i n t h e P o l i c y
Schedule/Certificate who is nominated by the Policy
Holder/Insured Person, to receive the benefits under the Policy
in accordance
with the terms of the Policy, if the Policy Holder/ Insured
Person is deceased.
43 Notification of Claim means the process of intimating a claim
to the insurer or TPA through any of the recognized modes of
communication.
44 Outpatient (OPD) Treatment means the 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.
45 Permanent Total Disablement means when Insured is
permanently, totally and absolutely unable to engage in any
occupation or employment of any description whatsoever.

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SBI General Insurance Company Limited

55 Reasonable and Customary Charges means the charges for d. Anaesthesia, blood, oxygen, operation theatre charges,
services or supplies, which are the standard charges for the surgical appliances
specific provider and consistent with the prevailing charges in e. Medicines, drugs and consumables
the geographical area for identical or similar services, taking into f. Diagnostic procedures
account the nature of the Illness/Injury involved. g. The Cost of prosthetic and other devices or equipment if
56 Renewal means the terms on which the contract of insurance implanted internally during a Surgical Procedure.
can be renewed on mutual consent with a provision of Grace Conditions:
Period for treating the renewal continuous for the purpose of i. If Insured is admitted in an ICU category those specified in the
gaining credit for Pre-existing diseases, time bound exclusions Policy Schedule of this Policy, then proportionate deductions
and for all waiting periods. shall not be applicable on the total Associated Medical
57 Room Rent means the amount charged by a Hospital towards Expenses in the proportion of the ICU Charges.
Room and Boarding expenses and shall include the associated ii. In case of admission to a room at rates exceeding the limits as
medical expenses. mentioned, the reimbursement of all other Associated
58 Spouse means the Primary Insured’s legally married spouse as Medical Expenses incurred at the Hospital, shall be payable in
long as he/she continues to be married to the Primary Insured. the same proportion as the admissible rate per day bears to
59 Sum Insured means, the amount as opted by you and stated in the actual rate per day of room rent charges.
the Policy Schedule / Certificate of Insurance against the iii. Proportionate deductions shall not apply in respect of the
section/cover for each Insured Person for Individual Sum Hospitals which do not follow differential billings or for those
Insured and aggregately for all Insured members for a Floater expenses in respect of which differential billing is not adopted
Policy based on the room category.
60 Surgery/Surgical Procedure means manual and/or operative I.A.2 - PRE-HOSPITALIZATION MEDICAL EXPENSES
procedure(s) required for treatment of an Illness or Injury, We will pay for Pre-Hospitalization Medical Expenses of an Insured
correction of deformities and defects, diagnosis and cure of Person which are incurred due to an Accident, Injury or Illness
diseases, relief from suffering or prolongation of life, performed immediately prior to the Insured Person’s date of admission to the
in a Hospital or day care centre by a Medical Practitioner. Hospital or in case of domiciliary hospitalisation up to 30 or 60
61 Survival Period means the benefits under the Policy shall be days as specified in the Policy Schedule/Certificate of Insurance,
payable only if the Insured is first diagnosed as suffering from a provided that a claim made by the Insured Person on Us has been
defined Critical Illness during the Policy Period, and the Insured admitted under In-patient Benefit under Section I.A.1 or I.A.5 or
survives for at least 28 days following such diagnosis. I.A.7 or I.A.8 and is related to the same Accident, Injury or Illness.
62 Tele-consultation means engagement between licensed Note -For the purpose of calculating Our liability under this benefit
teleconsultation service provider/ professional and the insured/ in an event of multiple Hospitalization claims for any one Illness,
covered member that is provided via a range of technology Injury or Accident We shall consider date of admission to the
enabled communication media other than face-to-face Hospital for Insured Person’s first Hospitalization in order of its
interactions, such as telephone, internet, and others. occurrence, for such Illness Injury or Accident.
63 Unproven/Experimental Treatment means the treatment
including drug experimental therapy which is not based on I.A.3 - POST-HOSPITALIZATION MEDICAL
established medical practice in India, is treatment experimental EXPENSES We will pay for Post-Hospitalization Medical Expenses
or unproven. of an Insured Person which are incurred due to an Accident, Injury
64 We/ Our/ Us/Insurer means SBI General Insurance Company or Illness immediately from the date of Your discharge from
Limited. Hospital or in case of domiciliary hospitalisation up to 60 or 90
65 You / Your means the Policy Holder or the Primary Insured days as specified in the Policy Schedule/Certificate of Insurance,
person named in the Policy Schedule / Certificate of Insurance provided that a claim made by the Insured Person on Us has been
admitted under In-patient Benefit under Section I.A.1 or I.A.5 or
I.A.7. or I.A.8 and is related to the same Accident, Injury or Illness.
COVERAGE Note -For the purpose of calculating Our liability under this benefit
SECTION I - HOSPITALIZATION COVER in an event of multiple Hospitalization claims for any one Illness,
Injury or Accident We shall consider date of discharge from the
I.A. BASE COVER Hospital for Insured Person’s first Hospitalization in order of its
SUM INSURED AND LIMITS occurrence, for such Illness Injury or Accident.
We will pay under below listed Covers on Medically Necessary I.A.4 - MENTAL HEALTHCARE
Hospitalization of an Insured Person due to Illness or Injury If an Insured Person is hospitalized for any Mental Illness
sustained or contracted during the Policy Period. The payment is contracted during the Policy Period, We will pay Medical Expenses
subject to Sum Insured and limits, co-payments and deductible, if -upto the limit as specified in Policy Schedule under Section C.1. in
applicable as specified on the Schedule of Coverage in the Policy accordance with The Mental Health Care Act, 2017, subsequent
Schedule / Certificate of Insurance. Subject to otherwise terms amendments and other applicable laws and Rules provided that;
and conditions of the Policy i. The Hospitalization is prescribed by a Medical Practitioner for
I.A.1 - HOSPITALIZATION MEDICAL EXPENSES Mental Illness
ii. The Hospitalization is done in Mental Health Establishment
a. Room Rent, Boarding & Nursing Charges (2% of Sum Insured)
b. Intensive Care Unit Charges (4% of Sum Insured)
c. Medical Practitioner and Specialists Fees including
Teleconsultation

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SBI General Insurance Company Limited

Sub-limit: Obsessive-compulsive disorder is

a. The following disorders / conditions shall be covered only up to 10% an anxiety disorder in which
of Base Sum Insured or Rs. 50,000, whichever is lower. This sub-limit people have recurring, unwanted
shall apply for all the following disorders / conditions on cumulative Obsessive compulsive disorders thoughts, ideas or sensations
basis. (obsessions) that make them feel
b. Pre-hospitalization and Post-hospitalization Medical Expenses are driven to do something repetitively
also covered within the overall benefit sub-limit as specified above in (compulsions).
point (a).
Panic disorder is an anxiety
Disorder/Condition Description disorder characterized by
reoccurring unexpected panic
Severe depression is characterized
attacks with sudden periods of
by a persistent feeling of sadness
Panic disorders intense fear. It may include
Severe Depression or a lack of interest in outside
palpitations, sweating, shaking,
stimuli. It affects the way one
shortness of breath, numbness, or
feels, thinks, and behaves.
a feeling that something terrible is
Schizophrenia is mental disorder, going to happen.
that distorts the way a person
Personality disorder is a type of
thinks, acts, expresses emotions,
mental disorder in which people
perceives reality, and relates to
have a rigid and unhealthy pattern
Schizophrenia others. Schizophrenia result in
Personality disorders of thinking, functioning and
combination of hallucinations,
behaving. It includes trouble in
delusions, and extremely
perceiving and relating to
disordered thinking and behaviour
situations and people.
that impairs daily functioning,
Conversion disorder is a type of
Bipolar disorder is a mental illness
mental disorder where mental or
that brings severe high and low
Conversion disorders emotional distress causes physical
moods and changes in sleep,
symptoms without the existence
Bipolar Disorder energy, thinking, and behaviour. It
of an actual physical condition.
includes periods of extreme mood
swings with emotional highs and Dissociative disorders are mental
lows. disorders that involve experiencing
a disconnection and lack of
Post-traumatic stress disorder is an Dissociative disorder
continuity between thoughts,
anxiety disorder caused by very
memories, surroundings, actions
stressful, frightening, or distressing
and identity
Post-traumatic stress disorder events. It includes flashbacks,
nightmares, severe anxiety and *ICD codes for the above disorders / conditions are provided below
uncontrollable thoughts about the
What is not covered:
events.
a. Treatment related to intentional self-inflicted Injury or attempted
Eating disorder is a mental suicide by any means.
condition where people b. Treatment and complications related to disorders of intoxication,
Eating disorder experience severe disturbances in dependence, abuse, and withdrawal caused by drugs and other
their eating behaviours and related substances such as alcohol, opioids or nicotine.
thoughts and emotions.
Generalized Anxiety Disorder is a
mental health disorder
Generalized anxiety disorder characterized by a perpetual state
of worry, fear, apprehension,
inability to relax.

PAGE 13 OF 38
SBI General Insurance Company Limited

ICD Codes Disorder / Condition I.A.7 - DOMICILIARY HOSPITALISATION

F33.0, F33.1, F33.2, F33.4, F33.5, We will pay the Medical Expenses incurred up to 20% of Sum
F33.6, F33.7, F33.8, F33.9, O90.6, Insured subject to maximum of Rs. 50,000/- or Rs. 2,00,000/- as
F34.1, F32.81, F32.0, F32.1, specified in Policy Schedule/Certificate of Insurance, on
F32.2,F32.4, F32.5, F32.6, F32.7, Domiciliary Hospitalization of the Insured Person provided that:
Severe Depression a. It has been prescribed by the treating Medical
F32.8, F32.9, F33.9, F30.0, F30.1,
F30.2, F30.4, F30.5, F30.6, F30.7, Practitioner and
F30.8, F30.9, F32.3, F33.3, b. the condition the Insured Person is such that he/she
F43.21, F32.8, F33.40, F32.9 could not be moved to a Hospital or
c. the Medical Necessary Treatment is taken at Home on
F20.0, F20.1, F20.2, F20.3, F20.5, account of non-availability of room in Hospital
F21, F22, F23, F24, F20.8, F25.0, Schizophrenia Expenses incurred on Domiciliary Hospitalization in respect to
F25.1, F25.8, F25.9 following treatment are excluded under the Policy
a. Asthma, bronchitis, tonsillitis and upper respiratory tract
F31.0, F31.1, F31.2, F31.4, F31.5,
Bipolar Disorder infection including laryngitis and pharyngitis, cough and
F31.6, F31.7, F31.8, F31.9
cold, influenza,
F40.1, F41.0, F40.2, F40.8, F40.9, b. Arthritis, gout and rheumatism,
Generalized anxiety disorder
F41.1, F41.3, F41.8 c. Chronic nephritis and nephritic syndrome,
d. Diarrhoea and all type of dysenteries, including
F50.0, F50.2, F50.8, F98.3, gastroenteritis,
Eating disorder
F98.21, F50.8 e. Epilepsy
F42 Obsessive compulsive disorders f. Pyrexia of Unknown Origin for less than 10 Days.
- Insured Person shall not bear specified percentage of
F41.1, F40.1, F60.7, F93.0, F94.0 Panic disorders admissible Claim amount under each and every Claim of this
F60.0, F60.1, F60.2, F60.3, F60.4, section even if Co-payment under Section I.B.5 is opted and
Personality disorders specified in the Policy Schedule/Certificate of Insurance.
F60.8, F60.6, F60.7, F60.5
I.A.8 - ALTERNATIVE TREATMENTS
F44.4, F44.5, F44.6, F44.7 Conversion disorders
We will pay Medical Expenses Upto Sum Insured as specified in
F44.5, F44.8, F48.1, F44.1, F44.2 Dissociative disorders Policy Schedule / Certificate of Insurance, in accordance with
I.A.5 - DAY CARE SURGERY/PROCEDURES Section I.A.1 on Hospitalization of Insured Person for following
We will pay for the Medical Expenses as listed under Section I.A.1 Alternative Treatments prescribed by Medical Practitioner.
on Hospitalization of Insured Person in Hospital or Day Care a. Ayurvedic
Centre for Day Care TreatmentIndicative list of Day Care b. Unani
Treatment is attached in Annexure V (Please refer at the end of c. Siddha
this document) d. Homeopathy
a. The procedure performed on the insured Person cannot
I.A.6- AMBULANCE CHARGES be carried out on Outpatient basis.
We will pay for expenses incurred up to 1% of Sum Insured subject b. The treatment has been undertaken in a government
to maximum of Rs. 5,000/- or Rs. 10,000/- as specified in Policy Hospital or in any institute recognized by government
Schedule/ Certificate of Insurance, on Road Ambulance Services if and/or accredited by Quality Council of India/National
Insured Person is required; Accreditation Board or authorised medical council of the
a. to be transferred to the nearest Hospital following an respective country/state as applicable.
emergency - Insured Person shall not bear specified percentage of
b. or from one Hospital to another Hospital admissible Claim amount under each and every Claim of this
c. or from Hospital to Home (within same City) following section even if Co-payment under Section I.B.5 is opted and
Hospitalization specified in the Policy Schedule/Certificate of Insurance.
provided that Claims under Section I.A.1 is admissible under the
I.A.9 - ORGAN DONOR EXPENSES
Policy.
-Insured Person shall not bear specified percentage of admissible We will pay Medical Expenses of 50% of Sum Insured as specified
Claim amount under each and every Claim of this section even if in Policy Schedule / Certificate of Insurance, as listed under
Co-payment under Section I.B.5 is opted and specified in the Policy Section I.A.1 towards organ donor’s Hospitalization for harvesting
Schedule/Certificate of Insurance. of the donated organ where an Insured Person is the recipient,
provided that;
a. The organ donor is any person whose organ has been
made available in accordance and in compliance with The
Transplantation of Human Organ (amendment) Act, 2011
and Transplantation of Human Organs and Tissues Rules,
2014
b. Hospitalization Claim under Section I.A.1 is admissible
under the Policy

PAGE 14 OF 38
SBI General Insurance Company Limited

We will not cover expenses towards the donor in respect of: I.A.13.- HIV/AIDS COVER
a. Any Pre or Post - Hospitalization Medical Expenses,
If Insured Person is diagnosed with HIV during the Policy Period
b. Cost towards donor screening.
c. Cost associated to the acquisition of the organ. and require Hospitalization under Section C.1 in accordance with
d. Any other medical treatment or complication in respect the Human Immunodeficiency Virus and Acquired Immune
of the donor, consequent to harvesting. Deficiency Syndrome (Prevention and Control) Act, 2017 and
e. Expenses related to organ transportation or preservation. amendments thereafter, then We will pay medical expenses up
f. Transplant of any organ/tissue where the transplant is to the Sum Insured as specified in Policy Schedule.
experimental or investigational. i. Medical Expenses which are arise from or are in way
g. Hospitalisation or any other Medical Expenses if Insured related to Human Immunodeficiency Virus (HIV) and/ or
Person is Hospitalised for donating organ HIV related illness and including Acquired Immune
This is an in-built cover for Sum Insured options Rs. 600,000.00 Deficiency Syndrome (AIDS) being maintained
and above. throughout or AIDS Related Complex (ARC) and/or any
mutant the period, derivative or variations thereof.
- Insured Person shall not bear specified percentage of admissible ii. Medical Expenses as listed in Section C.1
Claim amount under each and every Claim of this section even if Conditions
Co-payment under Section I.B.5 is opted and specified in the
• Claim under Section C.1 is admissible under the Policy
Policy Schedule/Certificate of Insurance.
Any Expenses taken at OPD for the treatment on HIV/AIDS
I.A.10 - REINSTATEMENT BENEFIT •
shall be excluded
We will automatically reinstate the Sum Insured immediately HIV/AIDS Cover shall be examined and confirmed by Medical
upon exhaustion of the limit of coverage, which has been •
Practitioner
defined, during the policy period. The stage of AIDS experienced by You shall be the first
•
incidence during the Policy Period
Other conditions applicable to this benefit: - Insured Person shall bear specified percentage of admissible
a. The reinstated Sum Insured will be triggered only after Claim amount under each and every Claim of this section even if Co
the Hospitalisation Sum Insured has been completely payment under Section I.B.5 is opted and specified in the Policy
exhausted during the Policy Period; Schedule/Certificate of Insurance.
b. If the claimed amount is higher than the balance Sum
Insured under the Policy, then this Benefit will not be I.A.14- ADVANCED TREATMENTS
triggered for such claims. The following procedures will be covered (wherever medically
c. The reinstated Sum Insured would be triggered only for indicated) either as in patient or as part of day care treatment in
subsequent claims made by the Insured Person and not a hospital up to 25% of Sum Insured as specified in the Policy
arising out of any Illness/disease/ Injury or Accident Schedule /Certificate of Insurance, during the policy period:
(including its complications) for which a claim has been A. Uterine Artery Embolization and HIFU (High Intensity
lodged in the current Policy year under Hospitalisation Focused Ultrasound)
Expenses Section I.A.1 B. Balloon Sinuplasty
d. This benefit is applicable only once during each Policy C. Deep Brain Stimulation
Period & will not be carried forward to the subsequent D. Oral Chemotherapy
renewals if the Benefit is not utilized. E. Immunotherapy - Monoclonal Antibody to be given as
e. The reinstated Sum Insured shall not be available for injection
claims towards Alternative treatments I.A.9 and F. Intra Vitreal Injections
Maternity Expenses I.B.3 and New Born Baby Expenses G. Robotic Surgeries
I.B.4 and, if opted for H. Stereotactic Radio Surgeries
This is an in-built cover for Sum Insured options Rs. 600,000.00 I. Bronchial Thermoplasty
and above. J. Vaporisation of the Prostrate ( Green Laser Treatment or
Holmium Laser Treatment)
- Insured Person shall not bear specified percentage of K. IONM - (lntra Operative Neuro Monitoring)
L. Stem Cell Therapy: Hematopoietic stem cells for bone
admissible Claim amount under each and every Claim of this
marrow transplant for haematological conditions to be
section even if Co-payment under Section I.B.5 is opted and
covered
specified in the Policy Schedule/Certificate of Insurance.
- Insured Person shall not bear specified percentage of
I.A.11 - GENETIC DISORDER OR DISEASES admissible Claim amount under each and every Claim of this
Insured Person shall not bear specified percentage of admissible section even if Co-payment under Section I.B.5 is opted and
Claim amount under each and every specified in the Policy Schedule/Certificate of Insurance.

Claim of this section even if Co-payment under Section I.B.5 is

opted and specified in the Policy Schedule/Certificate of
Insurance.
I.A.12- INTERNAL CONGENITAL DISEASES
We will pay the medical expenses of 25% of Sum Insured as
specified in Policy Schedule / Certificate of Insurance, under
Section I. If the insured person is hospitalized for any condition
related to Internal Congenital Diseases -.

- Insured Person shall not bear specified percentage of

admissible Claim amount under each and every Claim of this
section even if Co-payment under Section I.B.5 is opted and
specified in the Policy Schedule/Certificate of Insurance.

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SBI General Insurance Company Limited

I.B. OPTIONAL COVERS d. We will pay expenses of 20% of Sum Insured subject to
maximum of Rs. 2,00,000/- under this cover as specified in
In consideration of payment of additional Premium or reduction
Policy Schedule / Certificate of Insurance.
in the Premium as applicable, it is hereby declared and agreed
This is an optional cover for Sum Insured options Rs. 6,00,000/-
that We will pay the expenses under below listed Covers subject
and above.
to all other terms, conditions, exclusions and waiting periods - Insured Person shall not bear specified percentage of
applicable to the Policy. admissible Claim amount under each and every Claim of this
These Covers are optional and applicable only if opted for and up section even if Co-payment under Section I.B.5 is opted and
to the Sum Insured or limits and subject to copayments/ specified in the Policy Schedule/Certificate of Insurance.
deductibles, if any, mentioned on the Schedule of Coverage in Other conditions applicable to this benefit
the Policy Schedule/ Certificate of Insurance. a. Can be opted only under Family Floater plans covering
I.B.1 - MATERNITY EXPENSES COVER two or more members under the same Policy
We will cover In-patient Maternity Expenses as listed in Section b. This cover cannot be opted independent of Maternity
I.A.1. We shall allow Hospitalizations for maximum up to 3 live Expenses cover.
children or lawful termination of pregnancy/pregnancies (or I.B.3 - OUTPATIENT EXPENSES
either) of an Insured Person. We will, on reimbursement basis, pay the expenses of 1% of
Claim in respect of delivery for only first 3 living children and/or Sum Insured subject to maximum of Rs. 10,000/- as specified in
operations associated therewith will be considered in respect of Policy Schedule / Certificate of Insurance, if an Insured Person
any one Insured Person. Those Insured Persons who are already undergoes Out Patient Treatment, on advice of a Medical
having three or more living children will not be eligible for this Practitioner because of Illness/disease and/or injury sustained
benefit. or contracted during the Policy period up to the limit specified
This is an optional cover for Sum Insured options Rs. 6,00,000/- in the Policy Schedule /Certificate, for the Expenses incurred on:
and above. a. Medical Practitioner’s consultation excluding Dental
a. We will pay medical expenses up to 10% of Sum Insured Treatment;
subject to maximum of Rs. 1,00,000/-under this cover as b. Pharmacy expenses;
specified in Policy Schedule / Certificate of Insurance. c. Diagnostic procedures.
b. The Insured Person should have been continuously d. Teleconsultation
covered under this Policy for at least 24 months before Other conditions applicable to this benefit .
availing this Benefit. a. Pharmacy expense is supported with a valid medical
c. The payment towards any admitted claim for Insured prescription.
Person under this cover for any complication arising out of b. Expense for diagnostic procedure is on the advice of the
or as a consequence of pregnancy or childbirth will be Medical Practitioner.
restricted to limits specified in the Policy c. Single claim is raised for all expenses incurred during the
Schedule/Certificate of Insurance. However, any Policy Period, within 30 days from the date of the expiry of
“reinstated Sum Insured” will not be available for coverage the Policy, reimbursement of the same will be done once
under this section. during the Policy year.
d. Pre or post-natal Maternity Expenses will be covered This is an optional cover for Sum Insured options Rs. 6,00,000/-
within the maternity Sum Insured under this Cover. and above.
However, the Pre or post-natal Maternity Expenses cannot - Insured Person shall not bear specified percentage of
be claimed under Pre or Post - Hospitalisation Expenses admissible Claim amount under each and every Claim of this
under Section I.A.2 and I.A.3, respectively. section even if Co-payment under Section I.B.5 is opted and
e. Any Pre and Post Hospitalization expenses will be covered specified in the Policy Schedule/Certificate of Insurance.
under maternity Sum Insured. I.B.4 - AGGREGATE DEDUCTIBLE
- Insured Person shall not bear specified percentage of
admissible Claim amount under each and every Claim of this We will pay under Covers listed from I.A.1 to I.A.14 on
section even if Co-payment under Section I.B.5 is opted and Medically Necessary Hospitalization of an Insured Person due to
specified in the Policy Schedule/Certificate of Insurance. Illness or Injury sustained or contracted during the Policy
Period. The payment is subject to Sum Insured and post the
I.B.2 - NEW BORN BABY EXPENSE COVER Aggregate Deductible is met.
Subject to a claim being admitted under Maternity Expenses This is an optional cover for Sum Insured options Rs. 6,00,000/-
Cover under Section I.B.I, We will cover the following: and above.
a. We will cover the New Born Babies of the Insured Person Insured Person shall not bear specified percentage of
from the date of birth of the baby, for any admissible Claim amount under each and every Claim If Co-
disease/sickness/ailment /Injury up to 90 days from the payment under Section I.B.5 is opted and specified in the Policy
date of delivery Schedule/Certificate of Insurance.
b. Subject to the terms and conditions of the Policy, on
I.B.5 VOLUNTARY CO-PAYMENT
request of the Policy Holder, We will cover the New Born
Baby beyond 90 days on payment of requisite premium for If You avail this option, 20% Co-Payment as mentioned on the
the New Born Baby into the Policy by way of an Schedule of Coverage in the Policy Schedule / Certificate of
endorsement or at Renewal, whichever is earlier. Insurance will be applied on each and every admissible claim
c. Mandatory Vaccinations of the New Born baby up to 90 after Deductible/Excess if any, applicable under the Policy.
days, as recommended by the Indian Pediatric Association Once the Co-Payment option is availed by the Insured Person, it
will be covered, subject to maximum of Rs 2,500/-. cannot be opted out of at subsequent Renewal.

PAGE 16 OF 38
SBI General Insurance Company Limited

SECTION II - CRITICAL ILLNESS MYOCARDIAL INFARCTION (FIRST HEART ATTACK OF SPECIFIC

If an Insured Person is diagnosed to be suffering from a Critical SEVERITY)
Illness (as defined below), while the Policy is in force then We The first occurrence of heart attack or myocardial infarction,
will pay the Critical Illness Sum Insured specified in the Policy which means the death of a portion of the heart muscle as a
Schedule /Certificate provided that: result of inadequate blood supply to the relevant area. The
a. The Critical Illness, which the Insured Person is suffering diagnosis for Myocardial Infarction should be evidenced by all
from, occurs or first manifests itself during the Policy of the following criteria:
Period as a first incidence; and i. A history of typical clinical symptoms consistent with the
b. The Insured Person survives for at least 28 days from the diagnosis of acute myocardial infarction (For e.g. typical
date of Diagnosis of the Critical Illness; and chest pain)
c. Upon Our admission of the first claim under this Section II ii. New characteristic electrocardiogram changes
in respect of an Insured Person in any Policy Period, the iii. Elevation of infarction specific enzymes, Troponins, or
cover under this shall automatically terminate in respect of other specific biochemical markers
that Insured Person; The following are excluded:
d. Our total liability for an Insured Person under this Benefit i. Other acute Coronary Syndromes
will be limited to the Critical Illness Sum Insured. ii. Any type of angina pectoris
e. For the purpose of this Policy, Critical Illness means an iii. A rise in cardiac biomarkers or Troponin T or I in absence
illness, sickness or a disease or a corrective measure as of overt ischemic heart disease OR following an intra-
specifically defined below first commence at least 90 days arterial cardiac procedure.
after the commencement of the Policy Period. PRIMARY (IDIOPATHIC) PULMONARY HYPERTENSION
f. This coverage applicable for Individual basis only I. An unequivocal diagnosis of Primary (Idiopathic)
STANDARD DEFINITION Pulmonary Hypertension by a Cardiologist or specialist in
CANCER OF SPECIFIED SEVERITY respiratory medicine with evidence of right ventricular
A malignant tumor characterized by the uncontrolled growth enlargement and the pulmonary artery pressure above 30
and spread of malignant cells with invasion and destruction of mm of Hg on Cardiac Cauterization. There must be
normal tissues. This diagnosis must be supported by histological permanent irreversible physical impairment to the degree
evidence of malignancy. The term cancer includes leukemia, of at least Class IV of the New York Heart Association
lymphoma and sarcoma. Classification of cardiac impairment.
The following are excluded - II. The NYHA Classification of Cardiac Impairment are as
i. All tumors which are histologically described as carcinoma follows:
in situ, benign, pre-malignant, borderline malignant, low i. Class III: Marked limitation of physical activity.
malignant potential, neoplasm of unknown behavior, or Comfortable at rest, but less than ordinary activity
noninvasive, including but not limited to: Carcinoma in situ causes symptoms.
of breasts, Cervical dysplasia CIN-1, CIN - 2 and CIN-3. ii. Class IV: Unable to engage in any physical activity
ii. Any non-melanoma skin carcinoma unless there is without discomfort. Symptoms may be present even
evidence of metastases to lymph nodes or beyond; at rest.
iii. Malignant melanoma that has not caused invasion beyond III. Pulmonary hypertension associated with lung disease,
the epidermis; chronic hypoventilation, pulmonary thromboembolic
iv. All tumors of the prostate unless histologically classified as disease, drugs and toxins, diseases of the left side of the
having a Gleason score greater than 6 or having heart, congenital heart disease and any secondary cause
progressed to at least clinical TNM classification T2N0M0 are specifically excluded.
v. All Thyroid cancers histologically classified as T1N0M0 END STAGE LUNG FAILURE
(TNM Classification) or below; End stage lung disease, causing chronic respiratory failure, as
vi. Chronic lymphocytic leukaemia less than RAI stage 3
confirmed, and evidenced by all the following:
vii. Non-invasive papillary cancer of the bladder histologically
i. FEV1 test results consistently less than 1 litre measured
described as TaN0M0 or of a lesser classification,
on 3 occasions 3 months apart; and
viii. All Gastro-Intestinal Stromal Tumors histologically
ii. Requiring continuous permanent supplementary oxygen
classified as T1N0M0 (TNM Classification) or below and
therapy for hypoxemia; and
with mitotic count of less than or equal to 5/50 HPFs; iii. Arterial blood gas analysis with partial oxygen pressure of
OPEN CHEST CABG 55mmHg or less (PaO2 < 55mmHg); and iv. Dyspnea at
The actual undergoing of heart surgery to correct blockage or rest.
narrowing in one or more coronary artery(s), by coronary artery In case the Insured person dies after the survival period of 30
bypass grafting done via a sternotomy (cutting through the days but before assessment period 90 days where the death is
breastbone) or minimally invasive keyhole coronary artery due to complications arising out of the said major illness or the
bypass procedures. The diagnosis must be supported by a said major illness is the predisposing reason for death, then
coronary angiography and the realization of surgery has to be such claims will be paid by Us.
confirmed by a cardiologist.The following are excluded:
i. Angioplasty and/or any other intra-arterial procedures
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
confirmed by a specialist medical practitioner Catheter based
techniques including but not limited to, balloon
valvotomy/valvuloplasty are excluded.

PAGE 17 OF 38
SBI General Insurance Company Limited

STROKE RESULTING IN PERMANENT SYMPTOM

Any cerebrovascular incident producing permanent Motor neuron disease diagnosed by a specialist medical
neurological sequelae. This includes infarction of brain tissue, practitioner as spinal muscular atrophy, progressive bulbar
thrombosis in an intracranial vessel, haemorrhage and palsy, amyotrophic lateral sclerosis or primary lateral
embolisation from an extracranial source. Diagnosis has to be sclerosis. There must be progressive degeneration of
confirmed by a specialist medical practitioner and evidenced corticospinal tracts and anterior horn cells or bulbar efferent
by typical clinical symptoms as well as typical findings in CT neurons. There must be current significant and permanent
Scan or MRI of the brain. Evidence of permanent neurological functional neurological impairment with objective evidence of
deficit lasting for at least 3 months has to be produced. motor dysfunction that has persisted for a continuous period
of at least 3 months.
The following are excluded:
In case the Insured person dies after the survival period of 30
i. Transient ischemic attacks (TIA)
ii. Traumatic injury of the brain days but before assessment period 90 days where the death is
iii. Vascular disease affecting only the eye or optic nerve or due to complications arising out of the said major illness or
vestibular functions. the said major illness is the predisposing reason for death,
then such claims will be paid by Us
In case the Insured person dies after the survival period of 30
COMA OF SPECIFIED SEVERITY
days but before assessment period 90 days where the death is
due to complications arising out of the said major illness or A state of unconsciousness with no reaction or response to
the said major illness is the predisposing reason for death, external stimuli or internal needs. This diagnosis must be
then such claims will be paid by Us. supported by evidence of all of the following:
PERMANENT PARALYSIS OF LIMBS I. no response to external stimuli continuously for at least
96 hours;
Total and irreversible loss of use of two or more limbs as a ii. life support measures are necessary to sustain life; and
result of injury or disease of the brain or spinal cord. A iii. permanent neurological deficit which must be assessed at
specialist medical practitioner must be of the opinion that the least 30 days after the onset of the coma.
paralysis will be permanent with no hope of recovery and The condition has to be confirmed by a specialist medical
must be present for more than 3 months. practitioner. Coma resulting directly from alcohol or drug
In case the Insured person dies after the survival period of 30 abuse is excluded.
days but before assessment period 90 days where the death is
due to complications arising out of the said major illness or MAJOR HEAD TRAUMA
the said major illness is the predisposing reason for death, Accidental head injury resulting in permanent Neurological
then such claims will be paid by Us. deficit to be assessed no sooner than 3 months from the date
MULTIPLE SCLEROSIS WITH PERSISTING SYMPTOMS of the accident. This diagnosis must be supported by
unequivocal findings on Magnetic Resonance Imaging,
I. The unequivocal diagnosis of Definite Multiple Sclerosis Computerized Tomography, or other reliable imaging
confirmed and evidenced by all of the following:
i. investigations including typical MRI findings which techniques. The accident must be caused solely and directly
unequivocally confirm the diagnosis to be multiple by accidental, violent, external and visible means and
sclerosis and independently of all other causes.
ii. there must be current clinical impairment of motor The Accidental Head injury must result in an inability to
or sensory function, which must have persisted for a perform at least three (3) of the following Activities of Daily
continuous period of at least 6 months. Living either with or without the use of mechanical
II. Neurological damage due to SLE is excluded. equipment, special devices or other aids and adaptations in
use for disabled persons. For the purpose of this benefit, the
BENIGN BRAIN TUMOR
word “permanent” shall mean beyond the scope of recovery
Benign brain tumor is defined as a life threatening, with current medical knowledge and technology.
noncancerous tumor in the brain, cranial nerves or meninges
The Activities of Daily Living are:
within the skull. The presence of the underlying tumor must
be confirmed by imaging studies such as CT scan or MRI. i. Washing: the ability to wash in the bath or shower
(including getting into and out of the bath or
This brain tumor must result in at least one of the following shower) or wash satisfactorily by other means;
and must be confirmed by the relevant medical specialist.
ii. Dressing: the ability to put on, take off, secure and
i. Permanent Neurological deficit with persisting
unfasten all garments and, as appropriate, any
clinical symptoms for a continuous period of at
braces, artificial limbs or other surgical appliances;
least 90 consecutive days or iii. Transferring: the ability to move from a bed to an
ii. Undergone surgical resection or radiation therapy
upright chair or wheelchair and vice versa;
to treat the brain tumor. The following conditions iv. Mobility: the ability to move indoors from room to
are excluded: room on level surfaces;
Cysts, Granulomas, malformations in the arteries or veins of v. Toileting: the ability to use the lavatory or otherwise
the brain, hematomas, abscesses, pituitary tumors, tumors of manage bowel and bladder functions so as to
skull bones and tumors of the spinal cord. maintain a satisfactory level of personal hygiene;
vi. Feeding: the ability to feed oneself once food has
been prepared and made available.
The following are excluded:
i. Spinal cord injury;

PAGE 18 OF 38
SBI General Insurance Company Limited

BLINDNESS SPECIFIC DEFINITION

SURGERY OF AORTA
Total, permanent and irreversible loss of all vision in both
eyes as a result of illness or accident. The Blindness is The actual undergoing of surgery for a disease or injury of
evidenced by: the aorta needing excision and surgical replacement of the
i. corrected visual acuity being 3/60 or less in both eyes or; diseased part of the aorta with a graft.
ii. the field of vision being less than 10 degrees in both eyes The term “aorta” means the thoracic and abdominal aorta
The diagnosis of blindness must be confirmed and must not be but not its branches.
correctable by aids or surgical procedure. Surgery performed using only minimally invasive or intra-
MAJOR ORGAN / BONE MARROW TRANSPLANT arterial techniques are excluded.

The actual undergoing of a transplant of: PARKINSON'S DISEASE

i. One of the following human organs: heart, lung, liver, The unequivocal diagnosis of progressive degenerative
kidney, pancreas, that resulted from irreversible end- primary idiopathic Parkinson’s disease (all other forms of
stage failure of the relevant organ, or occasions 3 Parkinsonism are excluded) made by a consultant
months apart; and neurologist. This diagnosis must be supported by all the
ii. Human bone marrow using haematopoietic stem cells. following conditions:
The undergoing of a transplant has to be confirmed by a • The disease cannot be controlled with medication;
specialist medical practitioner
and
The following are excluded:
i. Other stem-cell transplants • Objective signs of progressive impairment; and
ii. Where only islets of langerhans are transplanted • There is an inability of the Life assured to perform
(whether aided or unaided) atleast 3 of the following
THIRD DEGREE BURNS
five (6) “Activities of Daily Living” for a continuous
There must be third-degree burns with scarring that cover at period of at least 6 months.
least 20% of the body’s surface area. The diagnosis must The Activities of Daily Living are:
confirm the total area involved using standardized, clinically I. Washing: the ability to wash in the bath or shower
accepted, body surface area charts covering 20% of the body (including getting into and out
surface area. ii. Dressing: the ability to put on, take off, secure and
unfasten all garments and, as appropriate, any braces,
DEAFNESS artificial limbs or other surgical appliances;
Total and irreversible loss of hearing in both ears as a result iii. Transferring: the ability to move from a bed to an
of illness or accident. This diagnosis must be supported by upright chair or wheelchair and vice versa;
pure tone audiogram test and certified by an Ear, Nose and iv. Mobility: the ability to move indoors from room to
Throat (ENT) specialist. Total means “the loss of hearing to room on level surfaces;
the extent that the loss is greater than 90decibels across all v. Toileting: the ability to use the lavatory or otherwise
frequencies of hearing” in both ears. manage bowel and bladder functions so as to maintain
a satisfactory level of personal hygiene;
LOSS OF SPEECH vi. Feeding: the ability to feed oneself once food has been
Total and irrecoverable loss of the ability to speak as a result prepared and made available
of injury or disease to the vocal cords. The inability to speak Drug-induced or toxic causes of Parkinsonism are excluded.
must be established for a continuous period of 12 months. BRAIN SURGERY
This diagnosis must be supported by medical evidence The actual undergoing of surgery to the brain under
furnished by an Ear, Nose, Throat (ENT) specialist. general anesthesia during which a craniotomy with
KIDNEY FAILURE REQUIRING REGULAR DIALYSIS removal of bone flap to access is the brain is performed.
The following are excluded:
End stage renal disease presenting as chronic irreversible
a) Burr hole procedures, transphenoidal procedures and
failure of both kidneys to function, as a result of which
either regular renal dialysis (haemodialysis or peritoneal other minimally invasive procedures such as
dialysis) is instituted, or renal transplantation is carried out. irradiation by gamma knife or endovascular
Diagnosis has to be confirmed by a specialist medical embolizations, thrombolysis and stereotactic biopsy
practitioner b) Brain surgery as a result of an accident
END STAGE LIVER FAILURE APALLIC SYNDROME

Permanent and irreversible failure of liver function that has Universal necrosis of the brain cortex, with the brain stem
resulted in all three of the following: remaining intact. Diagnosis must be definitely confirmed
i. Permanent jaundice; and by a Registered Medical practitioner who is also a
ii. Ascites; and neurologist holding such an appointment at an approved
iii. Hepatic encephalopathy. hospital. This condition must be documented for at least
Liver failure secondary to drug or alcohol abuse is excluded. one (1) month

PAGE 19 OF 38
SBI General Insurance Company Limited

ALZHEIMER'S DISEASE LOSS OF INDEPENDENT EXISTENCE

Progressive and permanent deterioration of memory and Confirmation by a Consultant Physician of the loss of
intellectual capacity as evidenced by accepted standardised independent existence due to illness or trauma, lasting for a
questionnaires and cerebral imaging. The diagnosis of minimum period of 6 months and resulting in a permanent
Alzheimer’s disease must be confirmed by an appropriate inability to perform at least three (3) of the following Activities
consultant and supported by the Company’s appointed doctor. of Daily Living either with or without the use of mechanical
There must be significant reduction in mental and social equipment, special devices or other aids and adaptations in
functioning requiring the continuous supervision of the life use for disabled persons. For the purpose of this benefit, the
assured. There must also be an inability of the Life Assured to word “permanent”, shall mean beyond the scope of recovery
perform (whether aided or unaided) at least 3 of the following with current medical knowledge and technology.
6 “Activities of Daily Living” for a continuous period of at least 3 Activities of Daily Living:
months: a) Washing: the ability to wash in the bath or shower (including
Activities of Daily Living are defined as: getting into and out of the bath or shower) or wash
I. Washing - the ability to wash in the bath or shower (including satisfactorily by other means;
getting into and out of the bath or shower) or wash b) Dressing: the ability to put on, take off, secure and unfasten all
satisfactorily by other means; garments and, as appropriate, any braces, artificial limbs or
ii. Dressing - the ability to put on, take off, secure and unfasten all other surgical appliances;
garments and, as appropriate, any braces, artificial limbs or c) Transferring: the ability to move from a bed to an upright chair
other surgical appliances; or wheelchair and vice versa;
iii. Transferring - the ability to move from a bed to an upright chair d) Mobility: the ability to move indoors from room to room on
or wheelchair and vice versa; level surfaces;
iv. Toileting - the ability to use the lavatory or otherwise manage e) Platelet count of 20 000 per cubic millimetre or less. Temporary
bowel and bladder functions so as to maintain a satisfactory or reversible aplastic anaemia is excluded.
level of personal hygiene; f) Feeding: the ability to feed oneself once food has been
v. Feeding - the ability to feed oneself once food has been prepared and made
prepared and made available. In case the Insured person dies after the survival period of 30
vi. Mobility - the ability to move from room to room without days but before assessment period 6 months where the death is
requiring any physical assistance. due to complications arising out of the said major illness or the
The following are excluded: said major illness is the predisposing reason for death, then
• Any other type of irreversible organic disorder/dementia such claims will be paid by Us.
• Non-organic disease such as neurosis and psychiatric illnesses; ENCEPHALITIS
and
• Alcohol-related brain damage It is a severe inflammation of brain tissue, resulting in
APLASTIC ANAEMIA permanent neurological deficit lasting for a minimum period of
60 days. This must be certified by a Specialist Medical
Chronic Irreversible persistent bone marrow failure which
Practitioner (Neurologist). The permanent deficit must result
results in Anaemia, Neutropenia and Thrombocytopenia
in an inability to perform at least three of the Activities of Daily
requiring treatment with at least TWO of the following:
Living either with or without the use of mechanical equipment,
• Regular blood product transfusion;
special devices or other aids and adaptations in use for
• Marrow stimulating agents;
disabled persons.
• Immunosuppressive agents; or
• Bone marrow transplantation. FULMINANT VIRAL HEPATITIS
The diagnosis and suggested line of treatment must be A submissive to massive necrosis of the liver by the Hepatitis
confirmed by a Haematologist acceptable to the Company using virus, leading precipitously to liver failure. The diagnosis must
relevant laboratory investigations, including bone marrow be supported by all of the following:
biopsy. Two out of the following three values should be present: • Rapid decreasing of liver size as confirmed by abdominal
• Absolute neutrophil count of 500 per cubic millimetre or less; ultrasound;
• Absolute erythrocyte Reticulocyte count of 20 000 per cubic • Necrosis involving entire lobules, leaving only a collapsed
millimetre or less; and reticular framework (histological evidence is required);
• Platelet count of 20 000 per cubic millimetre or less. Temporary • Rapid deterioration of liver function tests;
or reversible aplastic anaemia is excluded. • Deepening jaundice; and
BACTERIAL MENINGITIS • Hepatic encephalopathy.
Hepatitis B infection or carrier status alone does not meet the
Bacterial infection resulting in severe inflammation of the
diagnostic criteria. This excludes Fulminant Viral Hepatitis
membranes of the brain or spinal cord resulting in significant,
caused by alcohol, toxic substance, or drug.
irreversible and permanent neurological deficit. The
neurological deficit must persist for at least 6 weeks. This
diagnosis must be confirmedby : The presence of bacterial
infection in cerebrospinal fluid by lumbar puncture; and A
consultant neurologist.

PAGE 20 OF 38
 SBI General Insurance Company Limited

SECTION III - HOSPITAL DAILY CASH The Benefit under this Section shall be available for a maximum of 2 Day
Care Treatments per Insured Person per Policy Period. For list of Day
III. A. BASE COVER
Care treatments refer Annexure V of the Policy.
If an Insured Person is Hospitalised during the Policy Period solely and
directly due to an Accident, Illness, Injury or Sickness that occurs during SECTION IV - PERSONAL ACCIDENT
the Policy Period, We shall pay the corresponding Benefits specified IV.A.1 - ACCIDENTAL DEATH
below for each continuous and completed period of 24 hours of If the Insured Person suffers an Injury during the Policy Period solely and
Hospitalisation and in aggregate during the policy period subject to the directly due to an Accident that occurs during the Policy Period and that
deductible applicable of first 24 hours, as mentioned in the Policy Injury solely and directly results in the death of the Insured Person
Schedule / Certificate of Insurance. within 365 days from the date of the Accident, We will pay the Sum
Each member will be offered this cover separately and the same will not Insured as specified against this benefit in the Policy
be available on floater basis. Schedule/Certificate
Coverage under this section shall terminate on payment of benefit for IV.A.2 - PERMANENT TOTAL DISABLEMENT
prescribed number of days as opted by the insured. If during the Policy Period a Primary Insured Person sustains Bodily
III.A.1 - SICKNESS HOSPITAL CASH BENEFIT injury which directly and independently of all other causes results in
We will pay the Daily Hospital Cash Benefit, if the Insured Person is disablement within 12 months of the date of loss, then the company
Hospitalized during the Policy Period for Medically Necessary treatment agrees to pay the insured person the compensation stated in the
of an Illness that occurred during the Policy Period specific table of benefits below.
III.A.2 - ACCIDENT HOSPITAL CASH BENEFIT
We will pay the Daily Hospital Cash Benefit, if the Insured Person is
Table of benefits
Hospitalized during the Policy Period for Medically Necessary treatment
due to an Injury resulting from an Accident that occurred during the Permanent Total Disability % of Sum Insured
Policy Period. We will pay 2 times the daily cash Benefit.
Both Hands or Both Feet 100%
III.A.3 - ICU CASH BENEFIT
If the Insured Person is Hospitalized in an Intensive Care Unit (ICU) Sight of Both Eyes 100%
during the Policy Period for Medically Necessary treatment of an Illness
One Hand and One Foot 100%
or an Injury that occurred during the Policy Period, We will pay 3 times
the daily Hospital cash Benefit. Either Hand or Foot and Sight of
100%
Coverage under this benefit is limited to a maximum of 15 days in One Eye
aggregate per Insured Person per Policy Year. Speech and Hearing in Both Ears 100%
Other conditions applicable to this benefit
a. Either Hand or Foot 50%
Where a benefit is admissible under ICU Cash benefit, no other benefit
is payable for the same day/(s) of Hospitalisation under section III.A.1 Sight of One Eye 50%
and III.A.2. Speech or Hearing in Both Ears 50%
b. In the event of transfer from ward to Intensive Care Unit and vice versa,
the hospitalization would be regarded as continuous and the daily benefit Hearing in One Ear 25%
payable would be as per the limits stated in III.A.1 or III.A.2 Thumb and Index Finger of Same
25%
Provided Our maximum liability shall be restricted to the amount and Hand
period mentioned in the Schedule.
III.A.4 - CONVALESCENCE BENEFIT
If the Insured Person is Hospitalized during the Policy Period for Other conditions applicable to this benefit
Medically Necessary treatment of an Illness or an Injury or Accident a. If an Insured person dies as a result of bodily injury any amount
that occurred during the Policy Period and the continuation of such claimed and paid to an Insured person under this section will be
Hospitalisation is Medically Necessary for at least 10 consecutive days, deducted from any payment under Accidental Death (IV.A.1).
then We will pay a lump sum amount equal to 5 times the daily Hospital IV.A.3 - FUNERAL EXPENSES
cash Benefit. This Benefit is available only once per Insured Person, per If We have accepted a claim for Accidental Death in accordance with
Policy Period Section IV.A.1. in respect of an Insured Person, then in addition to any
III.A.5 - COMPASSIONATE BENEFIT amount payable under Section IV.A.1, We will make a onetime lump
If the Insured Person is Hospitalized for more than 24 hours for sum payment of 1% of Sum Insured subject to maximum of `10,000/- as
Medically Necessary treatment of an Injury due to an Accident that specified in the Policy Schedule/ Certificate of Insurance, towards
occurred during the Policy Period and the Insured Person dies during transportation of mortal remains and funeral/cremation in respect of
the course of such Hospitalisation, We will pay the Nominee of the that Insured Person.
Insured Person a lump sum amount equal to 10 times the daily Hospital
cash benefit amount, subject to admissibility of the claim under Section
III.A.2
III.A.6 - DAY CARE TREATMENT BENEFIT
If the Insured Person requires and avails a Medically Necessary Day
Care Treatment during the Policy Period, We will pay a lump sum
benefit amount which is the lower of either 5 times the daily Hospital
cash Benefit or Rs. 10,000/- to the Insured Person for such Day Care
Treatment provided the Insured Person is admitted in the Hospital/Day
Care Centre for such Day Care Treatment for less than 24 hours.

PAGE 21 OF 38
SBI General Insurance Company Limited

WAITING PERIODS g. List of Diseases excluded for 90 days:

i. Hypertension, Heart Disease and related
All claims payable will be subject to the waiting periods specified below [
complications
Except for Section IV. Personal Accident]
ii. Diabetes and related complications
1. Pre-Existing Diseases (Code- Excl01)
a. Expenses related to the treatment of a pre-existing Disease h. Covid-19 - 15 days
(PED) and its direct complications shall be excluded until the 3. 30 Days Waiting Period (Code- Excl03)
a. Expenses related to the treatment of any illness within 30
expiry of 48 months of continuous coverage after the date of
days from the first policy commencement date shall be
inception of the first policy with us.
b. In case of enhancement of sum insured the exclusion shall excluded except claims arising due to an accident, provided
apply afresh to the extent of sum insured increase the same are covered.
c. If the Insured Person is continuously covered without any b. This exclusion shall not, however, apply if the Insured Person
break as defined under the portability norms of the extant has Continuous Coverage for more than twelve months.
c. The within referred waiting period is made applicable to the
IRDAI (Health Insurance) Regulations then waiting period for
enhanced sum insured in the event of granting higher sum
the same would be reduced to the extent of prior coverage.
d. Coverage under the policy after the expiry of 48 months for insured subsequently.
any pre-existing disease is subject to the same being declared EXCLUSIONS
at the time of application and accepted by Insurer. We will not make any payment for any claim in respect of any Insured
2. Specified disease/procedure waiting period: (Code- Excl02) Person directly or indirectly for, caused by, arising from or in any way
a. Expenses related to the treatment of the listed Conditions, attributable to any of the following unless expressly stated to the
surgeries/treatments shall be excluded until the expiry of 12 contrary in this Policy:
months of continuous coverage after the date of inception of 1. Investigation & Evaluation (Code- Excl04)
the first policy with the Insurer. This exclusion shall not be
a. Expenses related to any admission primarily for diagnostics
applicable for claims arising due to an accident.
b. In case of enhancement of sum insured the exclusion shall and evaluation purposes.
b. Any diagnostic expenses which are not related or not
apply afresh to the extent of sum insured increase.
c. If any of the specified disease/procedure falls under the incidental to the current diagnosis and treatment.
2. Rest Cure, rehabilitation and respite care (Code- Excl05)
waiting period specified for preExisting diseases, then the
a. Expenses related to any admission primarily for enforced bed
longer of the two waiting periods shall apply.
d. The waiting period for listed conditions shall apply even if rest and not for receiving treatment. This also includes:
i. Custodial care either at home or in a nursing facility for
contracted after the policy or declared and accepted without
personal care such as help with activities of daily living
a specific exclusion.
e. If the Insured Person is continuously covered without any such as bathing, dressing, moving around either by skilled
break as defined under the applicable norms on portability nurses or assistant or non-skilled persons.
ii. Any services for people who are terminally ill to address
stipulated by IRDAI, then waiting period for the same would
physical, social, emotional and spiritual needs.
be reduced to the extent of prior coverage.
f. List of Diseases excluded for 12 months: 3. Obesity/ Weight Control (Code- Excl06)
i. Any types of gastric or duodenal ulcers; Expenses related to the surgical treatment of obesity that does
ii. Tonsillectomy, Adenoidectomy, Mastoidectomy, not fulfil all the elow conditions:
Tympanoplasty; a. Surgery to be conducted is upon the advice of the Doctor
iii. Surgery on all internal or external tumor/cysts/nodules/ b. The surgery/Procedure conducted should be supported by
polyps of any kind including breast lumps; clinical protocols
v. All types of Hernia and Hydrocele; c. The member has to be 18 years of age or older and
d. Body Mass Index (BMI)
vi. Anal Fissures, Fistula and Piles;
i. greater than or equal to 40 or
vii. Cataract;
ii. greater than or equal to 35 in conjunction with any of
viii. Benign Prostatic Hypertrophy;
the following severe comorbidities following failure of
ix. Hysterectomy/ myomectomy for menorrhagia or
less invasive methods of weight los
fibromyoma or prolapse of uterus;
x. Noninfective Arthritis, Treatment of Spondylosis / • Obesity-related cardiomyopathy
Spondylitis, Gout & Rheumatism; • Coronary heart disease
xi. Surgery of Genitourinary tract; • Severe Sleep Apnea
xii. Calculus Diseases; • Uncontrolled Type2 Diabetes
xiii. Sinusitis, nasal disorders and related disorders; 4. Change-of-Gender treatments: (Code- Excl07)
xiv. Surgery for prolapsed intervertebral disc unless arising Expenses related to any treatment, including surgical
from accident; management, to change characteristics of the body to those of the
xv. Vertebro-spinal disorders (including disc) and knee opposite sex.
conditions;
xvi. Surgery of varicose veins and varicose ulcers; Chronic
xvii. Renal failure;
xviii. Medical Expenses incurred in connection with joint
replacement surgery due to Degenerative condition,
Age related osteoarthritis and Osteoporosis unless such
Joint replacement surgery unless necessitated by
Accidental Bodily Injury.

PAGE 22 OF 38
SBI General Insurance Company Limited

5. Cosmetic or plastic Surgery: (Code- Excl08) 16. Treatment taken outside geographical limits of India
Expenses for cosmetic or plastic surgery or any treatment to change 17. In respect of the existing diseases, disclosed by the insured and
appearance unless for reconstruction following an Accident, Burn(s) or mentioned in the Policy Schedule /Certificate of Insurance (based on
Cancer or as part of medically necessary treatment to remove a direct insured’s consent), policyholder is not entitled to get the coverage for
and immediate health risk to the insured. For this to be considered a specified ICD codes and the same are permanently excluded.
medical necessity, it must be certified by the attending Medical 18. The cost of spectacles, contact lenses, hearing aids, crutches,
Practitioner. wheelchairs, dentures, artificial teeth and all other external appliances
6. Hazardous or Adventure sports: (Code- Excl09) and/or devices unless specifically covered.
Expenses related to any treatment necessitated due to participation as a 19. Expenses incurred on Items for personal comfort like television,
professional in hazardous or adventure sports, including but not limited telephone, incurred during hospitalization and which have been
to, para-jumping, rock climbing, mountaineering, rafting, motor racing, specifically charged for in the hospitalisation bills issued by the hospital.
horse racing or scuba diving, hand gliding, sky diving, deep-sea diving. 20. Circumcision unless necessary for treatment of a disease, illness or
7. Breach of law: Code- (Excl10) injury not excluded hereunder or due to an Accident.
Expenses for treatment directly arising from or consequent upon any 21. Any Deductible amount or percentage of admissible claim under
Insured Person committing or attempting to commit a breach of law Co-Payment if applicable and as specified in the Policy Schedule /
with criminal intent. Certificate of Insurance.
8. Excluded Providers: Code- (Excl11) 22. Circumcision unless necessary for treatment of a disease, illness or
Expenses incurred towards treatment in any hospital or by any Medical injury not excluded hereunder, or, as may be necessitated due to an
Practitioner or any other provider specifically excluded by the Insurer accident.
and disclosed in its website / notified to the policyholders are not 23. Act of self-destruction or self-inflicted injury or suicide
admissible. However, in case of lifethreatening situations following an 24. Outpatient Diagnostic, Medical and Surgical procedures or
accident, expenses up to the stage of stabilization are payable but not treatments, unless specifically covered and specified in the Policy
the complete claim. Schedule / Certificate of Insurance.
9. Treatment for, Alcoholism, drug or substance abuse or any addictive 25. Costs of donor screening or treatment including organ extraction,
condition and consequences thereof. (Code- Excl12) unless specifically covered and specified in the Policy Schedule /
10. Treatments received in heath hydros, nature cure clinics, spas or Certificate of Insurance.
similar establishments or private beds registered as a nursing home 26. Medical Practitioner’s or Private Nurse home visit during pre and
attached to such establishments or where admission is arranged wholly post Hospitalization period, attendant nursing expenses
or partly for domestic reasons. (Code- Excl13) 27. Chemical & Nuclear Exposure
11.Dietary supplements and substances that can be purchased without We will not pay for the treatment costs caused by or contributed to or
prescription, including but not limited to Vitamins, minerals and organic arising from nuclear weapons/materials, radiations of any kind,
substances unless prescribed by a medical practitioner as part of contamination by radioactive material, nuclear waste, nuclear fuel or
hospitalization claim or day care procedure (Code- Excl14) from the combustion of nuclear fuel, nuclear, chemical or biological
12. Refractive Error:(Code- Excl15) weapons/attack.
Expenses related to the treatment for correction of eye sight due to a. Chemical attack or weapons means the emission, discharge,
refractive error less than 7.5 dioptres. dispersal, release or escape of any solid, liquid or gaseous
13. Unproven Treatments:(Code- Excl16) chemical compound which, when suitably distributed, is
Expenses related to any unproven treatment,services and supplies for or capable of causing any Illness, incapacitating disablement or
in connection with any treatment. Unproven treatments are treatments, death.
procedures or supplies that lack significant medical documentation to b. Biological attack or weapons means the emission, discharge,
support their effectiveness. dispersal, release or escape of any pathogenic (disease
14. Sterility and Infertility: (Code- Excl17) producing) microorganisms and/or biologically produced
Expenses related to sterility and infertility this includes: toxins (including genetically modified organisms and
i. Any type of sterilization chemically synthesized toxins) which are capable of causing
ii. Assisted Reproduction services including artificial insemination and any Illness, incapacitating disablement or death.
advanced reproductive technologies such as IVF, ZIFT, GIFT ICSI 28. War
iii. Gestational Surrogacy We will not pay for the treatment related to and arising out of, or directly
iv. Reversal of sterilization or indirectly connected with or traceable to, war, invasion, act of foreign
15. Maternity: (Code- Excl18) enemy, hostilities (whether war be declared or not) civil war, rebellion,
a. Medical treatment expenses traceable to childbirth revolution, insurrection, mutiny, military or usurped power, seizure,
(including complicated deliveries and caesarean sections capture, arrests, restraints and detainment of all Heads of State and
incurred during hospitalization) except ectopic pregnancy; citizens of whatever nation
b. Expenses towards miscarriage (unless due to accident) and
lawful termination of pregnancy during the policy period.
Unless specifically covered and specified in Policy Schedule /
Certificate of Insurance

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SBI General Insurance Company Limited

GENERAL CONDITIONS 9. Premium

CONDITIONS PRECEDENT TO THE CONTRACT The premium payable under this Policy shall be paid in accordance with
1. Condition Precedent to Admission of Liability The terms and the schedule of payments in the Policy Schedule agreed between the
conditions of the policy must be fulfilled by the insured person for the Policyholder and Us in writing. No receipt for premium shall be valid
company to make any payment for claim(s) arising under the policy except on Our official form signed by Our duly authorized official. The
2. Age Limit due payment of premium and realization thereof by Us and the
To be eligible to be covered under the Policy or get any benefits under observance and fulfilment of the terms, provisions, conditions and
the Policy, the Insured Person should have attained the age of at least endorsements of this Policy by the Policyholder/Insured Person in so far
18 years and shall not have completed the age of 65 years on the date as they relate to anything to be done or complied with by the
of commencement of the Policy Period as applicable to such Insured Policyholder/Insured Person shall be a condition precedent to Our
Person unless it is renewal of Policy. The entry age for dependent child liability to make any payment under this Policy.
will be 91 days to 25 years as on date of policy commencement, unless CONDITIONS APPLICABLE DURING THE CONTRACT
specifically covered and specified in the Policy Schedule.
1. Alterations in the Policy
3. Insured Person
The Proposal Form, Certificate, and Policy Schedule / Certificate if
a. Only those persons named as an insured person in the policy schedule / Insurance constitute the complete contract of insurance. This Policy
certificate of insurance shall be covered under this policy. constitutes the complete contract of insurance between the
b. You can add more persons during the policy period but only after Policyholder and Us. No change or alteration will be effective or valid
payment of an additional premium and subject to acceptance of unless approved in writing which will be evidenced by a written
proposal by us (wherever necessary) and after we haveissued an endorsement, signed and stamped by Us. All endorsement requests will
endorsement confirming the addition of such person as an insured be made by the Policy Holder and/or the Insured Person only. This
person. Policy cannot be changed by anyone (including an insurance agent or
4. Nomination :The policyholder is required at the inception of the broker) except Us.
policy to make a nomination for the purpose of payment of claims 2. Cancellation
under the policy in the event of death of the policyholder. Any change I. The policyholder may cancel this policy by giving
of nomination shall be communicated to the company in writing and 15days'written notice and in such an event, the Company
such change shall be effective only when an endorsement on the policy shall refund premium for the unexpired policy period as
is made. ln the event of death of the policyholder, the Company will pay detailed below.
the nominee {as named in the Policy Schedule/Policy
Certificate/Endorsement (if any)} and in case there is no subsisting Period on risk Rate of premium refunded
nominee, to the legal heirs or legal representatives of the policyholder
whose discharge shall be treated as full and final discharge of its liability Up to one month 75% of annual rate
under the policy. Up to three month 50% of annual rate
5. Currency
The monetary limits applicable to this Policy will be in INR. Up to six months 25% of annual rate
6. Disclosure of Information Exceeding six months Nil
The policy shall be void and all premiums paid thereon shall be void and
all premium paid thereon shall be forfeited to the company in the event Notwithstanding anything contained herein or otherwise, no refunds of
of misrepresentation, misdescription or nondisclosure of any material premium shall be made in respect of Cancellation where, any claim has
fact by the policy holder. been admitted or has been lodged or any benefit has been availed by the
7. Electronic Transactions insured person under the policy.
The Insured Person agrees to adhere to and comply with all such terms ii. The Company may cancel the policy at any time on grounds
and conditions as may be prescribed by Us from time to time, and of misrepresentation non-disclosure of material facts, fraud
hereby agree and confirm that all transactions effected by or through by the insured person by giving 15 days' written notice. There
facilities for conducting remote transactions including the Internet, would be no refund of premium on cancellation on grounds
World Wide Web, electronic data interchange, call centers, teleservice or misrepresentation, non-disclosure of material facts or
operations (whether voice, video, data or combination thereof) or by fraud.
means of electronic, computer, automated machines network or
3. Free look period
through other means of telecommunication, established by or on behalf
The Free Look Period shall be applicable on new individual health
of Us, for and in respect of the Policy or its terms, or the Company's
insurance policies and not on renewals or at the time of porting/
other products and services, shall constitute legally binding and valid
migrating the policy. The insured person shall be allowed free look
transactions when done in adherence to and in compliance with Our
period of fifteen days from date of receipt of the policy document to
terms and conditions for such facilities, as may be prescribed from time
review the terms and conditions of the policy, and to return the same if
to time.
not acceptable.
8. Observance of Terms and Conditions
If the insured has not made any claim during the Free Look Period, the
The due observance and fulfilment of the terms and conditions of the
insured shall be entitled to
Policy (including the realisation of premium by their respective due
dates by Us and compliance with the specified procedure on all claims) i. a refund of the premium paid less any expenses incurred by
in so far as they relate to anything to be done or complied with by the the Company on medical examination of the insured person
Policyholder or any of the Insured Persons or Claimants, shall be the and the stamp duty charges or
condition precedent to Our liability to make payment under this Policy. ii. 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

PAGE 24 OF 38
SBI General Insurance Company Limited

iii. Where only a part of the insurance coverage has The following details are to be provided to Us at the time of intimation
commenced, such proportionate premium commensurate of Claim:
with the insurance coverage during such period; • Health Card ID number
4. Possibility of Revision of Terms of the Policy lncluding the Premium • Policy Number
Rates • Name of the Policyholder
The Company, with prior approval of lRDAl, may revise or modify the • Name of the Insured Person in whose relation the Claim is being
terms of the policy including thepremium rates. The insured person lodged
shall be notified three months before the changes are effected. • Nature of Hospitalisation/ Critical Illness
5. Withdrawal of the Product • Name and address of the attending Medical Practitioner and
i. ln the likelihood of this product being withdrawn in future, Hospital (if admission has taken place)
the Company will intimate the insured person about the • Date of Admission if applicable
same 90 days prior to expiry of the policy. • Any other information, documentation as requested by Us
ii. Insured Person will have the option to migrate to similar 3.A Claim Cashless Process
health insurance product available with the Company at the Cashless facility is available for Hospitalization only at our Network
time of renewal with all the accrued continuity benefits such Provider. The Insured Person can avail Cashless facility at Network
as cumulative bonus, waiver of waiting period. as per IRDAI Provider, by presenting the health card as provided by Us with this
guidelines, provided the policy has been maintained without Policy, alongwith a valid photo identification proof (Voter ID card /
a break. Driving License / Passport / PAN Card / Aadhar Card, any other identity
CONDITIONS APPLICABLE WHEN A CLAIM ARISES proof as approved by Us).
3. A. 1 For Planned Hospitalization
1. Claims Process and Management
Completed claim forms and processing documents must be furnished to a. The Insured Person should at least forty-eight (48) hours prior to
Us / TPA within the stipulated timelines for all reimbursement claims. admission to the Hospital approach the Network Provider for
Failure to furnish this documentation within the time required shall not Hospitalization for medical treatment.
invalidate nor reduce any claim if You can satisfy that it was not b. The Network Provider will issue the request for authorization
reasonably possible for You to submit / give proof within such time. letter for Hospitalization in the pre-authorization form prescribed
Cashless and Reimbursement Claim processing is through Our service by the IRDAI.
partner TPA, details of the same will be available on the Health Card c. The Network Provider shall electronically send the filled
issued by Us as well as on Our /TPA website. For the latest list of preauthorization form along with all the relevant details to the
Network Providers, you can log on to Our /TPA website. TPA will twenty-four (24) hour authorization/cashless department of TPA
facilitate health claims processing. along with contact details of the treating Medical Practitioner and
2. Policyholder/ Insured Person’s Duty at the Time of Claim the Insured Person.
d. Upon receiving the pre-authorization form and all related medical
On occurrence of an event which may lead to a claim under this Policy,
information from the Network Provider, the eligibility of cover
the following shall be complied with:
under the Policy will be verified.
a. Forthwith notify, file and submit the claim in accordance e. Wherever the information provided in the request is sufficient to
with the claim procedure ascertain the authorisation, the authorisation letter will be issued
b. If so requested by Us, the Insured Person must submit to the Network Provider. Wherever additional information or
himself/herself for a medical examination by Our nominated documents are required, the same will be called for from the
Medical Practitioner as often as We consider reasonable and Network Provider and upon satisfactory receipt of last necessary
necessary. The cost of such examination will be borne by Us. documents the authorisation will be issued. All authorisations will
c. Allow the Medical Practitioner or any of Our representatives be issued within a period of six (6) hours from the receipt of last
to inspect the medical and Hospitalization records, complete documents.
investigate the facts and examine the Insured Person as also f. The authorisation letter will include details of sanctioned amount,
verify the certificate of disability issued in respect of an any specific limitation on the claim, any Co-Payment or Deductible
Insured Person. and non- payable items if applicable.
d. Assist and not hinder or prevent Our representatives in the g. The authorization letter shall be valid only for a period of fifteen
pursuance of their duties for ascertaining the admissibility of (15) days from the date of issuance of authorization
the claim, its circumstances and its quantum under the In the event that the cost of Hospitalization exceeds the authorized limit
provisions of the Policy as mentioned in the authorization letter:
3. Claims Intimation a. The Network Provider shall request for an enhancement of
If You meet with any Accidental bodily Injury or suffer an Illness that authorisation limit.
may result in a claim, then as a Condition Precedent to Our liability, You b. Eligibility will be verified, and the enhancement will be evaluated
must comply with the following claim procedures on the availability of further limits.
c. In the event of a change in the treatment during Hospitalization of
Notify Us or Our TPA (either at the Insured Person, the Network Provider shall obtain a fresh
S No Type of Hospitalization
Our call centre or in writing) authorization letter from Us
At the time of discharge:
within 48 hours of the a. The Network Provider may forward a final request for
Hospitalization but not later authorization for any residual amount along with the discharge
1 Planned Hospitalization
than discharge from the summary and the billing format in accordance with the process.
Hospital. b. Upon receipt of the final authorisation letter, the Insured Person
within twenty-four (24) hours may be discharged by the Network Provider.
of Your admission to hospital c. Ensure that the final authorization letter is signed by the Insured
2 Emergency Hospitalization Person.
or before discharge whichever
is earlier d. Ensure to take photocopies of relevant medical records for future
reference.

PAGE 25 OF 38
SBI General Insurance Company Limited

3. A. 2 For Emergency Hospitalization List of necessary claim documents/information to be submitted for

a. The Insured Person may approach the Network Provider for reimbursement are as following:
Hospitalization
b. Insured Person will need to provide health card / health
insurance Policy at hospital admission counter
c. The Network Provider shall forward the request for
authorization to TPA within twenty-four (24) hours of Persona
Hospital Hospital
admission to the Hospital or before discharge whichever is Sr List of Documents/ Critical l
ization Daily
earlier. No Information Illness Acciden
Cover Cash
d. In the interim, the Network Provider may either consider t
treating the Insured Person by taking a token deposit or 1 Duly Filled and Signed
treating as per their norms. Y Y Y Y
Claim Form
e. The Network Provider shall refund the deposit amount to
you barring a token amount to take care of non-covered 2 Discharge Summary Y Y Y Y
expenses once the authorization is issued
3 Medical Records
The Network Provider will send the claim documents to TPA within
(Indoor Case Papers, OT Y Y Y Y
fifteen (15) days from the date of discharge from Hospital.
notes, PAC Notes etc.)
List of necessary claim documents to be submitted for Cashless are as
following: 4 Original Hospital Main
Y Y Y Y
• Claim Form duly filled and signed Bill
• Original signed pre-authorisation request 5 Original Hospital Bill
• Copy of authorisation approval letter (s) Y N N N
Break-up
• Copy of Photo ID of Patient Verified by the Hospital
• Original Discharge/Death Summary 6 Original Pharmacy Bills Y N N N
• Operation Theatre Notes (if any) 7 Prescriptions for the
• Original Hospital Main Bill along with break up Bill and original medicines purchased
receipts (except hospital supply) Y N N N
• Original Investigation Reports, X Ray, MRI, CT Films, HPE etc. and investigations done
• Details of the implants including the sticker indicating the type as outside the hospital
well as invoice towards the cost of implant.
• Doctors Reference Slips for Investigations/Pharmacy 8 Consultation Papers Y Y Y Y
• Original Pharmacy Bills 9 Investigation Reports Y Y Y Y
• MLC/FIR Report/Post Mortem Report (if applicable and conducted)
Any additional documents may be called as required based on the 10 Digital Images/ CDs of
circumstances of the claim the Investigation Y Y N N
There can be instances where Cashless Facility may be denied for Procedures (if required)
Hospitalization due to insufficient Sum Insured or insufficient 11 MLC/FIR Report (If
information to determine admissibility in which case You/Insured Y N N Y
applicable)
Person may be required to pay for the treatment and submit the claim
for reimbursement to TPA which will be considered by Us subject to the 12 Original Invoice/ Sticker
Y N N N
Policy Terms &Conditions. (If applicable
We in Our sole discretion, reserves the right to modify, add or restrict 13 Post Mortem Report (If
any Network Provider for Cashless services under the Policy. Before Y N Y Y
applicable)
availing the Cashless service, the Policyholder / Insured Person is
required to check the applicable/latest list of Network Provider on TPA’s 14 Disability Certificate (If
Y N N Y
website or by calling call centre. applicable)
3. B Claim Reimbursement Process
Wherever You have opted for a reimbursement of expenses, You may
submit the documents for reimbursement of the claim to Our / TPA
office not later than thirty (30) days from the date of discharge from the
Hospital. You can obtain a Claim Form from any of Our / TPA Offices or
download a copy from Our website https://www.sbigeneral.in

PAGE 26 OF 38
SBI General Insurance Company Limited

Attending Physician 7. Settlement and Repudiation of Claim

15 Certificate (If Y Y N Y We shall be under no obligation to make any payment under this Policy
applicable) unless We have been provided with the documentation and
information to our satisfaction to establish the validity of the claim.
Ante-natal Record (If
16 Y N N N a. We shall settle a claim or reject a claim within 30 days of the
applicable)
receipt of the last “necessary” documents by Us. In case of
Birth Discharge suspected frauds, the last “necessary” document shall mean
17 Y N N N
Summary (If applicable the receipt of verification/ investigation report to determine
Death Certificate (If the validity of the claim as stated Where the circumstances
18 Y Y Y Y of a claim warrant an investigation, it shall initiate and
applicable)
complete such investigation at the earliest, in any case not
KYC (Photo ID card, If later than 30 days from the date of receipt of last necessary
19 Y Y Y Y
applicable) document. In such cases, Insurer/We shall settle the claim
Bank Details with within 45 days from the date of receipt of last necessary
20 Cancelled Cheque (If Y Y Y Y document by Us. Repudiated claims will be informed to You
applicable in writing with appropriate reasons of repudiation.
b. The Policy Holder shall assist Us, if We so require, in any
a. The above list is indicative, and We may call for any prosecution, proceeding or in the matter of recovery of
additional documents/ information/ subject the Insured claims by Us against third parties. The Policy Holder shall
Person to additional medical examinations as required to furnish all information that is sought from him by Us, either
ascertain the admissibility of any Benefit including Optional directly or through the distribution channels, which We
Covers under the relevant Section of the Policy, based on the consider as having a bearing on the risk to enable Us to
circumstances of the claim on a case to case basis. assess properly the risk covered under a proposal for
b. Our branch offices shall give due acknowledgement of insurance.
collected documents. In case there is a delay in the c. We shall at all times maintain total confidentiality of the
submission of claim documents, then in addition to the Policy Holder’s information, unless it becomes necessary to
documents mentioned above, the claimant is also required to disclose the information to any statutory authorities or
provide Us the reasons for such delay in writing. We shall courts due to operation of any law. Any breach of the
condone delay on merit for delayed claims where delay is obligations cast on Us or distribution channels or surveyors in
proved to be for reasons beyond the control of the Policy terms of these regulations may enable the Authority to
Holder or Insured Person anyone claiming from their behalf, initiate action against each or all of Us, jointly or severally,
as the case may be. under the Act and/or the Insurance Regulatory and
4. Scrutiny of Claim documents Development Authority Act, 1999.
a. We shall scrutinize the claim and accompanying documents. d. We will only make payment to the Policyholder or Primary
Any deficiency of documents shall be intimated to Insured Insured under this Policy. Policyholders’ / Insured Person’s
Person and the Network Provider, as the case may be, within receipt of payment shall be considered as a complete
5 days of their receipt. discharge of Our liability against any claim under this Policy.
b. If the deficiency in the necessary claim documents is not met In the event of Primary Insured’s death, We will make
or are partially met in 10 working days of the first intimation, payment to the Nominee (as named in the Schedule) of such
We shall remind the Insured Person of the same and every 10 Insured Person. The payments under this Policy shall only be
(ten) days thereafter made in Indian Rupees within India.
c. We will send a maximum of 3 (three) reminders following 8. Penal interest provision:
which We will send a closure letter. i. The Company shall settle or reject a claim, as the case may
d. We may at Our sole discretion decide to deduct the amount be, within 30 days from the date of receipt of last necessary
of claim for which deficiency is intimated to the Insured document.
Person or settle the claim if We observe that such a claim is ii. ln the case of delay in the payment of a claim, the Company
otherwise valid under the Policy. shall be liable to pay interest to the policyholder from the
5. Claims Investigation date of receipt of last necessary document to the date of
Verification carried out, if any, will be done by individuals or entities payment of claim at a rate 2% above the bank rate.
authorized by Us to carry out such verification/investigation(s) and the iii. However, where the circumstances of a claim warrant an
costs for such verification/investigation shall be borne by Us. You investigation in the opinion of the Company, it shall initiate
additionally hereby consent to disclose Us of documentation and and complete such investigation at the earliest, in any case
information that may held with Your medical professionals and other not later than 30 days from the date of receipt of last
insurers. necessary document- ln such cases, the Company shall settle
6. Physical Examination or reject the claim within 45 days from the date of receipt of
Any Medical Practitioner authorized by the TPA /Us shall be allowed to last necessary document.
examine the Insured Person in case of any alleged disease/Illness/Injury iv. ln case of delay beyond stipulated 45 days, the Company
requiring Hospitalization. Non-cooperation by the Insured Person will shall be liable to pay interest to the policyholder at a rate 2%
result into rejection of claim. We will bear the cost towards performing above the bank rate from the date of receipt of last
such medical examination (at the specified location) of the Insured necessary document to the date of payment of claim.
Person.

PAGE 27 OF 38
SBI General Insurance Company Limited

9. Multiple Policies( Applicable for Section I) 14. Re-opening of Claim

i. In case of multiple policies taken by an insured person during a The claim would be rejected if shortfall documents are not received
period from one or more insurers to indemnify treatment costs, within stipulated timelines as communicated through deficiency &
the insured person shall have the right to require a settlement reminder letters. However, such rejected claim shall be reviewed for
of his/her claim in terms of any of his/her policies. In all such settlement if, Requisite document sufficient for settlement are
cases the insurer chosen by the insured person shall be obliged received.
to settle the claim as long as the claim is within the limits of and 15. Representation against Rejection
according to the terms of the chosen policy. Where a rejection is communicated by Us, the Insured Person may if so
ii. Insured person having multiple policies shall also have the right desired within 15 days of the communication of the rejection, represent
to prefer claims under this policy for the amounts disallowed to Us for reconsideration of the decision
under any other policy / policies even if the sum insured is not 16. Payment Terms
exhausted. Then the insurers hall independently settle the
a. All claims will be payable in India and in Indian rupees.
claim subject to the terms and conditions of this policy.
b. In case of Benefits provided under Section II of the Policy,
iii. If the amount to be claimed exceeds the sum insured under a
once a claim has been paid in respect of any of the Insured
single policy, the insured person shall have the right to choose
Persons, this section will terminate
insurer from whom he/she wants to claim the balance amount. c. In case of reimbursement claims to be payable under Section I
iv. Where an insured person has policies from more than one
of the Policy, a claim should be admissible with Us under
insurer to cover the same risk onindemnity basis, the insured
Section I.A.1 or I.A.8
person shall only be indemnified the treatment costs in
d. The payment will be made to You or the Insured Person as
accordancewith the terms and conditions of the chosen policy. specified in the Policy Schedule/Certificate. In the unfortunate
10. Arbitration
event of Your death, We will pay the Nominee (as named in
If We admit liability for any claim but any difference or dispute arises as
the Policy Schedule/Certificate) and in case of no Nominee to
to the amount payable for any claim the same shall be decided by
Your legal heir who holds a succession certificate or an
reference to Arbitration. The Arbitrator shall be appointed in accordance
indemnity bond to that effect, whichever is available and
with the provisions of the Arbitration and Conciliation Act, 1996 or any
whose discharge shall be treated as full and final discharge of
amendment thereof. No reference to Arbitration shall be made unless
Our liability under the Policy.
We have admitted Our liability for a claim in writing. The arbitration shall
be governed by Indian Law and the venue of arbitration shall be within 17. Subrogation (Applicable only to Personal Accident Section)
India. The Policyholder and/or any Insured Person will do or concur in doing
a. All proceedings in any arbitration shall be conducted in english or permit to be done all such acts and things that may be necessary or
and a daily transcript in english of such proceedings shall be reasonably required by Us for the purpose of enforcing and/or securing
prepared. any civil or criminal rights and remedies or obtaining relief or indemnity
b. The cost of arbitration undertaken in accordance with this from any other party to which We are/or would become entitled upon
section shall be borne by the parties associated with the Us making any payment of a claim under this Policy, whether such acts
arbitration and shall share equally in the costs of the arbitration or things shall be or become necessary or required before or after its
proceedings and presiding arbitrator. payment. Neither You nor any Insured Person shall prejudice these
c. It is clearly agreed and understood that no reference to subrogation rights in any manner and provide Us with whatever
arbitration can be made if the We have either not admitted or assistance or cooperation is required to enforce such rights. Any
has disputed liability in respect of any claim under or in respect recovery that We make pursuant to this clause shall first be applied to
of this Policy. the amounts paid or payable by Us under this Policy and any costs and
d. In the event that these arbitration provisions shall be held to be expenses incurred by Us for effecting a recovery, whereafter We shall
invalid then all such disputes or differences shall be referred to pay any balance remaining to the Insured person. This clause does not
the exclusive jurisdiction of the Indian Courts apply to any Sections where the amount payable is on a fixed benefit
basis.
11. Complete Discharge
18. Special Provisions
Any payment to the policyholder, insured person or his/ her nominees
Any special provisions subject to which this Policy has been entered
or his/ her legal representative or assignee or to the Hospital, as the
into or endorsed on the Policy or in any separate instrument shall be
case may be, for any benefit under the policy shall be a valid discharge
deemed to be part of this Policy and shall have effect accordingly
towards payment of claim by the Company to the extent of that amount
19. Fraud
for the particular claim.
lf any claim made by the insured person, is in any respect fraudulent, or
12. Disclaimer of Claim
if any false statement, or declaration is made or used in support
If We disclaim the liability to the Insured Person for any claim and if the
thereof, or if any fraudulent means or devices are used by the insured
Insured Person within twelve (12) calendar months from the date or
person or anyone acting on his/her behalf to obtain any benefit under
receipt of the notice of such disclaimer does not, notify Us in writing
this policy, all benefits under this policy and the premium paid shall be
that he does not accept such disclaimer and intends to recover his claim
forfeited.
from Us, then the claim shall for all purposes be deemed to have been
Any amount already paid against claims made under this policy but
abandoned and shall not thereafter be recoverable under the Policy.
which are found fraudulent later shall be repaid by all recipient(s)/
13. Claim Assessment
policyholder(s), who has made that particular claim, who shall be jointly
We will pay fixed or indemnified amounts as specified in the Policy
and severally liable for such repayment to the insurer.
Schedule/ Certificate of Insurance applicable for Benefits in accordance
For the purpose of this clause, the expression "fraud" means any of the
with the terms of this Policy. We are not liable to make any payments
following acts committed by the insured person or by his agent or the
that are not specified in the Policy
hospital/doctor/any other pa(y acting on behalf of the insured person,
with intent to deceive the insurer or to induce the insurer to issue an
insurance policy:

PAGE 28 OF 38
SBI General Insurance Company Limited

a) the suggestion, as a fact of that which is not true and which b. This benefit is available only at the time of Renewal of the
the insured person does not believe to be true; existing health insurance policy.
b) the active concealment of a fact by the insured person having c. If the proposed Sum Insured is higher than the Sum insured
knowledge or belief of the fact; under the expiring policy, then all waiting periods would be
c) any other act fitted to deceive; and applied on the increased Sum Insured.
d) any such act or omission as the law specially declares to be d. Waiting period credits shall be extended to Pre-Existing
fraudulent Diseases and time bound exclusions/waiting periods.
The Company shall not repudiate the claim and / or forfeit the policy e. We will process Portability application within 15 days of
benefits on the ground of Fraud, if the insured person / beneficiary can receiving the complete proposal form and Portability Form.
prove that the misstatement was true to the best of his knowledge and 3. Migration
there was no deliberate intention to suppress the fact or that such The insured person will have the option to migrate the policy to other
misstatement of or suppression of material fact are within the health insurance products/plans offered by the company by applying for
knowledge of the insurer. migration of the policyatleast30 days before the policy renewal date as
20. Limitation of Liability per IRDAI guidelines on Migration. If such person is presently covered
If a claim is rejected or partially settled and is not the subject of any and has been continuously covered without any lapses under any health
pending suit or other proceeding or arbitration, as the case may be, insurance product/plan offered by the company, the insured person will
within thirty-six (36) months from the date of such rejection or get the accrued continuity benefits in waiting periods as per IRDAI
settlement, the claim shall be deemed to have been abandoned and guidelines on migration.
Our liability shall be extinguished and shall not be recoverable Where We allow lower waiting period for the Pre Existing Diseases
thereafter. (PEDs) (say 12 months or 24 months or 36 months), in the event of
Any claim for which the notification of Claim is received 12 calendar withdrawal of the said product, We shall give credit to the accrued
months after the event or occurrence giving rise to the Claim shall not waiting period benefits of PEDs gained under the withdrawn product
be admissible, unless it is proved to Our satisfaction that the delay in and allow coverage on any of the health products available in Our
reporting of the Claim was for reasons beyond Your or the Insured product portfolio with no additional waiting period beyond the chosen
Persons control. PED period of the withdrawn product.
For Detailed Guidelines on migration, kindly refer the link
CONDITIONS FOR RENEWAL OF THE CONTRACT
https://www.irdai.gov.in/ADMINCMS/cms/whatsNew_Layout.aspx?pag
1. Renewal e=PageNo3987&flag=1
The policy shall ordinarily be renewable except on misrepresentation by 4. Moratorium Period
the insured person. grounds of fraud, After completion of eight continuous years under the policy no look
i. The Company shall endeavor to give notice for renewal. back to be applied. This period of eight years is called as moratorium
However, the Company is not under obligation to give any period. The moratorium would be applicable for the sums insured of the
notice for renewal. first policy and subsequently completion of 8 continuous years would be
ii. Renewal shall not be denied on the ground that the insured applicable from date of enhancement of sums insured only on the
person had made a claim or claims in the preceding policy enhanced limits. After the expiry of Moratorium Period no health
years. insurance claim shall be contestable except for proven fraud and
iii. Request for renewal along with requisite premium shall be permanent exclusions specified in the policy contract. The policies
received by the Company before the end of the policy period would however be subject to all limits, sub limits, co payments,
iv. At the end of the policy period, the policy shall terminate and deductibles as per the policy contract.
can be renewed within the Grace Period of 30 days to maintain
CUSTOMER GRIEVANCE REDRESSAL POLICY
continuity of benefits without break in policy. Coverage is not
available during the grace period. In case of any grievance the insured person may contact the company
v. No loading shall apply on renewals based on individual claims through Website: www.sbigeneral.in Toll free: 1800 22 1111 / 1800 102
experience 1111 Monday to Saturday (8 am - 8 pm).
2. Portability E-mail: [email protected]
The insured person will have the option to port the policy to other Fax : 1800 22 7244 / 1800 102 7244
insurers by applying to such insurer to port the entire policy along with Courier: "Natraj"301, Junction of Western Express Highway & Andheri
all the members of the family, if any, at least 45 days before, but not Kurla - Road, Andheri (East) Mumbai - 400 069
earlier than 60 days from the policy renewal date as per IRDAI Insured person may also approach the grievance cell at any of the
guidelines related to portability. lf such person is presently covered and company’s branches with the details of grievance
has been continuously covered without any lapses under any health If Insured person is not satisfied with the redressal of grievance through
insurance policy with an lndian General/Health insurer, the proposed one of the above methods, insured person may contact the grievance
insured person will get the accrued continuity benefits in waiting officer at [email protected]
periods as per IRDAI guidelines on portability. For Detailed Guidelines For updated details of grievance officer, kindly refer the link
on portability, kindly refer the link https://www.sbigeneral.in/portal/grievance-redressal
https://www.irdai.gov.in/ADMINCMS/cms/whatsNew_Layout.aspx?pag If Insured person is not satisfied with the redressal of grievance through
e=PageNo3987&flag=1 above methods, the insured person may also approach the office of
Procedure to avail portability Insurance Ombudsman of the respective area/region for redressal of
a. Portability benefit can be availed of by applying to Us with the grievance as per Insurance Ombudsman Rules 2017.
completed Proposal form and portability annexure along with
previous policy documents and Renewal notice of existing
policy, at least 45 days before, but not earlier than 60 days,
from the expiry of the existing health insurance policy.

PAGE 29 OF 38
SBI General Insurance Company Limited

LIST OF OMBUDSMEN OFFICES DELHI - Shri/Smt........ Office of the

Insurance Ombudsman, 2/2 A, Universal
Office Details Jurisdiction of Office
Insurance Building, Asaf Ali Road, New
Delhi.
AHMEDABAD - Shri/Smt........ Office of the Delhi - 110 002. Tel.: 011 -
Insurance Ombudsman, Jeevan Prakash 23232481/23213504 Email:
Building, 6th floor, Tilak Marg, Relief Road, Gujarat, Dadra & Nagar [email protected]
Ahmedabad - 380 001. Tel.: 079 - Haveli, Daman and Diu.
GUWAHATI - Shri Kiriti .B. Saha Office of
25501201/02/05/06 Email:
the Insurance Ombudsman, Jeevan
[email protected] Assam, Meghalaya,
Nivesh, 5th Floor, Nr. Panbazar over
Manipur, Mizoram,
BENGALURU - Smt. Neerja Shah Office of bridge, S.S. Road, Guwahati -
Arunachal Pradesh,
the Insurance Ombudsman, Jeevan 781001(ASSAM). Tel.: 0361 - 2632204 /
Nagaland and Tripura.
Soudha Building,PID No.57-27-N-19 2602205 Email:
Ground Floor, 19/19, 24th Main Road, JP Karnataka. [email protected]
Nagar, Ist Phase, Bengaluru - 560 078.
HYDERABAD - Shri I. Suresh Babu Office of
Tel.: 080 - 26652048 / 26652049 Email:
the Insurance Ombudsman, 6-2-46, 1st
[email protected]
floor, "Moin Court", Lane Opp. Saleem Andhra Pradesh,
BHOPAL - Shri Guru Saran Shrivastava Function Palace, A. C. Guards, Lakdi-Ka- Telangana, Yanam and part
Office of the Insurance Ombudsman, Pool, Hyderabad - 500 004. Tel.: 040 - of Territory of Pondicherry.
JanakVihar Complex, 2nd Floor, 6, Malviya 67504123 / 23312122 Fax: 040 - 23376599
Madhya Pradesh,
Nagar, Opp. Airtel Office, Near New Email: [email protected]
Chhattisgarh.
Market, Bhopal - 462 003. Tel.: 0755 -
JAIPUR - Smt. Sandhya Baliga Office of the
2769201 / 2769202 Fax: 0755 - 2769203
Insurance Ombudsman, Jeevan Nidhi - II
Email: [email protected]
Bldg., Gr. Floor, Bhawani Singh Marg, Rajasthan.
BHUBANESHWAR - Shri Suresh Chandra Jaipur - 302 005. Tel.: 0141 - 2740363
Panda Office of the Insurance Email: [email protected]
Ombudsman, 62, Forest park,
ERNAKULAM - Ms. Poonam Bodra Office
Bhubneshwar - 751 009. Tel.: 0674 - Orissa.
of the Insurance Ombudsman, 2nd Floor,
2596461 /2596455 Fax: 0674 - 2596429
Pulinat Bldg., Opp. Cochin Shipyard, M. G. Kerala, Lakshadweep,
Email:
Road, Ernakulam - 682 015. Tel.: 0484 - Mahea part of Pondicherry.
[email protected]
2358759 / 2359338 Fax: 0484 - 2359336
CHANDIGARH - Dr. Dinesh Kumar Verma Email: [email protected]
Office of the Insurance Ombudsman,
KOLKATA - Shri/Smt........ Office of the
S.C.O. No. 101, 102 & 103, 2nd Floor, Punjab, Haryana, Himachal
Insurance Ombudsman, Hindustan Bldg.
Batra Building, Sector 17 - D, Chandigarh - Pradesh, Jammu & West Bengal, Sikkim,
Annexe, 4th Floor, 4, C.R. Avenue,
160 017. Tel.: 0172 - 2706196 / 2706468 Kashmir, Chandigarh. Andaman & Nicobar
KOLKATA - 700 072. Tel.: 033 - 22124339 /
Fax: 0172 - 2708274 Email: Islands.
22124340 Fax : 033 - 22124341 Email:
[email protected]
[email protected]
CHENNAI - Shri M. Vasantha Krishna Office
of the Insurance Ombudsman, Fatima
Akhtar Court, 4th Floor, 453, Anna Salai, Tamil Nadu, Pondicherry
Teynampet, CHENNAI - 600 018. Town and Karaikal (which
Tel.: 044 - 24333668 / 24335284 Fax: 044 - are part of Pondicherry).
24333664 Email:
[email protected]

PAGE 30 OF 38
SBI General Insurance Company Limited

Districts of Uttar Pradesh : ANNEXURE I: THE LIST OF ITEMS THAT ARE TO BE SUBSUMED IN ROOM
Laitpur, Jhansi, Mahoba, CHARGE
Hamirpur, Banda,
Chitrakoot, Allahabad, SNO Item SNO Item
Mirzapur, Sonbhabdra,
BABY CHARGES (UNLESS
Fatehpur, Pratapgarh, 1 24 IM IV INJECTION CHARGES
SPECIFIED/INDICATED)
Jaunpur,Varanasi, Gazipur,
Jalaun, Kanpur, Lucknow, 25 CLEAN SHEET
LUCKNOW -Shri/Smt........ Office of the
Unnao, Sitapur, Lakhimpur,
Insurance Ombudsman, 6th Floor, Jeevan 2 HAND WASH BLANKET/WARMER
Bahraich, 26
Bhawan, Phase-II, Nawal Kishore Road, BLANKET
Barabanki, Raebareli, 3 SHOE COVER
Hazratganj, Lucknow - 226 001. Tel.: 0522
Sravasti, Gonda, Faizabad, 4 CAPS 27 ADMISSION KIT
- 2231330 / 2231331 Fax: 0522 - 2231310
Amethi, Kaushambi,
Email: [email protected] 5 CRADLE CHARGES 28 DIABETIC CHART CHARGES
Balrampur, Basti,
Ambedkarnagar, Sultanpur, 6 COMB DOCUMENTATION
Maharajgang, CHARGES /
Santkabirnagar, Azamgarh, EAU.DE-COLOGNE / ROOM 29
7 ADMINISTRATIVE
Kushinagar, Gorkhpur, FRESHNERS EXPENSES
Deoria, Mau, Ghazipur,
Chandauli, Ballia, 8 FOOT COVER DISCHARGE PROCEDURE
30
Sidharathnagar. 9 GOWN CHARGES
MUMBAI - Shri Milind A. Kharat Office of 10 SLIPPERS 31 DAILY CHART CHARGES
the Insurance Ombudsman, 3rd Floor,
Jeevan SevaAnnexe, S. V. Road, Santacruz Goa, Mumbai Metropolitan 11 TISSUE PAPER ENTRANCE PASS / VISITORS
32
(W), Mumbai - 400 054. Tel.: 022 - Region excluding Navi 12 TOOTH PASTE PASS CHARGES
26106552 / 26106960 Fax: 022 - Mumbai & Thane.
26106052 Email: 13 TOOTH BRUSH
EXPENSES RELATED TO
[email protected] 14 BED PAN 33 PRESCRIPTION ON
State of Uttaranchal and DISCHARGE
15 FACE MASK
the following Districts of
Uttar Pradesh: Agra, 16 FLEXI MASK 34 FILE OPENING CHARGES
Aligarh, Bagpat, Bareilly, 17 HAND HOLDER
Bijnor, Budaun, INCIDENTAL EXPENSES /
Bulandshehar, Etah, 18 SPUTUM CUP 35 MISC. CHARGES (NOT
NOIDA - Shri/Smt........ Office of the EXPLAINED)
Kanooj, Mainpuri, Mathura, 19 DISINFECTANT LOTIONS
Insurance Ombudsman, BhagwanSahai
Meerut, Moradabad,
Palace 4th Floor, Main Road, Naya Bans, 20 LUXURY TAX PATIENT IDENTIFICATION
Muzaffarnagar, Oraiyya, 36
Sector 15, Distt: Gautam Buddh Nagar, BAND / NAME TAG
Pilibhit, Etawah, 21 HVAC
U.P-201301. Tel.: 0120-2514250 /
Farrukhabad, Firozbad,
2514252 / 2514253 Email: 22 HOUSE KEEPING CHARGES PULSEOXYMETER\
Gautambodhanagar, 37
[email protected] 23 AIR CONDITIONER CHARGES CHARGES
Ghaziabad, Hardoi,
Shahjahapur,Hapur,Shamli,
Rampur, Kashganj, ANNEXURE II: THE LIST OF ITEMS THAT ARE TO BE SUBSUMED INTO
Sambhal, Amroha, Hathras, PROCEDURE CHARGES
Kanshiramnagar, SNO Item SNO Item
Saharanpur
SURGICAL BLADES,
PATNA - Shri/Smt........ Office of the 1 HAIR REMOVAL CREAM 12 HARMONICSCALPEL,
Insurance Ombudsman, 1st Floor,Kalpana SHAVER
Arcade Building, Bazar Samiti Road,
Bihar, Jharkhand. DISPOSABLES RAZORS
Bahadurpur, Patna 800 006. Tel.: 0612-
2680952 Email: 2 CHARGES (for site 13 SURGICAL DRILL
[email protected] preparations)

PUNE - Shri/Smt........ Office of the 3 EYE PAD 14 EYE KIT

Insurance Ombudsman, Jeevan Darshan Maharashtra,Area of Navi 4 EYE SHILED 15 EYE DRAPE
Bldg., 3rd Floor, C.T.S. No.s. 195 to 198, Mumbai and Thane
N.C. Kelkar Road, Narayan Peth, Pune - excluding Mumbai 5 CAMERA COVER 16 X-RAY FILM
411 030. Tel.: 020-41312555 Email: Metropolitan Region. 6 DVD, CD CHARGES BOYLES APPARATUS
[email protected] 17
7 GAUSE SOFT CHARGES
The updated details of Insurance Ombudsman are available on the IRDA
website: www.irda.gov.in and on the website of General Insurance
Council: www.gicouncil.in

PAGE 31 OF 38
SBI General Insurance Company Limited

8 GAUZE 18 COTTON ANNEXURE IV: INDICATIVE LIST OF DAY CARE

TREATMENTS/SURGERIES/PROCEDURES
WARD AND THEATRE 19 COTTON BANDAGE
9 SNo Procedure Name SNo Procedure Name
BOOKING CHARGES 20 SURGICAL TAPE
Fenestration Of The Inner
1 Coronary Angiography 13
ARTHROSCOPY AND 21 APRON Ear
10
ENDOSCOPY INSTRUMENTS 22 TORNIQUET Revision Of A Fenestration
2 Suturing Oral Mucosa 14
Of The Inner Ear
ORTHOBUNDLE, GYNAEC
11 MICROSCOPE COVER 23 Myringotomy With
BUNDLE 3 15 Palatoplasty
Grommet Insertion
ANNEXURE III: THE LIST OF ITEMS THAT ARE TO BE SUBSUMED INTO
COSTS OF TREATMENT Tymanoplasty (closure Of
Transoral Incision And
SI An Eardrum Perforation
4 16 Drainage Of A Pharyngeal
SI NO reconstruction Of The
Item Item Abscess
NO Auditory Ossicles)
Removal Of A Tympanic Tonsillectomy Without
ADMISSION/REGISTRATION NUTRITION PLANNING 5 17
1 Drain Adenoidectomy
CHARGES 9 CHARGES - DIETICIAN
CHARGES- DIET CHARGES Keratosis Removal Under Tonsillectomy With
6 18
Ga Adenoidectomy
HOSPITALISATION FOR 10 HIV KIT
2 EVALUATION/ DIAGNOSTIC Operations On The Excision And Destruction
11 7 19
PURPOSE Turbinates (nasal Concha Of A Lingual Tonsil
ANTISEPTIC MOUTHWASH
Removal Of Keratosis Revision of A
8 20
3 Obturans Tympanoplasty
URINE CONTAINER 12 LOZENGES
Stapedotomy To Treat Other Microsurgical
13 MOUTH PAINT 9 Various Lesions In Middle 21 Operations On The Middle
BLOOD RESERVATION Ear Ear
4 CHARGES AND ANTE NATAL 14 VACCINATION CHARGES
BOOKING CHARGES Revision of A Incision Of The Mastoid
15 ALCOHOL SWABES 10 22
Stapedectomy Process And Middle Ear
5 BIPAP MACHINE SCRUB Other Operations On The
16 11 23 Mastoidectomy
6 CPAP/ CAPD EOUIPMENT SOLUTIONISTERILLIUM Auditory Ossicles
Myringoplasty (post-aura/ Reconstruction Of The
7 INFUSION PUMP-COST 17 GLUCOMETRE & STRIPS 24
endaural Approach As Well Middle Ear
HYDROGEN PEROXIDE\ 12
8 18 URINE BAG As Simple Type-I Other Excisions Of The
SPIRIT\DISINFECTANTS ETC Tympanoplasty) 25
Middle And Inner Ear

PAGE 32 OF 38
SBI General Insurance Company Limited

Incision (opening) And Incision and Excision of

Excision Of Angioma Small Bowel Endoscopy
26 Destruction (elimination) 51 77 102 Tissue In The Perianal
Septum (therapeutic)
Of The Inner Ear Region
Other Operations On The Colonoscopy ,lesion
27 52 Turbinoplasty
Middle And Inner Ear Removal -( only for
Surgical Treatment of
Excision And Destruction of 78 investigation purpose is 103
Incision & Drainage Of Hemorrhoids
28 Diseased Tissue Of The 53 considered under
Retro Pharyngeal Abscess investigation purpose)
Nose
Other Operations On The
Other Operations On The 79 ERCP 104
Anus
Nose - ( other operation of
UvuloPalatoPharyngoPlast
29 the nose is very broad if 54 Colonscopy Stenting Of Ultrasound Guided
y 80 105
any drainage of local pus Stricture Aspirations
will be considered as OPD)
Percutaneous Endoscopic
81 106 Sclerotherapy, Etc
Adenoidectomy With Gastrostomy
30 Nasal Sinus Aspiration 55
Grommet Insertion
Laparotomy For Grading
Eus And Pancreatic Pseudo
Foreign Body Removal 82 107 Lymphoma With
Cyst Drainage
From Nose ( if same is Adenoidectomy Without Splenectomy
31 56
removed without using any Grommet Insertion
Laparotomy For Grading
anesthesia at OPD) ERCP And
83 108 Lymphoma with Liver
Choledochoscopy
Other Operations On The Vocal Cord Lateralisation Biopsy
32 57
Tonsils And Adenoids Procedure
Laparotomy For Grading
Proctosigmoidoscopy
Incision & Drainage Of Para 84 109 Lymphoma with Lymph
33 Adenoidectomy 58 Volvulus Detorsion
Pharyngeal Abscess Node Biopsy
Labyrinthectomy For Therapeutic Laparoscopy
34 59 Tracheoplasty 85 ERCP And Sphincterotomy 110
Severe Vertigo With Laser
35 Stapedectomy Under Ga 60 Cholecystectomy Esophageal Stent Appendicectomy With
86 111
Placement Drainage
36 Stapedectomy Under La 61 Choledocho-jejunostomy
ERCP + Placement Of Biliary Appendicectomy without
37 Tympanoplasty (Type IV) 62 Duodenostomy 87 112
Stents Drainage
Endolymphatic Sac Surgery 88 Sigmoidoscopy W / Stent 113 Infected Keloid Excision
38 63 Gastrostomy
For Meniere's Disease
89 Eus + Coeliac Node Biopsy 114 Axillary Lymphadenectomy
Exploration Common Bile
39 Turbinectomy 64 UgiScopy And Injection Of
Duct Wound Debridement And
90 Adrenaline, Sclerosants 115
Cover
40 Endoscopic Stapedectomy 65 Esophagoscopy Bleeding Ulcers
Incision And Drainage Of Incision Of A Pilonidal
41 66 Gastroscopy 91 116 Abscess-decompression
Perichondritis Sinus/ Abscess
Duodenoscopy with Fissure In Cervical
42 Septoplasty 67 92 117
Polypectomy AnoSphincterotomy Lymphadenectomy
43 Vestibular Nerve Section 68 Removal of Foreign Body Surgical Treatment Of A
Varicocele And A
Diathery Of Bleeding 93 118 Infected Sebaceous Cyst
44 Thyroplasty Type I 69 Hydrocele Of the
Lesions
Spermatic Cord
Pseudocyst Of The Pinna Pancreatic PseudocystEus
45 70 Inguinal
Excision & Drainage 94 Orchidopexy 119
Lymphadenectomy
Incision And Drainage - Rf Ablation For Barrett's
46 71 Abdominal Exploration In
Haematoma Auricle Oesophagus 95 120 Infected Lipoma Excision
Cryptorchidism
47 Tympanoplasty (Type II) 72 Ercp And Papillotomy
Surgical Treatment Of Anal
Reduction Of Fracture Of Esophagoscope And 96 121 Maximal Anal Dilatation
48 73 Fistulas
Nasal Bone Sclerosant Injection
Division Of The Anal
Eus + Submucosal 97 122 Piles
49 Thyroplasty (Type II) 74 Sphincter (sphincterotomy)
Resection
98 Epididymectomy 123 A) Injection Sclerotherapy
Construction Of
75 Incision Of The Breast
Gastrostomy Tube 99 124 B) Piles Banding
50 Tracheostomy Abscess
Eus + Aspiration Pancreatic
76 100 Operations On The Nipple 125 Liver Abscess- Catheter
Cyst
Excision Of Single Breast Fissure In Ano-
101 126
Lump Fissurectomy

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SBI General Insurance Company Limited

Rigid Oesophagoscopy For Laparoscopic Hysteroscopic Resection Of

Fibroadenoma Breast 179 204
127 154 Dilation Of Benign Pyloromyotomy( Ramstedt) Fibroid
Excision
Strictures Operations On Bartholin’s
180 205 Lletz
OesophagealVaricesSclerot Glands (cyst)
128 155 Eversion Of Sac
herapy 181 Incision Of The Ovary 206 Conization
ERCP - Pancreatic Duct Insufflations Of The
129 156 Unilateral 182 207 Polypectomy Cervix
Stone Removal Fallopian Tubes
130 Perianal Abscess I&d 157 Bilateral Other Operations On The Hysteroscopic Resection Of
183 208
Fallopian Tube Endometrial Polyp
Perianal Hematoma
131 158 Lord's Plication
Evacuation Conisation Of The Uterine
184 209 Vulval Wart Excision
Cervix
UgiScopy And Polypectomy
132 159 Jaboulay's Procedure
Oesophagus Therapeutic Curettage Laparoscopic Paraovarian
185 210
With Colposcopy Cyst Excision
133 Breast Abscess I& D 160 Scrotoplasty
Therapeutic Curettage Uterine Artery
134 Feeding Gastrostomy 161 Circumcision For Trauma 186 211
With Biopsy Embolization
Oesophagoscopy And
Therapeutic Curettage
135 Biopsy Of Growth 162 Meatoplasty 187 212 Laparoscopic Cystectomy
With Diathermy
Oesophagus
Therapeutic Curettage Hymenectomy(
ERCP - Bile Duct Stone Intersphincteric Abscess 188 213
136 163 With Cryosurgery Imperforate Hymen)
Removal Incision And Drainage
Laser Therapy Of Cervix For
Psoas Abscess Incision And 189 214 Endometrial Ablation
137 Ileostomy Closure 164 Various Lesions Of Uterus
Drainage
Other Operations On The
190 215 Vaginal Wall Cyst Excision
Thyroid Abscess Incision Uterine Cervix
138 Polypectomy Colon 165
And Drainage
Incision Of The Uterus
Splenic Abscesses Tips Procedure For Portal 191 216 Vulval Cyst Excision
139 166 (hysterectomy)
Laparoscopic Drainage Hypertension
Local Excision And
UgiScopy And Polypectomy
140 167 Esophageal Growth Stent Destruction Of Diseased Laparoscopic Paratubal
Stomach 192 217
Tissue Of The Vagina And Cyst Excision
Rigid Oesophagoscopy For Pair Procedure Of Hydatid The Pouch Of Douglas
141 168
Fb Removal Cyst Liver
Repair Of Vagina ( Vaginal
193 Incision Of Vagina 218
142 Feeding Jejunostomy 169 Tru Cut Liver Biopsy Atresia )
Photodynamic Therapy Or Hysteroscopy, Removal Of
194 Incision Of Vulva 219
143 Colostomy 170 Esophageal Tumour And Myoma
Lung Tumour
195 Culdotomy 220 Turbt
144 Ileostomy 171 Excision Of Cervical Rib
Salpingo-oophorectomy Ureterocoele Repair
196 221
Laparoscopic Reduction Of Via Laparotomy Congenital Internal
145 Colostomy Closure 172
Intussusception
197 Endoscopic Polypectomy 222 Vaginal Mesh For Pop
Submandibular Salivary
146 Hysteroscopic Removal Of
Duct Stone Removal 198 223 Laparoscopic Myomectomy
173 Microdochectomy Breast Myoma
Pneumatic Reduction Of
147 199 D&C - 224 Surgery For Sui
Intussusception
Hysteroscopic Resection Of Repair Recto- Vagina
Varicose Veins Legs 200 225
148 Septum Fistula
Injection Sclerotherapy
174 Surgery For Fracture Penis Pelvic Floor Repair
Rigid Oesophagoscopy For Thermal Cauterisation Of 226
149 201 (Excluding Fistula Repair)
Plummer Vinson Syndrome Cervix
227 URS + LL
Pancreatic Pseudocysts
150 175 Parastomal Hernia Laparoscopic
Endoscopic Drainage 202 HysteroscopicAdhesiolysis 228
Oophorectomy
151 Zadek's Nail Bed Excision 176 Revision Colostomy
203 Polypectomy Endometrium 229 Percutaneous Cordotomy
Prolapsed
152 Subcutaneous Mastectomy 177
ColostomyCorrection
Excision Of Ranula Under Laparoscopic
153 178
Ga Cardiomyotomy( Hellers)

PAGE 34 OF 38
SBI General Insurance Company Limited

Intrathecal Baclofen Other Restoration And

230 255 Helical Tomotherapy
Therapy 280 Palliative Chemotherapy 299 Reconstruction Of The Skin
Entrapment Neuropathy SRS - Stereotactic And Subcutaneous Tissues
231 256
Release Radiosurgery 281 Template Brachytherapy 300 Chemosurgery To The Skin
Diagnostic Cerebral Destruction Of Diseased
232 257 X - Knife Srs
Angiography 282 Neoadjuvant Chemotherapy 301 Tissue In The Skin And
233 Vp Shunt 258 GammaknifeSrs Subcutaneous Tissues
Reconstruction Of
TBI - Total Body
234 Ventriculoatrial Shunt 259 283 Induction Chemotherapy 302 Deformity/ defect In Nail
Radiotherapy
Bed
235 Radiotherapy For Cancer 260 Intraluminal Brachytherapy
Consolidation 303 Excision Of Bursirtis
TSET - Total Electron Skin 284
236 Cancer Chemotherapy 261 Chemotherapy 304 Tennis Elbow Release
Therapy
Incision, Excision And
Extracorporeal Irradiation
237 IV Push Chemotherapy 262 285 HDR Brachytherapy 305 Destruction Of Diseased
Of Blood Products
Tissue Of The Tongue
HBI - Hemibody
238 263 Telecobalt Therapy Incision And Lancing Of A
Radiotherapy
286 Salivary Gland And A 306 Partial Glossectomy
Infusional Targeted Salivary Duct
239 264 Telecesium Therapy
Therapy
Excision Of Diseased Tissue
SRT - Stereotactic Arc External Mould 287 Of A Salivary Gland And A 307 Glossectomy
240 265
Therapy Brachytherapy Salivary Duct
Sc Administration Of
241 266 Interstitial Brachytherapy Resection Of A Salivary Reconstruction Of The
Growth Factors 288 308
Gland Tongue
Continuous Infusional Reconstruction Of A Salivary Other Operations On The
242 267 Intracavity Brachytherapy 289 309
Chemotherapy Gland And A Salivary Duct Tongue
243 Infusional Chemotherapy 268 3D Brachytherapy Other Operations On The
CCRT - Concurrent Chemo 290 Salivary Glands And 310 Surgery For Cataract
244 269 Implant Brachytherapy Salivary Ducts
+ Rt
245 2D Radiotherapy 270 Intravesical Brachytherapy Other Incisions Of The Skin
291 311 Incision Of Tear Glands
And Subcutaneous Tissues
3D Conformal
246 271 Adjuvant Radiotherapy Surgical Wound Toilet
Radiotherapy
(wound Debridement) And
IGRT - Image Guided After loading Catheter Other Operations On The
247 272 292 Removal Of Diseased 312
Radiotherapy Brachytherapy Tear Ducts
Tissue Of The Skin And
Conditioning Radiothearpy SubcutaneousTissues
248 IMRT - Step & Shoot 273
For Bmt Local Excision Of Diseased
Incision Of Diseased
Extracorporeal Irradiation 293 Tissue Of The Skin And 313
Eyelids
249 IMRT - DMLC 274 To The Homologous Bone Subcutaneous Tissues
Grafts Excision And Destruction
Other Excisions Of The Skin
250 Rotational Arc Therapy 275 Radical Chemotherapy 294 314 Of Diseased Tissue Of The
And Subcutaneous Tissues
Eyelid
251 Tele Gamma Therapy 276 Neoadjuvant Radiotherapy
Simple Restoration Of
252 FSRT - Fractionated Srt 277 LDR Brachytherapy Surface Continuity Of The Operations On The
295 315
VMAT - Volumetric Skin And Subcutaneous Canthus And Epicanthus
253 278 Palliative Radiotherapy Tissues
Modulated Arc Therapy
SBRT - Stereotactic Body Free Skin Transplantation, Corrective Surgery For
254 279 Radical Radiotherapy 296 316
Radiotherapy Donor Site Entropion And Ectropion
Free Skin Transplantation, Corrective Surgery For
297 317
Recipient Site Blepharoptosis
Removal Of A Foreign Body
298 Revision Of Skin Plasty 318
From The Conjunctiva

PAGE 35 OF 38
SBI General Insurance Company Limited

Removal Of A Foreign Body Closed Reduction On

351 366 Release Of Midfoot Joint
From The Cornea Fracture, Luxation
Enucleation Of Eye Reduction Of Dislocation Orif With Plating- Small
319 336 352 367
Without Implant Under Ga Long Bones
Epiphyseolysis With
353 368 Implant Removal Minor
Osteosynthesis
Dacryocystorhinostomy For
Incision Of The Cornea Excision Of Various Lesions Closed Reduction And
320 337 Various Lesions Of Lacrimal 354 369
Gland In Coccyx External Fixation

Laser Photocoagulation To Arthroscopic Repair Of Acl

321 Operations For Pterygium 338 355 370 Arthrotomy Hip Joint
Treat Retinal Tear Tear Knee

Other Operations On The Arthroscopic Repair Of Pcl

322 339 Biopsy Of Tear Gland 356 371 Syme's Amputation
Cornea Tear Knee

Removal Of A Foreign Body Treatment Of Retinal 357 Tendon Shortening 372 Arthroplasty
323 340
From The Lens Of The Eye Lesion Arthroscopic
358 373 Partial Removal Of Rib
Removal Of A Foreign Body Meniscectomy - Knee
324 From The Posterior 341 Surgery For Meniscus Tear Treatment Of Clavicle Treatment Of Sesamoid
Chamber Of The Eye 359 374
Dislocation Bone Fracture
Removal Of A Foreign Body Incision On Bone, Septic Haemarthrosis Knee- Shoulder Arthroscopy /
325 342 360 375
From The Orbit And Eyeball And Aseptic Lavage Surgery
Correction Of Eyelid Ptosis Abscess Knee Joint
By LevatorPalpebrae 361 376 Elbow Arthroscopy
326 Closed Reduction On Drainage
Superioris Resection
Fracture, Luxation Or Amputation Of Metacarpal
(bilateral) 343 362 Carpal Tunnel Release 377
Epiphyseolysis With Bone
Correction Of Eyelid Ptosis Osteosynthesis
327 By Fascia Lata Graft Closed Reduction Of Minor Release Of Thumb
363 378
(bilateral) Dislocation Contracture
Suture And Other 364 Repair Of Knee Cap Tendon 379 Incision Of Foot Fascia
Diathermy/cryotherapy To
328 344 Operations On Tendons
Treat Retinal Tear Orif With K Wire Fixation- Partial Removal Of
And Tendon Sheath 365 380
Small Bones Metatarsa
Anterior Chamber Reduction Of Dislocation
329 345
Paracentesis Under Ga
Anterior Chamber Arthroscopic Knee
330 346
Cyclodiathermy Aspiration
Anterior Chamber
331 347 Surgery For Ligament Tear
Cyclocyrotherapy
Surgery For
Anterior Chamber
332 348 Hemoarthrosis/
Goniotomy
pyoarthrosis
Anterior Chamber
333 Removal Of Fracture Pins/
Trabeculotomy 349
nails
334 Anterior Chamber Filtering
Allied Operations to Treat
335 350 Removal Of Metal Wire
Glaucoma

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Repair/Graft Of Foot Removal Of Tumor Of Arm 421 Vaginoplasty 441 Myocutaneous Flap
381 401
Tendon Under GA
Dilatation Of Accidental
Revision/removal Of Knee Removal of Tumor of Arm 422 Caustic Stricture 442 Fibro Myocutaneous Flap
382 402
Cap under RA Oesophageal
Removal of Tumor Of PresacralTeratomas Breast Reconstruction
383 Exploration Of Ankle Joint 403 423 443
Elbow Under GA Excision Surgery After Mastectomy
Remove/graft Leg Bone Removal of Tumor Of Sling Operation For Facial
384 404 424 Removal Of Vesical Stone 444
Lesion Elbow Under RA Palsy
Repair/graft Achilles Repair Of Ruptured 425 Excision Sigmoid Polyp 445 Split Skin Grafting Under Ra
385 405
Tendon Tendon
426 SternomastoidTenotomy 446 Wolfe Skin Graft
Remove Of Tissue Decompress Forearm
386 406 Infantile Hypertrophic
Expander Space Plastic Surgery To The Floor
427 Pyloric Stenosis 447
Revision Of Neck Muscle of The Mouth Under Ga
387 Biopsy Elbow Joint Lining 407 Pyloromyotomy
(torticollis Release )
Excision Of Soft Tissue Thoracoscopy And Lung
Removal Of Wrist Lengthening Of Thigh 428 448
388 408 Rhabdomyosarcoma Biopsy
Prosthesis Tendons
Excision Of Cervical
Treatment Fracture Of High Orchidectomy For
389 Biopsy Finger Joint Lining 409 429 449 Sympathetic Chain
Radius & Ulna Testis Tumours
Thoracoscopic
390 Tendon Lengthening 410 Repair Of Knee Joint Excision Of Cervical Laser Ablation Of Barrett's
430 450
External Incision And Teratoma Oesophagus
Treatment Of Shoulder
391 411 Drainage In The Region Of 431 Rectal-myomectomy 451 Pleurodesis
Dislocation
The Mouth.
Thoracoscopy And Pleural
External Incision And Rectal Prolapse (delorme's 452
Lengthening Of Hand 432 Biopsy
392 412 Drainage in the Region of Procedure)
Tendon 453 Ebus + Biopsy
the Jaw
External Incision And Thoracoscopy Ligation
433 Detorsion Of Torsion Testis 454
393 Removal Of Elbow Bursa 413 Drainage in the Region Of Thoracic Duct
the Face. Eua + Biopsy Multiple Thoracoscopy Assisted
434 455
Incision Of The Hard And Fistula In Ano Empyaema Drainage
394 Fixation Of Knee Joint 414
Soft Palate Construction Skin Pedicle
435 456 Haemodialysis
Treatment Of Foot Excision And Destruction Flap
395 415
Dislocation Of Diseased Hard Palate Gluteal Pressure Lithotripsy/nephrolithotom
436 457
Excision And Destruction of Ulcerexcision y For Renal Calculus
396 Surgery Of Bunion 416
Diseased Soft Palate 437 Muscle-skin Graft, Leg 458 Excision Of Renal Cyst
Incision, Excision And
397 Tendon Transfer Procedure 417 Drainage Of Pyonephrosis
Destruction In The Mouth 438 Removal Of Bone For Graft 459
Other Operations In The Abscess
398 Removal Of Knee Cap Bursa 418
Mouth Muscle-skin Graft Duct Drainage Of Perinephric
Treatment Of Fracture Of 439 460
399 419 Excision Of Fistula-in-ano Fistula Abscess
Ulna
Treatment Of Scapula Excision Juvenile Polyps 440 Removal Cartilage Graft 461 Incision ot the Prostate
400 420
Fracture Rectum

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SBI General Insurance Company Limited

Transurethral Excision And Surgery For Fournier's

Excision In The Area Of The 502 Tuna- Prostate 517
462 Destruction of Prostate 482 Gangrene Scrotum
Epididymis
Tissue
Excision Of Urethral
503 518 Surgery Filarial Scrotum
Transurethral And Diverticulum
Operations On The
463 Percutaneous Destruction 483
Foreskin Surgery For Watering Can
of Prostate Tissue 504 Removal Of Urethral Stone 519
Perineum
Open Surgical Excision And Local Excision And
Excision Of Urethral
464 Destruction Of Prostate 484 Destruction of Diseased 505 520 Repair Of Penile Torsion
Prolapse
Tissue Tissue Of The Penis
Drainage Of Prostate
Radical Mega-ureter 521
465 485 Amputation Of The Penis 506 Abscess
Prostatovesiculectomy Reconstruction
522 Orchiectomy
Other Excision And
Other Operations On The
466 Destruction of Prostate 486 Kidney Renoscopy And Cystoscopy And Removal of
Penis 507 523
Tissue Biopsy Fb
Operations On The Seminal Cystoscopical Removal of Ureter Endoscopy And
467 487 508 524 RF Ablation Heart
Vesicles Stones Treatment
Incision And Excision of Vesico Ureteric Reflux
468 488 Lithotripsy 509 525 RF Ablation Uterus
Periprostatic Tissue Correction
Other Operations On The Biopsy Oftemporal Artery Surgery For Pelvi Ureteric
469 489 510 526 RF Ablation Varicose Veins
Prostate For Various Lesions Junction Obstruction
Incision Of The Scrotum External Arterio-venous Percutaneous
470 490 511 Anderson Hynes Operation 527
And Tunica Vaginalis Testis Shunt nephrolithotomy (PCNL)
Operation On A Testicular Kidney Endoscopy And Laryngoscopy Direct
471 491 Av Fistula - Wrist 512 528
Hydrocele Biopsy Operative with Biopsy
Excision And Destruction of Treatment of Fracture of
472 492 Ursl With Stenting 529
Diseased Scrotal Tissue Long Bones
513 Paraphimosis Surgery
Other Operations On The Treatment of Fracture of
530
473 Scrotum AndTunica 493 Ursl With Lithotripsy Short Bones
Vaginalis Testis
Treatment of Fracture of
531
474 Incision Of The Testes 494 CystoscopicLitholapaxy Injury Prepuce- Foot
514
Excision And Destruction of Circumcision Treatment of Fracture of
532
475 Diseased Tissue of The 495 Eswl Hand
Testes
Treatment of Fracture of
533
476 Unilateral Orchidectomy 496 Bladder Neck Incision Wrist
515 Frenular Tear Repair
477 Bilateral Orchidectomy 497 Cystoscopy & Biopsy Treatment of Fracture of
534
Ankle
Surgical Repositioning of Cystoscopy And Removal
478 498
An Abdominal Testis of Polyp Treatment of Fracture of
Meatotomy For Meatal 535
516 Clavicle
Reconstruction Of The Stenosi
479 499 SuprapubicCystostomy
Testis 536 Chalazion Surgery
Implantation, Exchange
Percutaneous
480 And Removal of A 500
Nephrostomy
Testicular Prosthesis
Other Operations On The Cystoscopy And "sling"
481 501
Testis Procedure

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